module: health psychology lecture:consultation date: 9 february 2009
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Module: Health Psychology Lecture:Consultation Date: 9 February 2009. Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick Tel: +44(24) 761 50222 Email: [email protected] www.warwick.ac.uk/go/hpsych. Aims and Objectives. - PowerPoint PPT PresentationTRANSCRIPT
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Module: Health Psychology
Lecture: Consultation
Date: 9 February 2009
Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick
Tel: +44(24) 761 50222 Email: [email protected] www.warwick.ac.uk/go/hpsych
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Aims and Objectives Aim: To provide an overview of the psychological
influences within the consultation context Objectives: By the end of this session you should be
able to describe the following: the psychological factors relevant to the consultation
context; the behaviours that contribute to poor consultation; the effects / consequences of poor consultation; unconscious psychological processes that contribute to
consultation / communication inequalities.
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Consultation Quality People judge adequacy of care by criteria that are
irrelevant to its technical quality
Key criteria relate to manner in which care is delivered Warmth, listening and empathy = communication skills
Satisfaction declines when Drs express uncertainty about a condition/diagnosis, etc.
Uncertainty expressed in >30% of consultations
Technical quality of care and the manner in which it is delivered are not necessarily related
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Consultation Context
The patient must answer questions, be
poked/prodded, whilst in pain and unwell
may feel anxious, stressed and/or embarrassed
will want a clear diagnosis, answer and/or explanation
has expectations about the consultation and the Dr
The Doctor: must identify, elicit and
evaluate significant information quickly
may feel anxious, stressed and/or embarrassed
will be acutely aware of the need to find ‘the answer’
has expectations about the consultation and the patient
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Consultation Factors … just some …
ConsultationContextDoctor Patient
Experience
Personality
Training
Targets
Evidence
The last patient
Litigation
Healthcare experience
Health status
Personality
Health literacy
Beliefs, Fear
Consulting motivation
Social network
Rapport Language Time
Ethnicity SES Gender
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Bottom Line?
The consultation context is not naturally conducive to effective communication or patient and Dr satisfaction Realistic expectation is that good consultation should be
regarded as the exception and not the rule Surprising that consultation does not go ‘wrong’ more
often Nevertheless, patients describe Drs as poor communicators
What do patients highlight has indicators of poor communication?
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Poor Communication
Behaviours that block patient disclosure Not listening / interrupting (Beckman & Frankel, 1984)
Depersonalisation (Shapiro et al, 1992)
Explaining away distress as normal (Edwards et al, 2002)
Attending to physical aspects only (Maguire & Pitceath, 2002)
Jollying patients along (Erenes et al, 2001)
Use of jargon (Samora et al, 1991)
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An Example
Not Listening / Interrupting 74 GPs had 5K+ consultations recorded In 23% of the consultations patients finished
explanations, i.e. ¾ were interrupted before finishing
Average time to interruption = 18 seconds
(Beckman & Frankel, 1984;Dale et al. 2008)
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But does it matter?
Beyond ‘satisfaction’ are there any ‘real’ consequences for a patient’s health that
derive from poor communication?
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Effects of Poor Communication
1. Diagnosis2. Treatment3. Dose frequency4. Duration
(Bain et al, 1977) 1 2 3 40
102030405060
Not known or Incorrect
% o
f Pat
ient
s
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Poor Communication Effects: Summary
Less likely to adhere to medical regimens … and not just because they are dissatisfied
Less likely to use health care services / seek medical help in the future
Less likely to attend check-ups, screening or other forms of preventive health care
More likely to experience negative, but largely preventable, health outcomes
(Rutter et al., 1996;Erenes et al, 2001)
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Does it matter? YES!
Quality of communication in consultation can, and should, be
considered a risk factor for patient health
Hey, … I told you the first thing is to do no harm!
Iatrogenic harm
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What can be done to improve communication, and will this improvement
lead to better health outcomes?
Understand the problem Intervene in the process
Evaluate the effects
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Understanding the Dr’s Perspective
Why do Drs block? Pandora’s box effect Fear of increasing patient distress Limited time available Threat to one’s own emotional well-being Unaware patients fail to disclose important
information
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Understanding the Patient’s Perspective
Why do patients fail to disclose? Drs’ blocking behaviour Belief that nothing can be done Worry that fears will be confirmed Reluctance to burden healthcare provider Desire not to seem ungrateful or critical Concern that it is not appropriate / legitimate to
disclose some problems
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Intervening to Improve Communication
Providers: Med Ed – communication
as a core clinical skill Modelling – shadowing
effective communicators Ongoing assessment and
feedback Peer support Self-reflection
Patients: Preparation – planning
questions in advance Change attitudes –
personal responsibility Realistic expectations -
medicine and the certainty of uncertainty
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Effects of Good Communication
Increased patient satisfaction, greater recall of advice, and higher adherence (Hall et al, 2005)
Improvements in disease control markers such as HbA1c, blood pressure and circulating stress hormones (Stewart, 2005)
Increased Dr satisfaction and amelioration of burnout (Roter et al, 2003)
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If interventions are effective in promoting better communication between Drs and
patients, does that mean the ‘communication’ problem has been solved?
