health a2 revision. practitioner and patient interpersonal skills a

Health A2

Revision

Practitioner and Patient Interpersonal Skills

A


• Medicine has traditionally been based on the biomedical model • A reductionist model that sees the body as a machine to be fixed.• The patient was seen as passive and ignorant while the doctor was the

expert. • In medical training no attention was given to communication skills and

empathic listening.• Now it is recognised that good interpersonal skills are necessary to

make an accurate diagnosis, to help paients make decisions about their behaviour and treatment, to reduce anxiety and to improve adherence to medical advice.

• Moorhead (1991) found that a consultative interviewing style encouraging active patient participation has been found to be associated with patient and doctor satisfaction as well as positive health outcomes.

• But, there is a debate about the right balance between patient-centred and doctor-centred styles

• Jargon: • One problem in communicating can be the use

of inappropriate language, particularly jargon. • A study of 800 patients by Sommers (1985) of

patient satisfaction found 24% were grossly dissatisfied, 11% noncompliant and 38% only moderately compliant.

• Reasons for patient lack of satisfaction included lack of friendliness, failure to consider the patient’s concerns and the use of medical jargon (ie technical language).


Key Study Bourhis et al (1989): Communication in the hospital setting

• Aim: to examine the use of language between health professionals and their patients• Sample: 40 doctors, 40 student nurses, 40 patients. • Self-report questionnaire on the use of medical language (ML) and everyday

language (EL) in the hospital setting. The questionnaire had 4 sections:• - amount of ML & EL used in the hospital by the three groups• - evaluate appropriateness of use of ML & EL among the study groups in the hospital

setting• Results• - Doctors’ self-reports of their attempts to use EL with patients were supported by

other doctors • but not by patients or nurses.• - Patients reported they used EL with some attempts at ML when talking to doctors.

Doctors did • not encourage use of ML by their patients and preferred patients to use EL• - Nurses seen as ‘communication brokers’ between EL of patients and ML of doctors.• - All three groups agreed that EL was better for use with patients and ML often led to • communication problems• Conclusions• Training in better communication would help avoid misunderstandings. • Doctors used ML as a way of maintaining status and power over patients and nurses.


• Beckman & Frankel (1984) showed that doctors don’t listen.

• They studied 74 visits to the doctor. In only 23% of the cases did the patient have the opportunity to finish their explanation of concerns.

• In 69% of the visits, the doctor interrupted, directing the patient towards a particular disorder.

• On average doctors interrupted after their patients had spoken for only 18 seconds, with middle class patients having a little more and working class a little less than the mean.

• Non-verbal language• Much of the power and message in any

communication comes not from the words spoken but from the non-verbal aspects: the tone of voice, facial expressions, body posture and gesture.

• The body language needs to be in tune with the verbal language, which is not always the case. Non-verbal aspects may affect our trust of the doctor and our satisfaction with the consultation.


• McKinstry & Wang (1991) looked at judgments we make about professionals based on their appearance and dress. They showed pictures of doctors to patients attending surgeries.

• The pictures were of the same male and female doctors dressed either formally (white coat over skirt or suit) or very informally (jeans, open necked, short-sleeved shirt).

• Patients were asked to rate how happy they would be to see the doctor in the picture and how much confidence they would have in the doctor’s ability.

• The traditionally dressed images received higher preference rating than the casually attired ones, particularly in the older and professional-class patients.


• Evaluation• a) Usefulness• These skills can be learned in medical schools and applied in

medical practice. Bourhis and Beckman & Frankel are useful for language training, McKinstry & Wang for dress, etc, Better training would also have financial benefits as the resulting practice should be more cost effective. Also useful for doctors to learn to adjust their style to the social class of the patient.

• b) Validity and Reliability• Bourhis et al was a self-report questionnaire, asking them to

remember and judge others. It might be more valid to observe them in real conditions and see what they actually do, rather than what they report that they do. Also McKinstry & Wang used pictures without referring to the total experience of visiting the doctor which makes their study less valid. However, both studies gained quantitative data that are reliable.


