Diagnosis and style Health Psychology. The Practitioner’s Behaviour Physicians tend to use a...

Diagnosis and style

Health Psychology

The Practitioner’s Behaviour Physicians tend to use a consistent style. Two styles: Doctor-centered

Asks close-ended questions and focuses on first problem mentioned.

Ignores attempts to discuss other problems Patient-centered

Asks open-ended questions and allows discussion

Avoids jargon and encourages participation in decisions

Haug and Lavin (1981) Three conclusions

Both expressed a desire for the patient to participate in making decisions; but this didn't happen very often.

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.

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.

(Woodward and Wallston, 1987).

The elderly are more likely to prefer having decisions made for them (Woodward and Wallston, 1987).

Patient input If the doctor allows the patient to have

an input into the decision making process then 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).

What do we want in a doctor?

Competency Expertise Concern, warm, sensitivity How do “good” doctors benefit?

Patient is more adherent to treatment Obtain more extensive diagnostic

information

How do patients impair communications?

Not indicating distress

Poor communication of symptoms

Why do people describe their symptoms differently?

Symptom perception and interpretation

Differing common sense models of illness

Emphasizing or down-playing symptoms

Difficulties in communicating (e.g., language)

Kessler et al 1999 Kessler, D. A., Lloyd, K., Lewis, G., Gray, D. P., 1999,

'Cross-sectional study of symptom attribution and recognition of depression and anxiety in primary care', British Medical Journal, 318,7181,436-46

  Aim To investigate how a patient's style of behaviour

can intervene in the doctor-patient relationship to the extent that it results in misdiagnosis.

Kessler et al 1999   Participants 305 patients (225 women, 80 men), aged 16-90

years (mean age = 44 years), from a GP surgery in Bristol, consisting of eight doctors. Patients who attended both daytime and evening surgeries were included and were drawn from each of the eight doctors' panels. Informed consent was obtained and 26 patients declined taking part in the study. 24 participants failed to complete the surveys, so their data was discarded.

Kessler et al 1999   Procedure Prior to their appointment with their GP,

participants were asked to complete two questionnaires. The first was a 12-item general health questionnaire, which has been validated as a measure of psychological disorders. In particular, it is a valid tool for identifying the presence of depression and anxiety, where a score of three or more indicates the respondent has symptoms related to these two disorders.

Kessler et al 1999 The second questionnaire was the symptom

interpretation questionnaire, which consists of 13 common physical symptoms, accompanied by three possible causes, one from each of three categories. Depending on the number of choices made from each category (seven or more from one category), the participants were classified as having one of three attributional styles: psychologizing, somaticizing and normalizing. Both questionnaires are self-administered.

Kessler et al 1999 Following this they were seen by their GPs,

but told not to discuss the questionnaires with them. At the end of the surgery, the doctors, who were blind to which attributional category the patients were in, were asked to identify which patients they had noted as showing anxious and/or depressive symptoms and whether or not this was a new diagnosis.

Kessler et al 1999 Comparisons of the doctors' diagnoses with

the patients' attributional style found that doctors were far more likely to identify psychologizers as having depressive/ anxious symptoms and far less likely to identify the same symptoms in normalizers. Thus the patients' way of thinking about their health (their attributional style) can affect the way they interact with their GP and, therefore, the diagnosis that is given.

Wallston (1978) 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) Korsch et al (1968) found that a

quarter of mothers attending a paediatric (child) clinic failed to tell the doctor their major concerns.

Weinman (1981) Weinman (1981) choice of

hypotheses affected by: The doctor's approach to health - psychological,

biological or social explanations. The probability of having a certain disease The seriousness of the disease and its

treatability. Easy treatment and life threatening if left untreated? Then go ahead with treatment!

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.

There are cultural differences in the manifestation of symptoms

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.

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.

The Practitioner's behaviour and style

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.

The Practitioner's behaviour and style

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.

Memory

Ley et al (1973) found that information given in a structured way was better remembered than if given in an unstructured way.

Memory

25% more information was remembered.

Students remembered 50% more information.

The experiment involved list learning, so was not ecologically valid.

Ley (1988) Ley (1988) in a more ecologically

valid experiment asked patients to recall what had been said in a real consultation.

55% was remembered.

Ley (1988) The following patterns in the errors

made by the patients was found: they remembered the first thing they had

been told (primacy effect) the more information that was given, the less

the patient remembered repetition by the doctor had no effect they remembered categorised information they remembered more information, if they

already had some medical knowledge.

Ley (1988) 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

Style 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.

Style 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).

The Patient’s Behaviour that Upsets the Doctor

Expressing anger or criticism Ignoring or not listening Insisting on procedures the physician

thinks is not necessary Requesting the doctor certify

something he/she does not think is true (e.g., disability)

Sexually suggestive remarks

Doctors in the dock

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).

Doctors in the dock

Many court cases allege that doctors did not communicate important information to their patients.

(Bishop & Converse, 1986).

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 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.

Language differences Language differences may impair

communication. This is a particular problem with

young children, and people who cannot speak the language of the country.

Descriptions tend to be inaccurate or incomplete (Marcos et al, 1981).

