Doctor-Patient Relationships Interpersonal skills In your summary notes you should have the following studies: Although recent work has encouraged doctors to express their uncertainty to patients as a means to improve communication the potential impact of this on patients remains unclear. Ogden et al (2002) explored the impact of the way in which uncertainty was expressed (behaviourally versus verbally) on doctor's and patient's beliefs about patient confidence. Second the study examined the role of the patient's personal characteristics and knowledge of their doctor as a means to address the broader context. Matched questionnaires were completed by GPs (n=66, response rate=92%) and patients (n=550, response rate=88%) from practices in the south-east of England. The results showed that the majority of GPs and patients viewed verbal expressions of uncertainty such as `Let's see what happens' as the most potentially damaging to patient confidence and both GPs and patients believed that asking a nurse for advice would have a detrimental effect. In contrast, behaviours such as using a book or computer were seen as benign or even beneficial activities. When compared directly, GPs and patients agreed about behavioural expressions of uncertainty, but the patients rated the verbal expressions as more detrimental to their confidence than anticipated by the doctors. In terms of the context, patients who indicated that both verbal and behavioural expressions of uncertainty would have the most detrimental impact upon their confidence were younger, lower class and had known their GP for less time. Barnett (2002) has found that a quarter of surgeons are brusque, unsympathetic or impatient when they break bad news to patients. Family doctors are better at breaking bad news, but most patients are told by surgeons (86%). 106 cancer patients were interviewed. 94 of these had been told by doctors and the rest by family members. The patients were asked to rate the way the news was delivered in four categories: positive, neutral, negative and very negative. In 26 per cent of the cases, memories of the moment were negative or very negative. There were also complaints about the lack of clear, simple information. (The Times 01-07-02) Doctors could get their patients to smile and thus increase their positive feelings towards the illness. Smiling a lot can make people happy. Zuckerman et al (1981) divided males and females into three groups. The first group saw a film of a pleasant scene. The second group were shown a film of a neutral scene. The third group were shown a nasty film. Within each group a third were asked to suppress their facial expressions, a third were asked to exaggerate their facial expressions and the other third were not asked to do anything apart from watching the film. The people who exaggerated their facial expressions showed higher levels of arousal and reported stronger positive or negative emotional reactions, compared with the other two groups. So making patients smile will make them feel happier about themselves. Learning to suppress facial expressions at times of stress could reduce stress. The way the doctor dresses matters. McKinstry and Wang (1991) Pictures of same doctor dressed formally or informally. Pictures of formally dressed doctors rated higher for the amount of confidence the patients had in them, and on how happy they would be to see them. Older and professional-class patients particularly preferred the formally dressed doctors. In addition to this you might want to read other studies on http://homepage.ntlworld.com/gary.sturt/health/Interpersonal%20Skills.htm particularly Savage and Armstrong (1990) found that patients were more satisfied with a „directed consultation’ rather than a ‘sharing consultation’. Directed consultation (Doctor-centred) - statements made such as “You are suffering from…”, “It is essential that you take this medication”, “You should be better in …. Days”, “Come and see me in …. Days”. Sharing consultation (Patient-centred) - “What do you think that is wrong?”, “Would you like a prescription?”, “Are there any other problems?”, “When would you like to come and see me again?” 359 randomly selected patients - free to choose their doctor. 200 results used. 2 questionnaires - one immediately and one a week later. Results - overall a high level of satisfaction, but higher for directed group. Higher for „satisfaction with explanation of doctor‟ and with „own understanding of the problem‟. More likely to report that they had been „greatly helped‟. Comment - the results might reflect the individual choices of the patients studied; perhaps a sample from a different area would show a preference for a „sharing consultation‟. Evaluation points that apply to these studies are: Demand characteristics Generalisability Usefulness Ecological Validity Dated Finding Possibly Reductionism and Control as well. Diagnosis and Style Taking part in the decision making Some patients like to participate in the decision-making but others prefer the doctor to make all of the decisions. Patients differ in the degree they wish to participate in their medical care The elderly are more likely to prefer having decisions made for them (Woodward and Wallston, 1987). If the doctor allows the patient to have an input into the decision making process than the patient will better adjust to the treatment regimen. The patient would be more satisfied with the treatment as well. (Auerbach, et al 1983, Martelli et al 1987). Patients recover faster as well. (Brody et al 1989, Mahler & Kulik, 1991). It is important to get the correct match between doctor and patient Physicians differ in their willingness to share authority. (Eisenberg et al, 1983). Haug and Lavin (1981) Doctors and patients described their own attitude and behaviour related to the patients health. Three conclusions 1. Both expressed a desire for the patient to participate in making decisions; but this didn't happen very often. 