No
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Communication Inequalities
Providers give less information, are less supportive and less clinically proficient with certain patients: Ethnic minorities (Cooper, 2002) Low SES groups (Schmelkin et al, 1998) The elderly (Haug, 1987) Females (Hall et al, 1993) Chronic illness (Wilcox, 1992) Psychological symptoms (Hall, 1993)
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Why?
Widely regarded as being a consequence of Drs beliefs about members of various social
groups?
i.e. Stereotypic knowledge
Recall from Lecture 1: Stroop, and person perception
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New methodologies:Stroop & Person-perception
Race of Person
Colour
Of Ink B
W
Match
Mismatch
African-american (Black)
Mismatch
Match
Caucasian (White)
(Karylowski, et al., 2002)
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Stroop and Person-Perception
Race of Person
Colour
Of Ink B
W
Bill Cosby
Oprah Winfrey
African-american (Black)
Rosie O’Donnell
Jerry Seinfeld
Caucasian (White)
(Karylowski, et al., 2002)
Name/read the colour of the ink Mis-match
Match
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Slower to name ink colour in the mismatch condition Mismatched info requires
additional processing time What is the mismatched info?
Ink and skin colours are mismatched - not the name
Mismatch can only occur if reading name generates racial category information
Info generated in milliseconds
Stroop and Person-Perception
Reac
tion
Tim
e (m
s)
Ink Color(Karylowski, et al., 2002)
Racial categories come to mind automatically
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Just because some stereotypes are automatically
activated doesn’t mean they necessarily influence
our behaviour, ability, judgment, etc.
Three experiments to convince you otherwise
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Automatic Effects on Behaviour University students - mean age 24 years Prime: Words presented without awareness (<20ms)
Elderly stereotype words, e.g. wrinkle, old, knitting Neutral words, e.g. thirsty, clean, telephoneYou were just primed – ‘wrinkle’ – were you aware?
Told experiment is over Outcome measure: Time taken by the participant to
walk to the lift – 9.75m Design: Randomised cross-over (7 days)
(Bargh et al 1996)
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Study 1 Study 20
2
4
6
8
10
12
14
16
18
20
10.5 10.1
19.4 19.8
Neutral
PrimedSe
cond
s
ResultsParticipants exposed to the elderly prime took
significantly longer to walk to the lift …
… compared to unexposed participants and
themselves, i.e. cross-over in Study 2
Explanation: Behaviour unconsciously adjusted to be
consistent with primed stereotype
Mdif = 9.3 secondsAlmost twice as long!
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Automatic Effects of Performance
UK gen pop: N=1000; M age = 35; 53% female Prime: Write about the behaviour, lifestyle and
attributes of the typical X University professor or football support No prime/writing, or 2 or 9 mins prime
Outcome: Score on a 60 question general knowledge test
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Results
No Prime 2 Mins 9 Mins20
25
30
35
40
45
50
55
60
No Prime 2 Mins 9 Mins20
25
30
35
40
45
50
55
60
Prime: ProfessorImproved performance – stereotype consistent
Prime: HooliganImpaired performance – stereotype consistent
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Automatic Effect on Interaction White students unknowingly screened for relevant
stereotype belief – black males more aggressive Participate in ‘response task’ study – very boring Prime: Black male or white male faces presented without
awareness (<20 ms) Near end of ‘task’, message appears - ‘Warning: Fatal
Error Restart Computer’ Told they must re-do the entire (boring) task
Outcome: Hostility towards the experimenter - videotaped
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Results
0123456789
10
2.8 3.1
8.29.1
Level of hostility rated by experimenter and blinded assessor
Greater hostility among stereotype-activated participants black face prime
Behaviour became consistent with stereotype belief
ExperimenterRating
Blinded Assessor
Host
ility
Ratin
g
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Once activated, stereotypic knowledge influences behaviour, performance and judgements about, and
interaction with, other people
Helps us understand evidence showing that, for certain social groups, clinicians offer less information, less
support and are less clinically proficient
… of course, patients do it too!
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Conclusions Patients judge quality of care by how satisfied they are with
the consultation interaction – especially communication Quality of communication is linked strongly to clinical
outcome across wide range of illnesses Quality compromised by both Dr and patient factors, as well
as contextual demands Interventions for Drs and patients can improve consultation
quality, satisfaction and clinical outcomes Behaviour, communication and decision making can be (are
often) influenced by stereotypic beliefs Awareness of stereotype influence is a necessary but not
sufficient precondition to prevent their negative effects
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Summary This session would have helped you to understand …
the psychological factors that are relevant to the consultation context
the behaviours that contribute to poor consultation / communication between Dr and patient
the effects / consequences on patient behaviour and health of poor consultation / communication
unconscious psychological processes that help to explain consultation / communication inequalities
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Any questions? What now?
Obtain / download one of the recommended readings
In your small groups consider today’s lecture in relation to tutorial tasks:
a) integrated template b) ESA question