• c) Ethnocentricity: These ideas are all based on 21st century western ideas of the rights of the patients. Patients in other cultures might have different expectations of medical styles.

• d) Holistic Approach• These studies are all based on a holistic approach that

involves an interaction between the cognitive and physiological perspectives. They show how perceptions of both health professionals and patients can be altered by cognitive understanding. This can also be useful in CBT therapy. This approach is arguing against a reductionism of the physiological approach which depends on the biomedical model which sees the body as a machine.


Patient and Practitioner: Diagnosis And Style


• Style• Payne & Walker (1996) claim that being a doctor

is not just having the knowledge, it is also about establishing status and power over the patient.

• This is done by props such as clothing, medical equipment, title and the hierarchical organisation of a hospital or clinic.

• However, some doctors have attempted to change this and establish a patient-centred style.


• Doctor-Centred Style• Here the doctor takes charge of the interaction. • Byrne & Long (1976) analysed 2.500 tape-recorded medical

consultations with doctors in several countries including England, Ireland, Australia and Holland.

• Each doctor tended to use a consistent style. • Most were doctor-centred. • This was characterised by questions which required a simple yes/no

answer and focused on the problem which the patient had presented on arrival.

• They tended to ignore attempts by patients to discuss other problems.

• They seemed intent on establishing some link between the initial problem and some organic disorder.

• Patient-centred doctors in contrast asked more open-ended questions, avoided use of jargon and allowed clients to participate in some of the decision-making.

Key Study: Savage & Armstrong (1990

• Aim: To compare the effect of ‘directing’ and ‘sharing’ communication styles of doctors.• Sample: The study was carried out in an inner London general practice where patients were free

to choose which doctor they consulted. Some 359 participants were selected randomly, and form this original sample the results form 200 participants were used.

• Method: The 200 participants were either given a directed consultation or a sharing consultation.• Directed Consultation statements Sharing Consultation

statements• You are suffering from.. What do you think is

wrong?• It is essential that you take this medication Would you like a prescription?• You should be better in … days Are there any other problems?• Come and see me in …. Days When would you like to

come and see me?• The consultations were tape-recorded. The patents were given two questionnaires, one

immediately after the consultations and one a week later, to assess their satisfaction with the consultation.

• Results: Both groups reported a high level of satisfaction with their consultations. • However, the directed consultation group:• - reported a higher level of satisfaction in the explanation given by the doctor• - reported a higher level of satisfaction with their own understanding of the problem• - were more likely to report that they had been ‘greatly helped’ • Conclusion: The results show that the doctor-centred style is more popular among patients.


• Evaluation• a) Locus of control and self-efficacy: these

concepts are contradicted by S&A’s research.• b) Ecological validity (does it test what it aims to

test): the research is self-report on satisfaction, it does not refer to efficacy of the treatment.

• c) Generalisability: Size and range of Byrne & Long’s study compared to S&A.

Patient and Practitioner: Diagnosis

• a) Inductive versus deductive reasoning

• (i) Inductive

• This is where facts are gathered and then used to come to a diagnosis. Ogden describes diagnosis as a kind of problem solving where a doctor collects all the evidence first and then uses this to arrive at a conclusion or hypothesis.


• (ii) Deductive reasoning• However the approach which doctors often take is the

deductive model. Here a decision is arrived at fairly early on and then the doctor looks for evidence to support the hypothesis. This involves a number of stages:

• - Accessing information about symptoms.• - Developing a hypothesis• - Search for attributes – confirm or refute hypothesis• - Make a management decision.• So different doctors might come to different conclusions

as a result of the different ways they carry out these four stages.


• b) Heuristics• Heuristics can help to explain deductive reasoning.

These are ‘psychological rules of thumb’ which guide us when making decisions. For example if an illness has been talked about a great deal on TV recently we might be more likely to feel that we have contracted it. This means we have applied the ‘availability heuristic’.

• Knowing a patient is a smoker, the doctor may be more likely to apply the ‘representative heuristic’ and diagnose a smoking related illness.

• The first information the doctor hears from the patient produces a primacy effect and may carry more weight than it should and thus influence diagnosis.


