Martha S. Gerrity, MD, PhD Steven A. Cole, MD Allen J. Dietrich, MD James E. Barrett, MD Portland, Oregon; New Hyde Park, New York; and Hanover, New Hampshire Submitted, revised, September 9, 1999. From the Department of Medicine, Oregon Health Sciences University and the Portland Veterans Administration Medical Center, Portland (M.S.G.); the Department of Psychiatry, Long Island Jewish Medical Center and Care Management Group of Greater New York, Inc, New Hyde Park (S.A.C.); and the departments of Community and Family Medicine, Dartmouth Medical School, Hanover (A.J.D., J.E.B.). Reprint requests should be addressed to Martha S. Gerrity, MD, PhD, Department of Medicine, OP30, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97201. E-mail: gerritym@OHSU.edu
References
For Boyd Kelly, intervention physicians were more likely to assess for stresses at home and to schedule a follow-up visit within 2 weeks (Table 4). There was a trend toward intervention physicians being more likely to prescribe antidepressants (68% and 42%, respectively, P = .092). In addition, intervention physicians were more likely to encourage participatory decision making. However, participatory decision making varied on the basis of physicians’ suspicions that Mr Kelly was a standardized patient, (b coefficient for the interaction term = 3.19, P = .078). For physicians who suspected Mr Kelly was a standardized patient, intervention and control groups did not differ in their participatory decision making (mean scores ± SD: 11.4 ± 2.9 and 11.6 ± 2.5, respectively, t = -0.236, P = .82). For physicians who did not suspect Mr Kelly, intervention physicians encouraged more participation in their decision making than control physicians (10.6 ± 3.4 and 7.4 ± 3.6, respectively, t = 2.53, P = .019).
Boyd Kelly thought a greater percentage of intervention physicians attended the workshop (91% and 62%, respectively). This effect varied by sex (b coefficient for the interaction term = 4.41, P = .004). Mr Kelly thought more male intervention physicians attended the workshop than male control physicians (79% and 14%, respectively, c2 = 11.63, P = .001). In contrast, Mr. Kelly did not detect differences between female intervention and control physicians (50% and 55%, respectively, c2 = 0.52, P = .82). Intervention and control physicians did not differ in the amount of time they spent with Mr Kelly (mean minutes ± SD: 34.0 ± 14.5 and 29.6 ± 12.1, respectively, t = 1.12, P = .27) or in the percentage of physicians who suspected he was a standardized patient (52% and 40%, respectively, c2 = 0.192, P = .66).
Discussion
The results of this study suggest that the Depression Education Program improves physicians’ communication skills and behaviors toward patients who have common but complex presentations of depression and other medical illnesses. These patients are frequently seen in primary care settings and present difficult challenges to physicians.3,64-66 Differences between intervention physicians and control physicians were seen for both standardized patients and were evident in behaviors directly related to the objectives of the program and in ratings of patient satisfaction, rapport, and participatory decision making that were likely affected by communication skills. For both standardized patients, more intervention physicians asked about stresses at home, and they scored higher on the Participatory Decision-Making scale. For at least one of the patients, more intervention physicians asked about at least 5 criteria for major depression, discussed the possibility of depression, scheduled a return visit within 2 weeks, and scored higher on the Patient Satisfaction scale.
This study meets most of the criteria for rigorous evaluations of continuing medical education (CME) programs as described by Davis and colleagues.67,68 The criteria include thorough descriptions of the health professionals and educational program, use of an experimental design, meaningful outcomes, and potential generalizability. We used an experimental study design, and the results of the study suggest that physicians made clinically important improvements in behaviors likely to have an impact on the diagnosis or treatment of depression (eg, a 20% to 30% increase in the number of physicians inquiring about psychosocial stresses and criteria for major depression). In developing the Depression Education Program, we incorporated educational strategies that characterize those CME programs that have been successful in changing physician behavior or patient outcomes (eg, identifying personal goals or needs, peer discussion, and role-playing), as identified by Davis and coworkers.67,68
Limitations
Our study has several limitations. First, it suffers from a self-selection bias that may limit generalizability, as do all studies using volunteer participants. We felt the need to determine whether the workshop would be effective in a group of volunteer physicians from a variety of practice settings, before approaching practices or health plans to enroll all physicians or those who are not doing well with patients with depression. Compared with primary care physicians in general, our participants were likely to have had a greater interest in improving their care of depressed patients and greater skill in assessing and treating depressed patients. However, we demonstrated that the workshop had an effect even on knowledgeable physicians. The workshop may have had an impact on these physicians because it heightened awareness of the various presentations of depression in primary care, enhanced skills for asking about the criteria for major depression in the context of dealing with other medical issues, or suggested strategies for balancing medical and psychosocial issues. All of these issues were addressed in the workshop, and efficiently balancing medical and psychosocial issues was identified as a personal goal by many of the participants. Replication of this study with physicians of varying degrees of skill and motivation is needed to fully understand the generalizability of the results.