2. If the patient wants to take part in decision making, but the doctor wants to make all the decisions, without finding out the patients opinion, then there is much conflict. Patient often told to find another doctor. 3. If the patient wants the doctor to make all of the decisions, but the doctor wants participation then this causes the patient to feel uncomfortable. Mismatch between the doctor and patient will cause the patient stress. (Auerbach et al 1983, Miller & Mangan 1983). Doctors need to be aware of how much the patient wants to participate in decision- making. Preferences for participation in treatment o Physicians often misjudge amount and type of participation patient‟s want (Kindelan & Kent, 1987) o Patient differences in preferences Elderly prefer physician to make health-related decisions for them Those who want active role, adjust to recovery better and recover faster o Although both patients and physicians endorse patient involvement, neither tended to behave this way o Physician-patient mismatch in preferences Patient wants more - leads to conflict Patient wants less - both uncomfortable, shop for take-charge doctor When a doctor is considering a diagnosis he or she uses heuristics. These are simple rules of thumb that simplify the decision making process. Availability heuristics The probability of having a particular illness. This is affected by available information, which can be misleading. The more frightening the illness, can lead to people feeling that they have contracted it. If the illness has been featured in a television drama or documentary, this causes people to feel that they have a high chance of contracting the illness themselves. Representative Heuristic - e.g. knowing the patient to be a smoker, the doctor is more inclined to diagnose a smoking related illness. There are other factors that influence the decision-making process Information given first by the patient influences the doctor the most. Wallston (1978) found that doctors distorted the information that was given later in the consultation so that it fitted in with the diagnosis they made in the earlier part. Korsch et al (1968) found that a quarter of mothers attending a paediatric (child) clinic failed to tell the doctor their major concerns. Compare with results from computer doctors. Perhaps it is a good idea for patients to fill in a form on which they write their concerns and a list of symptoms before going to see the doctor. Weinman (1981) choice of hypotheses affected by: 1. The doctor's approach to health - psychological, biological or social explanations. 2. The probability of having a certain disease 3. The seriousness of the disease and its treatability. Easy treatment and life threatening if left untreated? Then go ahead with treatment! 4. Knowledge of the patient - Does the patient have a medical history of a certain type of illness? Do they go to the doctors often? There are cultural differences in the manifestation of symptoms People from non-European cultures may well exhibit symptoms of their illness in a fashion that is quite strange to Europeans. Torkington (1991) reports a case of a black man who had severe leg pains and convulsions. Doctors found nothing wrong with his legs, and therefore placed the man in a psychiatric ward. The symptoms of the patient were not recognised, when the patient really was suffering from physical distress. Many people from other cultures in Britain have to put up with racism, which can trigger stress responses. There are also cultural differences in the way different cultures view illness and health. Because our language refers to illnesses as if they are objects "I caught measles", then physical explanations of illness, and physical treatments are considered. The Chinese consider medicine to be a balance of two universal forces yin and yang. Illness occurs when organs are out of balance. So the Chinese would not just treat the organ that appears to be diseased. Horton (1967) points out that in Africa a traditional treatment would be to find out who has caused the illness. This makes sense if you consider that the removal of a source of stress can cause a person to feel better. Perhaps we should treat a patient's noisy neighbours! The Practitioner's behaviour and style Physicians can be doctor-centred or patient-centred. (Byrne and Long 1976). 2,500 tape recorded medical consultations in several countries including England, Ireland, Australia and Holland. Most styles were doctor-centred. Physicians asked questions that required only brief replies (e.g. yes no, etc.). Focus on first symptom or problem that was reported by the patient. Often ignored attempts by patient to mention other symptoms. Patient-centred approach - doctors ask open-ended questions, requiring the patient to give lengthy replies. Medical jargon was avoided. They allowed patients to participate in the decision making process. o Doctor-centred style – impersonal, intent on establishing link between symptoms and organic disorder (Byrne & Long, 1976) Ask closed yes-no questions, focus mainly on first problem, tend to ignore attempts to discuss other problems o Patient-centred – personal style, less controlling role Open questions to allow patient to share more information and introduce new facts, tended to avoid jargon, share decision making o Problems in communication Medical jargon - Only 39% of lower class women understood 13 commonly used medical terms (McKinlay, 1975: Assess yourself, p. 287, Sarafino) Physicians expected even lower levels of understanding, but used jargon anyway Patient doesn't need to know, not knowing would relieve stress, keeps interactions shorter, jargon elevates physician o Ideal interaction -- sensitive, warm, concerned, calm, competent Evaluate highly and prefer practitioners with these characteristics Fewer cancellations Physicians who asked more open questions, discussed etiology, prognosis, and treatment more à received more, nontrivial diagnostic information (Roter & Hall, 1987) Memory Ley et al (1973) found that information given in a structured way was better remembered than if given in an unstructured way. 25% more information was remembered. Students remembered 50% more information. The experiment involved list learning, so was not ecologically valid. Ley (1988) in a more ecologically valid experiment asked patients to recall what had been said in a real consultation. 