• Evaluation• a) Objectivity: the discussion of diagnosis suggests that

there is little objective measure of symptoms. This undermines the biomedical model.

• b) Ethnocentricity: Different cultural groups may have different expectations of the relationship and different expectations of the role of the patient. In some cultures it might be difficult for a female to communicate with a male doctor.

• c) Ecological validity (testing what it aims to test): How can you measure the success of a consultation? Is patient satisfaction enough? Is it a question of recovery or rate of recovery? Is it measured by compliance rates?

Patient and Practitioner: Using and Misusing Health Services


• Using Health Services• Social factors: • Gender: Women use health services more than men, • Class: the lower the social class the lower the use• Age: Under 5 and over 75 use them most

• All people are using health services more than 50 years ago, which is not just due to an aging population. This may be due to rising expectations of health. It explains why the cost of the NHS has increased so much more than the founders expected, and why health is such a big political issue.


• The Health Belief Model could help us understand why people do and don’t use health services. Perhaps their perceptions of susceptibility, perceptions of costs and benefits vary. Studies applying the model have shown that:

• the greater people’s beliefs in the effectiveness of medical care, the more likely they were to use the health services

• individuals who are aware of the symptoms of cancer and believe cancer cannot be treated effectively or cured are likely to delay seeking diagnosis much longer.

• Hypochondriasis• Hypochondriasis is the tendency for individuals

to worry excessively about their own health, monitor their own bodily sensations closely and make frequent unfounded medical complaints.

• You could call these ‘type 1 errors’ – remember Rosenhan’s study about accepting the experimental hypothesis when you should accept the null.


• There is a link between hypochondriasis and neuroticism.

• Costa and McCrae 1985 tested about 1000 normal adults using two self-report scales i) Cornell medical Index to assess level of physical complaints and ii) Emotional Stability scale to measure neuroticism. Participants were generally in good health and ranged from 20 to over 90.

• Analysis showed that complaints increased with neuroticism.

• But it is a correlation, neuroticism may cause hypochondria, or the other way round, or some other factor may be involved.



• Munchausen’s syndrome is a very rare condition in which the individual falsely claims to have symptoms of serious illness.

• Self-harm can be a form of it. • Another form of this is Munchausen’s by proxy in

which you (most frequently this is mothers for children) fake the symptoms in another person so that they can have treatment.

• Sometimes the mother inflicts physical injury on the child to achieve this end. So this is a form of child abuse.

• Evaluation• Approaches: Behaviourism• a) Classical conditioning: It is possible that

Munchausen’s sufferers have had experience of hospital when younger, and they associate it with security and care. They might yearn for this to recur.

• b) Operant conditioning: It could be argued that sufferers from Munchausen’s crave the reinforcement that attention gives them. Being ill is an attractive role which gains them such reinforcement.


• Underusing Health Services

• Delay is much more common than overuse (‘type 2 error’). The classic study is by Safer et al.


Key Study - Safer et al: Determinants of three stages of delay in seeking care at a

medical clinic• Aim• Previous studies on delay in seeking medical help have focused on the total time

from when a symptom is first noticed to the time that treatment starts. Safer et al argue that different factors will affect delay at different times, and it is more useful to break down total delay into three sequential states:

• 1 Appraisal delay: the time taken for the patient to recognise a symptom as a sign of illness

• 2 Illness delay: the time taken from deciding that one is ill to deciding to seek medical care.

• 3 Utilisation delay: the time taken from deciding to seek medical care to actually getting it.

• This study aims to discover which psychological factors affect delay at each of these three stages.

• Sample: The study was carried out in the waiting rooms of four clinics in a large inner-city hospital in the USA. Interviewers approached patients who were there to report a new symptom or complaint and asked them a series of questions that took about 45 minutes. They interviewed a total of 93 patients, 60% were black, average age 44. They were interviewed by a black female nurse and a white male undergraduate.

• Method• Interview. Participants were asked about when they first noticed the symptom, when

they decided they were ill, and when they decided to seek medical help. They were asked a range of other questions, some open and some closed, aimed at discovering the factors that may have contributed to the decisions involved in getting medical help.