Medical Terms Meaning – Match terms to meanings

Antibiotics Breech Enamel Glucose Mucus Suture Protein Umbilicus

1. A hard glossy coating2. The rump or back part3. Agent to treat bacteria4. Secretion of body tissues5. Sugar produced by the body 6. The navel7. A device to join separated

tissue or bone8. Substance that makes up

plant or animal tissue

Why Physicians Use Jargon Habit Patient doesn’t need to know Patient better off not knowing Keep interactions short Reduce emotional reactions Reduce recognition of errors Elevate practitioner’s status Not aware of jargon

medical jargon The doctor may use medical jargon,

that is not understood by the patient. Most patients, particularly those

from less educated backgrounds fail to understand terms such as `mucus', `sutures' and glucose'. (DiMatteo & DiNicola, 1982, McKinley 1975).

medical jargon 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.

Patient dissatisfaction Ley (1989) 21 surveys, 41% of

patients dissatisfied with information given by hospital doctors.

28% of patients dissatisfied with information given by general practitioners.

Patient dissatisfaction 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) Boyle (1970) 42% of patients

cannot identify position of heart, 20% the stomach, and 49% the liver.

Bourhis, Roth and MacQueen (1989)

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: -

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:

Aim: the use of language between health

professionals and their patients the motivation either to change or to

maintain the type of language used the norms of communication in a

hospital, and the status and power differences

that categorise 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.

Method: 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.

Method: 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.

Results: 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.

Results: 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.

So why is it that many doctors do not improve their interpersonal skills?

Taylor (1986) Taylor (1986) suggests that many

doctors have not been trained in communication skills, because of three reasons:

No general agreement as to what is a good consultation.

Good communication might make the doctor too sensitive to the needs of the patient and then cloud their medical judgement.

Doctors are too busy to be nice!

DiMatteo and DiNicola (1982) 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.

(Thompson et al, 1990) 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

Doctors get little feedback 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.

Computer Doctors

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.

Schofield, M. J.. Walkom, S., Sanson-Fisher, R., 1997,

Schofield, M. J.. Walkom, S., Sanson-Fisher, R., 1997, 'Patient-provider agreement on guidelines for preparation for breast cancer treatment', Hospital Topics, 75, 2, 18-27

Schofield, M. J.. Walkom, S., Sanson-Fisher, R., 1997,

Aim To investigate the level of agreement

between doctors and patients and nurses and patients on guidelines needed to help prepare patients for breast cancer treatment. It was hypothesized that, due to their lack of interpersonal skills training, doctors would agree less with patients on the content and need for such guidelines than would nurses.

Schofield, M. J.. Walkom, S., Sanson-Fisher, R., 1997,

Procedure Each participant was sent a copy

of the guidelines for preparing those with breast cancer for treatment and instructions on how to apply a rating scale to these guidelines. The guidelines were divided into two categories.

Schofield, M. J.. Walkom, S., Sanson-Fisher, R., 1997,

The first concerned participants' attitudes to the importance of general principles about how patients should be prepared for potentially threatening medical procedures and contained 20 items about such areas as medical practitioners giving patients time to ask questions and answering them fully, avoiding the use of jargon, being sensitive to the needs of the patient and so on.

Schofield, M. J.. Walkom, S., Sanson-Fisher, R., 1997,

The second category contained items concerned with the specific steps that should be taken to prepare patients for such procedures, including the type of information and how it should be given before, during and after the treatment procedure.

Schofield, M. J.. Walkom, S., Sanson-Fisher, R., 1997,

Example items from this category included asking the patient about the amount of detail they wanted to be given before the procedure and giving them an appropriate explanation of why that particular procedure had been chosen, summarizing what had been discussed, describing what was happening during the procedure and encouraging the patient to take an active part in the recovery phase, for example, by taking their own temperature.

Schofield, M. J.. Walkom, S., Sanson-Fisher, R., 1997,

The following 5-point rating scale was used to measure the participants' attitudes to the questionnaire items: 1 = doctors should always do this, 2 = desirable but not essential that doctors always do this, 3 = not necessary for the doctor to always do this, 4 = doctors should never do this, 5 = not sure whether doctors should always do this.

Schofield, M. J.. Walkom, S., Sanson-Fisher, R., 1997,

Results I Overall, there was a high level of

agreement about the nature of the guidelines, with only one from the first category (about patients viewing a video of the procedure before they underwent it themselves) and one from the second category (about asking patients about their previous ways of coping) not getting agreement from the majority of the three groups of participants.

Schofield, M. J.. Walkom, S., Sanson-Fisher, R., 1997,

With regard to differences between the groups, doctors rated significantly fewer guidelines as important (i.e. scored them 1 or 2) than did nurses and patients. In particular, for the general principles they considered the provision of standardized written information to ensure consistency between staff, early preparation to allow time to practice for the recovery phase and the provision of additional ongoing support, for example by nurses, to be non-essentials.  

Schofield, M. J.. Walkom, S., Sanson-Fisher, R., 1997,

In relation to the specific stages of preparation, doctors regarded such items as listening to the patients' concerns and tailoring information to meet them, asking them how much detail they would like on the procedure and teaching them specific coping strategies to be less important than did both nurses and patients. These results support the experimental hypothesis.

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.

McDoctors

Ritzer (1993) - patients are now seen as customers or consumers.

Limited range of services, quick treatment - walk-in doctors.

Hospitals getting more commercial.

The end