Transcript Patient-Practitioner Relationship – Study 1

Health Psychology
Patient-Practitioner Relationships
Requirements
• Interpersonal skills
• Diagnosis and Style
• Using and Misusing
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Use either the first 4 studies OR the last 3 to illustrate the above ideas
Background
• COMMUNICATION
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Message sender – message – message receiver
Non verbal; assist, replace, signal attitude, signal emotion
Dress of dcotors
Taylor – doctors are not trained in communication
No agreement on good consultation; Sensitivity;
Complicated
• DiMatteo & DiNicola – basic courtesy
• Ley – 28-41% dissatisfied with information given. Much
forgotten or not understood. Patients lack awareness of
body therefore explanations are meaningless (Boyle)
• Doctor-centred/Patient-centred. Beckman & Frankel
doctors interrupt patients. Edelmann compared styles,
Benbasset, elderly people do not want patient-centred
Background 2
• JUDGEMENTS/DECISIONS
• Heuristics – rules for probabilities. Availability heuristic
uses information available to make decision.
Representative heuristic make judgements about
individual based on whole group
• Primacy effect of information given – immediate decision
made based on early information and later information
made to fit the decision
• Risk – Marteau present information in positive frame and
its more likely to be chosen (10% survival, 90% chance
dying)
• Long adjustments take place after serious diagnosis.
Taylor – search for meaning, search for mastery, selfenhancement
Background 3
• LAY CONSULTATION
• Asking others for advice
• Scambler – 11 lay consultations for every
doctors visit
• Why doctors visit – persistence, critical
incident (change), treatment expectation
• McDoctors – assembly line, shopping mall
Background 4
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DELAY
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Appraisal (time to interpret)
Illness (realising and deciding)
Utilisation (deciding and turning up)
Character of patient (age, gender, culture)
Illness related factors (site of symptom, type, speed of development,
embarrassment)
Health beliefs (susceptibility, examination)
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Overly worried about health
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Excessive medical attention
By proxy
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Doctor made illness
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HYPOCHONDRIASIS
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MUNCHAUSENS
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IATROGENICS
3 Short Summaries
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Communication between doctor and patient is an important aspect
of healthcare. It is made difficult by many factors, including
different experiences, expectations and style of language that
health workers use compared to general public
Diagnosis is difficult to make because of varied ways illness shows
up in people and varied ways individuals describe symptoms. Health
workers make best use of available evidence but may also bring
biases into the judgement process. Diagnoses are not always
welcomed by the patient and there is a long process of adjustment
to development of a chronic illness.
Our general experience of health workers is good, but it is also fair
to say a significant number of patients have poor experience for a
number of reasons. It is true that hospitals can make us sick and
doctors can make the wrong diagnosis, but the cost-benefit analysis
suggests healthcare in the UK contributes massively to increasing
the length and enhancing the quality of life.
Patient-Practitioner
Relationship – Study 1
 Kessler et al
 Who
 1999
 Symptom attribution and recognition of depression
 305 (most women)
 16-90y
 8 doctors, 1 surgery
 Informed
 What
 General health questionnaire (depression/anxiety) + symptom
interpretation questionnaire (symptoms + 3 causes, categorised
psychologising, somaticising, normalising)
 Seen by GP; spot symptoms anxiety/depression
 Results
 Patients way of thinking about own health affects way they
interact with GP and therefore diagnosis given
 If previously diagnosed depressive likely to be misdiagnosed with it
this time
Patient-Practitioner
Relationship – Study 2
 Schofield
 Who
 1997
 Agreement on preparation for breast cancer treatment
 164 patients
 5 specialists, 140 nurses, 64 doctors
 What
 Sets of likert scales. Doctor should always do…doctors should
never do (+ not sure)
 1. How patients should be prepared – times, jargon, sensitivity
 2. steps to prepare – type of information, when delivered, how
 Results
 High level agreement
 Only video information and previous ways of coping vary in response
 Doctors rated less guidelines as important
 Agrees with hypothesis that doctors lack interpersonal skills
Patient-Practitioner
Relationship – Study 3
 Mooney
 Who
 2001
 Predictors of satisfaction
 345 patients
 1 clinic
 Informed
 What
 Questionnaire (used before) after visit, likert scale,
 Transferred to 0-100 scale to give score
 Results
 90% rated as very good or excellent satisfaction
 Quality of interaction received higher rating than facilities/access
to services
 Interpersonal skills of doctor predictor of satisfaction
Patient-Practitioner
Relationship – Study 4
 Smucker
 Who
 1998
 Practitioner self-confidence and patient outcome
 Random 189 doctors & chiropractors
 Informed
 What
 Correlation
 Questionnaire. I lack knowledge…I know exactly what to do…I feel
comfortable treating. Likert, 1 Strongly agree – 5 Strongly
disagree. 4Q self confidence, 4Q attitudes, 2Q knowledge of
progression acute-chronic
 Contact details 1633 patients, telephone contact made after 1st
visit & 2, 8, 12, 24 weeks after.