Key Study - Safer et al: Determinants of three stages of delay in seeking care at a

medical clinic• Results• The mean total delay was 14.2 days.• a) Appraisal delay• Three variables correlated significantly: pain, bleeding, whether the patient had read

about the symptoms.• Pain and bleeding made the patient think they were ill, while reading about it had the

opposite effect. Safer explains this by describing reading as ‘passive monitoring’ (compared to the ‘active monitoring’ of looking for symptoms) which leads to more information gathering and so increases the appraisal delay.

• b) Illness delay• Three factors were correlated with delay. a) if the symptoms were old rather than

new, b) if patients had a negative idea about the symptoms, c) females had longer delays than males.

• c) Utilisation delay• Longer Delay Patients concerned about cost • Shorter delay: Patients in pain; patients who thought they could be cured • Finally, one variable correlated with total delay was patients who had personal

problems (work, family etc). • Conclusions• Different factors mediate delay at each of three different stages. There is no point in

examining total delay.

Patient and Practitioner: Misusing Health Services

• Evalution• a) Locus of control: Study supports this concept. If the patient felt

they had some control they delayed less. Eg if they could afford treatment or if they felt treatment might work.

• b) HBM. Delay was shortest for people less concerned about cost of treatment, had severe pain and felt symptoms could be cured. This fits in with the Health Belief Model in that it shows appraisal in practice. It also shows (to some extent) the cost benefit analysis that takes place.

• c) Generalisability: difficult to generalise because the study took place in only 4 clinics in one US inner city hospital

• d) Usefulness: this study could be used to devise programmes to encourage people to reduce delays at each stage. Appraisal time could be reduced by increasing knowledge so people wouldn’t need to look it up eg breast cancer awareness.

Adherence to medical advice:

B

Non-Adherence: Examples and Reasons

• Examples:• Milgram looked at obedience and found that

people obeyed authority. • However, doctors have authority but many

studies show lots of people not doing what they are told.

• (It is difficult to know what word to use here – should it be obedience, or compliance or adherence? They all mean pretty much the same, but adherence seems a little less ‘top-down’ and implies a sense of partnership).


• Kent & Dalgleish (1996) describe a study in which many parents of children who were prescribed a ten-day course of penicillin for a throat infection did not ensure that their children completed the treatment.

• The majority of the parents understood the diagnosis, were familiar with the medicine and knew how to obtain it.

• Even though the medication was free, the doctors were aware of the study, and the families knew they would be followed up, by day three of the treatment only 41% of the children were still being given the penicillin, and by day six only 29%.


• Sackett (1976) found that 50% of patients in America did not take prescribed medications according to the instructions and scheduled appointments for treatment were missed 20-50% of the time.

• McKenny (1973) looked at hypertension. • He studied 50 patients for 7 months. • He found that only 65% of pills were taken. • Only 20% of the patients took as many as 90% of the

pills and that after the detection of High blood pressure only 50-70% sought treatment.

• 33% of those who sought it dropped out. • Sarafino(1994) argued that people adhere reasonably

closely about 78% of the time for short-term treatments and 54% for chronic.


• Reasons:• These results seem to contradict Milgram’s

study on obedience to authority which found that people are highly compliant.

• Perhaps the difference is that the situation of visiting and complying with a doctor's suggestions is very different.

• Patients have more knowledge and the doctor is not there when the treatment is actually being carried out.

• Health Belief Model: Perceived Threat

• HBM:

• a) evaluating the threat (perceived seriousness, perceived vulnerability),

• b) Cost benefit analysis



• Kent & Dalgleish argued in their study (see above) that the key factor is not the doctor’s perception of how serious the matter is, rather it is the patient’s perception (or the patient’s mother’s perception).

• The antibiotics caused the symptoms disappear quickly, as a result the mother no longer perceived a threat, so discontinued the treatment.


• Rational non-adherence: • This concept provides evidence to support use

of cost-benefit analysis. • Some people might decide rationally that the

treatment is not in their best interest. • Bulpit (1988) looked at treatments for

hypertension and found that the side-effects could cause sexual problems.