55% was remembered. The following patterns in the errors made by the patients was found: 1. they remembered the first thing they had been told (primacy effect) 2. the more information that was given, the less the patient remembered 3. repetition by the doctor had no effect 4. they remembered categorised information 5. they remembered more information, if they already had some medical knowledge. A follow up study found that if doctors had read a booklet on how to communicate more clearly, then their patients remembered 70% of the information given to them. Style Patients prefer the doctor to show competence, sensitivity, warmth, and concern. (Ben-Sira, 1980). Patients take into account words, and body language - facial expressions, eye contact and body positions (DiMatteo, 1985). Patients rate physicians who show little emotion less positively Open, approachable doctors are given more information by their patients. The first complaint or detail a patient gives is often not the most significant. Patients like a chance to be able to express themselves. They like clear explanations. They like the doctor to show concern, and to give reassurance. More sensitive doctors had less cancellations of appointments (DiMatteo et al, 1986). Medical schools educate future doctors to understand psychosocial factors in treating patients. Harvard's 'New Pathway' program is an example (Seligman et al, 1991). Physicians do not like patients who criticise, ignore them or make unnecessary requests. They also do not like patients to make sexual approaches towards them! Poor relationships between patients and doctors can increase the number of court cases against doctors for malpractice. This in turn leads to more dissatisfaction with their career amongst doctors, also doctors become more wary of patients. (Kolata, 1990). Many court cases allege that doctors did not communicate important information to their patients. Patients do not always give signs of their distress (Roter & Ewart, 1992). People may only communicate the points that they feel are important according to their notion of what is important about a particular complaint. (Bishop & Converse, 1986). Hypochondriacs will overemphasise the symptoms, whereas another patient might play down their symptoms, in the hope that the physician will agree there is not much wrong with them. The way a person interprets symptoms may affect the way they are reported. Language differences Language differences may impair communication. This is a particular problem with young children, and people who can not speak the language of the country. Descriptions tend to be inaccurate or incomplete (Marcos et al, 1981). The doctor may use medical jargon, which is not understood by the patient. Most patients, particularly those from lower-class backgrounds fail to understand terms such as `mucus', `sutures' and glucose' (DiMatteo & DiNicola, 1982, McKinley 1975). McKinlay (1975), study to see whether women in a maternity ward would understand 13 medical terms. Two-thirds understood "breech" and "navel". Almost none understood "protein" or "umbilicus". On average each word was understood by 39% of the patients. The physicians expected even poorer comprehension, even though they used these terms often with their patients. Reasons for doctors using jargon might be: habit, forgot the client would nor understand, may feel the patient doesn't need to know, patient shouldn't know what is to happen, as there would be too much stress, could keep conversations short, less emotional response from the patient, reduce awkward questions, reduce the patient finding out an error had been made, and increases the status of the doctor. Ley (1989) 21 surveys, 41% of patients dissatisfied with information given by hospital doctors. 28% of patients dissatisfied with information given by general practitioners. Much of this is owing to the patients not understanding the doctors, or forgetting what they were told. Patients also were reluctant to ask questions. Boyle (1970) 42% of patients cannot identify position of heart, 20% the stomach, and 49% the liver. This study looks at the complexity of language used in hospitals and finds that whereas nurses are prepared to use everyday language as well as medical language doctors prefer medical language. The medical language acts to increase the status and power of the doctors: - Researchers: Bourhis, Roth and MacQueen (1989) Aim: Bourhis et al were interested in finding out what factors affect communication between hospital staff and their patients. Their aims were to examine the relationship between: i. the use of language between health professionals and their patients ii. the motivation either to change or to maintain the type of language used iii. the norms of communication in a hospital, and iv. the status and power differences that categorize patients, doctors and nurses. Method: The study was carried out using three groups of respondents: 40 doctors, 40 student nurses and 40 patients. All respondents were asked to complete a written questionnaire