 Confidence score compared to length of recovery
 Results
 Strong correlation self-confidence and attitude
 Patient satisfaction higher for chiropractors than doctors
 No correlation with length of recovery
Study 5
 Bourhis
 Who
 1989
 Communication in hospital setting
 40 doctors, 40 nurses, 40 patients
 What
 Questionnaire about medical language and everyday language in a
hospital. Part 1 about how much of each they used with the other
groups. Part 2 about how much they thought other groups used
with each other. Part 3 appropriateness scale for the use of the
languages in each group. Part 4 background information and
attitudes
 Results
 Doctors use ML to maintain status
 Nurses will converge
 Doctors say they use EL but not backed up by nurses or patients.
Patients try to use ML if they know some. Doctors prefer patients
to use EL. Nurses are communication brokers. EL is better for
patients (all agreed) and ML leads to difficulties.
 Courses in communication a good idea
Study 6
 Savage et al
 Who
 1990
 GP consulting style and satisfaction
 Inner London practice
 359 patients random – 200 used
 What
 Directed consultation – “you are suffering from… it is essential
that…you should be better in…come and see me in…” OR sharing
consultation “what do you think is wrong…would you like a
prescription…are there other problems…when would you like to see
me again…”
 Tape recorded
 Patients 2 questionnaires – one immediately one 1 week later assess
satisfaction
 Results
 Overall high level satisfaction
 Directed group – higher level
 Higher level of satisfaction with explanation and more likely to
report ‘greatly helped’
 Style of consultation affects patient satisfaction & contradicts
contemporary ideas about sharing decisions
 Safer et al
Study 7
 Who
 1979
 Determinants of delay
 4 clinics, 1 hospital
 Interviewer approached patients (new), questions 45 minutes. Black female
nurse + white male undergraduate
 93, ~44y, 60% black
 What
 When did first symptom occur…when decided il…when decided to seek help.
Range of questions open/closed to discover factors contributing to decision
 Results
 Factors operate independently as no correlation (appraisal, illness,
utilisation)
 Mean delay 14.2 days
 Appraisal variable – severe pain, reading about symptoms, bleeding. Pain
and bleeding speeds up process, reading is passive monitoring
 Illness variable – new symptom, negative consequences of illness, gender.
Old symptoms delay more, negative imagery delay more, females delay
more.
 Utilisation variable – cost increases delay, pain decreases delay, belief in
cure delay less long
 Personal problems lead to a longer delay in all areas
General Review
 Reductionism
 All rely on numerical scales
 Statistical analysis possible but excludes rich data
 Generalisation
 Smucker generalisable to rest of geographic area
 Others use convenience samples so findings restricted
 Determinism/Free will
 Kessler; the diagnosing behaviour is influenced by attribution style of
patient
 Schofield; preparedness of patients determined by doctors
 Usefulness
 Implications, benefit health services
 Kessler/Mooney suggest ways doctors need to be trained (attributional
styles, interpersonal skills)
 Schofield guidance on how to consult
Questions…
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Describe what psychologists have discovered about the relationship
between patients and practitioners (10)
Evaluate what psychologists have discovered about the relationships
between patients and practitioners (16)
One colleague in a group practice finds the elderly patients prefer to go to
her colleagues than make an appointment to see her. Suggest how she might
change her behaviour to encourage more elderly patients to make
appointments with her. Using your knowledge of psychology, give reasons
for your answer (8)
Suggest an intervention that will encourage people not to delay seeking help
when they have serious symptoms. Give reasons for the suggestion.
Describe one study of patient-practitioner interpersonal style (6)
Discuss ethics of research into patient-practitioner interactions (10)
Describe one piece of research into using health services (6)
Discuss usefulness of research into using health services (10)
Describe one piece of research into mis-using health services (6)
Discuss problems of researching mis-use of health services (10)