Transcript Module: Health Psychology Lecture: Personal Medicine Tutorial

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
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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:
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the psychological factors relevant to the consultation
context;
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the behaviours that contribute to poor consultation;
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the effects / consequences of poor consultation;

unconscious psychological processes that contribute to
consultation / communication inequalities.
Consultation Quality
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People judge adequacy of care by criteria that are
irrelevant to its technical quality
Key criteria relate to manner in which care is delivered
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Satisfaction declines when Drs express uncertainty
about a condition/diagnosis, etc.
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Warmth, listening and empathy = communication skills
Uncertainty expressed in >30% of consultations
Technical quality of care and the manner in which it
is delivered are not necessarily related
Consultation Context
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The patient
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must answer questions, be
poked/prodded, whilst in
pain and unwell
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The Doctor:
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may feel anxious, stressed
and/or embarrassed
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will want a clear diagnosis,
answer and/or explanation
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has expectations about the
consultation and the Dr
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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
Consultation Factors
Experience
… just some …
Rapport Language Time
Healthcare experience
Health status
Personality
Training
Targets
Doctor
Consultation
Context
Personality
Patient
Beliefs, Fear
Evidence
Litigation
The last patient
Health literacy
Ethnicity SES Gender
Social network
Consulting motivation
Bottom Line?
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The consultation context is not naturally conducive to
effective communication or patient and Dr satisfaction
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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?
Poor Communication
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Behaviours that block patient disclosure
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Not listening / interrupting
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Depersonalisation
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Explaining away distress as normal
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Attending to physical aspects only
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Jollying patients along
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Use of jargon
(Beckman & Frankel, 1984)
(Shapiro et al, 1992)
(Edwards et al, 2002)
(Maguire & Pitceath, 2002)
(Erenes et al, 2001)
(Samora et al, 1991)
An Example
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Not Listening / Interrupting
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74 GPs had 5K+ consultations recorded
In 23% of the consultations patients finished
explanations,
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i.e. ¾ were interrupted before finishing
Average time to interruption = 18 seconds
(Beckman & Frankel, 1984;
Dale et al. 2008)
But does it matter?
Beyond ‘satisfaction’ are there any ‘real’
consequences for a patient’s health that
derive from poor communication?
Effects of Poor Communication
60
Diagnosis
2.
Treatment
3.
Dose frequency
4.
Duration
50
% of Patients
1.
40
30
20
10
(Bain et al, 1977)
0
1
2
3
4
Not known or Incorrect
Poor Communication Effects: Summary
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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)
Does it matter? YES!
Hey, … I told you the first
thing is to do no harm!
Iatrogenic harm
Quality of communication in consultation
can, and should, be considered a risk
factor for patient health
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
Understanding the Dr’s Perspective
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Why do Drs block?
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Pandora’s box effect
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Fear of increasing patient distress
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Limited time available
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Threat to one’s own emotional well-being
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Unaware patients fail to disclose important
information
Understanding the Patient’s Perspective
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Why do patients fail to disclose?
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Drs’ blocking behaviour
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Belief that nothing can be done
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Worry that fears will be confirmed
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Reluctance to burden healthcare provider
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Desire not to seem ungrateful or critical
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Concern that it is not appropriate / legitimate to
disclose some problems
Intervening to Improve
Communication
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Providers:
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Med Ed – communication
as a core clinical skill
Modelling – shadowing
effective communicators
Ongoing assessment and
feedback
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Peer support
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Self-reflection
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Patients:
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Preparation – planning
questions in advance
Change attitudes –
personal responsibility
Realistic expectations medicine and the
certainty of uncertainty
Effects of Good Communication
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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)
If interventions are effective in promoting
better communication between Drs and
patients, does that mean the
‘communication’ problem has been solved?
No
Communication Inequalities
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Providers give less information, are less supportive
and less clinically proficient with certain patients:
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Ethnic minorities (Cooper, 2002)
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Low SES groups (Schmelkin et al, 1998)
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The elderly (Haug, 1987)
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Females (Hall et al, 1993)
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Chronic illness (Wilcox, 1992)
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Psychological symptoms (Hall, 1993)
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
New methodologies:
Stroop & Person-perception
Race of Person
Caucasian (White)
African-american (Black)
W
Match 
Mismatch 
B
Mismatch 
Match 
Colour
Of Ink
(Karylowski, et al., 2002)
Stroop and Person-Perception
Name/read the
colour of the ink
Race of Person
Mis-match
Caucasian (White)
African-american (Black)
W
Jerry Seinfeld
Oprah Winfrey
B
Rosie O’Donnell
Bill Cosby
Colour
Of Ink
Match
(Karylowski, et al., 2002)
Stroop and Person-Perception
Slower to name ink colour in the
mismatch condition
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What is the mismatched info?
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Mismatched info requires
additional processing time
Ink and skin colours are
mismatched - not the name
Mismatch can only occur if
reading name generates racial
category information
Info generated in milliseconds
Racial categories come to
mind automatically
Reaction Time (ms)
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Ink Color
(Karylowski, et al., 2002)
Just because some stereotypes are automatically
activated doesn’t mean they necessarily influence
our behaviour, ability, judgment, etc.
Three experiments to convince you
otherwise
Automatic Effects on Behaviour
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University students - mean age 24 years
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Prime: Words presented without awareness (<20ms)
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Elderly stereotype words, e.g. wrinkle, old, knitting
Neutral words, e.g. thirsty, clean, telephone
You were just primed – ‘wrinkle’ – were you aware?
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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)
Results
… compared to unexposed
participants and
themselves, i.e. cross-over
in Study 2
Mdif = 9.3 seconds
Almost twice as long!
Seconds
Participants exposed to
the elderly prime took
significantly longer to walk
to the lift …
20
18
16
14
12
10
8
6
4
2
0
Explanation: Behaviour
unconsciously adjusted to be
consistent with primed stereotype
19.8
19.4
10.5
10.1
Neutral
Primed
Study 1
Study 2
Automatic Effects of Performance
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UK gen pop: N=1000; M age = 35; 53% female
Prime: Write about the behaviour, lifestyle and
attributes of the typical X
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University professor or football support
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No prime/writing, or 2 or 9 mins prime
Outcome: Score on a 60 question general
knowledge test
Results
Prime: Hooligan
Impaired performance –
stereotype consistent
Prime: Professor
Improved performance
– stereotype consistent
60
60
55
55
50
50
45
45
40
40
35
35
30
30
25
25
20
20
No Prime
2 Mins
9 Mins
No Prime
2 Mins
9 Mins
Automatic Effect on Interaction
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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’
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Told they must re-do the entire (boring) task
Outcome: Hostility towards the experimenter videotaped
Results
 Level of hostility rated
10
 Greater hostility among
stereotype-activated
participants

black face prime
 Behaviour became
consistent with
stereotype belief
Hostility Rating
by experimenter and
blinded assessor
8
8.2
9.1
6
4
2.8
3.1
2
0
Experimenter
Rating
Blinded
Assessor
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!
Conclusions
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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
Summary
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This session would have helped you to understand …
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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
Any questions?
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What now?
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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