about the use of medical language (ML) and everyday language (EL) in the hospital setting. The questionnaire consisted of 4 sections. The first section asked about the amount of medical and everyday language the respondent used in the hospital with members of the other groups in the study. The second section asked the respondent to estimate how much ML and EL other members of their own group used with the other groups in the study. The third section asked the respondent to evaluate (on a 7-point scale) the appropriateness of the use of ML and EL among the study groups in the hospital setting. The fourth section asked the respondents for background information and about their attitudes to various communication issues in the hospital. Results: Doctors‟ self-reports of their efforts to use EL with their patients were confirmed by other doctors but not by patients or nurses. Patients‟ self-reports stated that they themselves used EL, although those with limited knowledge of ML used this to try to communicate better with doctors. Doctors, however, did not encourage the use of ML by their patients, and reported the strongest preference of all the groups for patients to use EL. Nurses were reported to have a very particular role by all three groups in their use of both EL and ML. They were seen as „communication brokers‟ between the EL of the patient group and the ML of the group of doctors. The nurses were perceived as being able to mediate between the doctors and their patients. All three groups agreed that EL was better for use with patients, and that use of ML often led to difficulties in communication. Conclusions: One of the overall conclusions drawn from the results of the study was that doctors used ML as a way of maintaining their status in relation to their patient group. Their use of ML was also interpreted as a way of maintaining the power and prestige accorded to doctors within society as a whole. Therefore there is a strong motivation for them to maintain (or even increase) their use of ML. The fact that nurses were prepared to „converge‟ with the doctors and patients is taken as an indication that they are less status conscious than doctors, as they are trained to know ML, just as doctors are. Bourhis et al suggest that the results show that experienced doctors and nurses, as well as students, might benefit from courses focused on effective communication between hospital staff and patients. They also note that a better understanding of the motivation behind the use of language may help to avoid communication breakdown between health workers and their patients. So why is it that many doctors do not improve their interpersonal skills? Doctor's interviewing skills can be improved with training. They can be taught how and when to summarise information, ask questions and to check for comprehension. (Roter & Hall, 1989). Taylor (1986) suggests that many doctors have not been trained in communication skills, because of three reasons: 1. No general agreement as to what is a good consultation. 2. Good communication might make the doctor too sensitive to the needs of the patient and then cloud their medical judgement. 3. Doctors are too busy to be nice! DiMatteo and DiNicola (1982) point out that it is simple to address people by their name, say hello and goodbye , and to show them where to hang their coat. Patients could be given simple forms, whilst they are waiting to see the doctor. They can write down any questions that they would like to ask the doctor in advance (Thompson et al, 1990) Doctors get little feedback as to how successful their communication skills have been. Is no news from the patient, an indication that they have been cured or have given up the treatment. Computer Doctors To get over the problem of embarrassment a computer could be used. Robinson and West (1992) patients at a genito-urinary clinic (specialises in venereal disease) gave more information to a computer than they subsequently gave to the doctor. Patients are less worried about social judgements and embarrassing details with a computer. They admitted having more sexual partners, having attended before, and revealed more symptoms. McDoctors Perhaps we are getting too much into a McDonald’s culture, where we expect a quick fix from the doctors using a limited range of treatments. Ritzer (1993) - patients are now seen as customers or consumers. Limited range of services, quick treatment - walk-in doctors. Hospitals getting more commercial. Using and Misusing health services Not a large section this one. Main studies are: Samet Macready Safer. Samet can be evaluated using: Dated study - Cancer research has advanced tremendously since the study was conducted. Perhaps the old folk delayed because they felt there was no cure. They probably wouldn't do this today. Generalisation - Only old folk and cancer; might not generalise to other age groups or types of illness. Studies that can be linked to Samet are Prohaska - illness seen as part of the ageing process and Day - old people feel less pain (please do not try this out on your elderly folk!) MacReady suggests that delay might generalise to other illnesses as Chronic Heart Disease (CHD) survivors delayed as well. Evaluate using: Sample - Glaswegians might be hardier and less likely to go to the doctor (rather like the Irish when we talk about pain later in the course). Also only the survivors were interviewed, perhaps those who did not survive (RIP!) didn't delay, we will never know. The fact that the survivors did survive shows that their delaying might have been justified as they didn't die! Safer - I have just sent you this in a seperate e-mail. Good for methodological criticisms and provides you with meat on the bone for a section A part a question.
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