• Some people might consider it a rational choice (or in cost-benefit terms, that the costs outweigh the benefits) not to take the drugs

Key Study: DiMatteo et al (2000

• Aim: To find out if there is a correlation between anxiety and depression with medical adherence. This is a review article of studies aimed at finding correlations between patients’ non-adherence to medical treatment and their levels of anxiety and depression.

• Sample: the authors looked at 25 studies carried out between 1968 and 1998, 12 of these were about depression and 13 about anxiety.

• Method: In order to qualify for this review, previous studies had to measure adherence and patient depression or anxiety and involve patients who were not being treated for depression or anxiety, but had been asked to follow a medical regime by a doctor who was not a psychiatrist.

• Results: The studies examined by the authors showed that there seems to be no correlation between anxiety and non-adherence, but a strong correlation between depression and non-adherence. Compared with non-depressed patients, depressed patients are three times more likely to fail to adhere to the medical regime that has been prescribed for them.

• Conclusions: Depression is an important risk factor for non-adherence

• This study supports HBM.

• Depressed people tend to be fatalistic, ie have a strong belief that nothing will improve the situation.

• Therefore they do not adhere.

• On the other hand, people suffering from anxiety have no such fatalistic beliefs and so take their medicine

Key Study: DiMatteo et al (2000


• Theory of Planned Behaviour

• TPB has three components,

• attitude towards a behaviour,

• subjective norm,

• perceived behavioural control.

• It is the last one that is most relevant, especially with its link to concepts of self-efficacy and the locus of control.


• Payne & Walker (1996) provide evidence to support TPB

• a) low self esteem: P&W suggest that because people who have low self-esteem and low self-efficacy do not value their own ideas, they are more likely to value the doctors’ ideas and so adhere to medical advice.

• b) knowledge: the less the knowledge the more the adherence.

• Social support• Kent & Dalgleish show that if family members

are present at the consultation adherence is twice as high.


• Ley`s Model of Compliance (1981): understanding and memory.

• A new model which specifically addresses compliance is very simple.

• It says that compliance follows if patients are satisfied with the consultation process.

• Both satisfaction and compliance are affected by understanding and memory.

• For example, Kent & Dalgleish have shown that patients can forget up to 50% of their instructions within minutes of leaving the surgery.


• In terms of understanding Waitkin (1976) did an observational study and recorded the proportion of time doctors spent informing patients about their illness or treatment.

• Average time spent with patients was 20 minutes, of which one minute was spent informing them.

• But the doctors estimated that they had spent between 10 and 15 mins.


• K&D also show that doctor-centred consultations have lower levels of adherence.

• This varies according to the degree of knowledge of the patient. I

• t also conflicts with the Armstrong and Savage study from the practitioner-patient topic.

• But an evaluation of this could be that patients might be more satisfied subjectively by doctor-centred consultations, but they might, objectively, understand and remember better with a patient-centred style.


• Evaluation• - Link with HBM and cost benefit analysis.• - Use the studies to evaluate the models.• - Relate to doctor-centred versus patient-centred • style referred to in the practitioner-patient topic.• - Usefulness• - Ethnocentrism: these are all western models • and may not be generalisable to other cultures.• - DiMatteo’s article is a review, not based on • original research, so we don’t know the • variables.• - Effectiveness: DiMatteo’s study can be applied • so that doctors can screen for depression before • giving prescriptions.


• Practical Application• When visiting the doctor people are often anxious and at

the same time they are getting lots of new information that is difficult to take in.

• Research has indicated that the way material is organised influences patients recall. Visual aids help. Over a three day period patients retain 10% of orally transmitted information, 20% visually transmitted and 65% information transmitted both ways.

• Doctors, however, must not receive all the blame for this. In one study patients asked questions only 7% of the time.

• They commonly express their confusion through facial expression, body movements and tone of voice.


health a2 revision. practitioner and patient interpersonal skills a

Documents

use of language

patients sample

preferred patients

patient satisfaction

use of medical language

middle class patients

communication skills

patient lack of satisfaction