Health Psychology Patient-Practitioner Relationships.

Health PsychologyHealth Psychology

Patient-Practitioner Patient-Practitioner RelationshipsRelationships

RequirementsRequirements

• Interpersonal skillsInterpersonal skills• Diagnosis and StyleDiagnosis and Style• Using and MisusingUsing and Misusing

• Use either the first 4 studies OR the last 3 to illustrate the above ideasUse either the first 4 studies OR the last 3 to illustrate the above ideas

BackgroundBackground• COMMUNICATIONCOMMUNICATION

• Message sender – message – message receiverMessage sender – message – message receiver• Non verbal; assist, replace, signal attitude, signal Non verbal; assist, replace, signal attitude, signal

emotionemotion• Dress of dcotorsDress of dcotors• Taylor – doctors are not trained in communicationTaylor – doctors are not trained in communication• No agreement on good consultation; Sensitivity; No agreement on good consultation; Sensitivity;

ComplicatedComplicated• DiMatteo & DiNicola – basic courtesyDiMatteo & DiNicola – basic courtesy• Ley – 28-41% dissatisfied with information given. Much Ley – 28-41% dissatisfied with information given. Much

forgotten or not understood. Patients lack awareness of forgotten or not understood. Patients lack awareness of body therefore explanations are meaningless (Boyle)body therefore explanations are meaningless (Boyle)

• Doctor-centred/Patient-centred. Beckman & Frankel Doctor-centred/Patient-centred. Beckman & Frankel doctors interrupt patients. Edelmann compared styles, doctors interrupt patients. Edelmann compared styles, Benbasset, elderly people do not want patient-centredBenbasset, elderly people do not want patient-centred

Background 2Background 2• JUDGEMENTS/DECISIONSJUDGEMENTS/DECISIONS

• Heuristics – rules for probabilities. Availability Heuristics – rules for probabilities. Availability heuristic uses information available to make heuristic uses information available to make decision. Representative heuristic make judgements decision. Representative heuristic make judgements about individual based on whole groupabout individual based on whole group

• Primacy effect of information given – immediate Primacy effect of information given – immediate decision made based on early information and later decision made based on early information and later information made to fit the decisioninformation made to fit the decision

• Risk – Marteau present information in positive frame Risk – Marteau present information in positive frame and its more likely to be chosen (10% survival, 90% and its more likely to be chosen (10% survival, 90% chance dying)chance dying)

• Long adjustments take place after serious diagnosis. Long adjustments take place after serious diagnosis. Taylor – search for meaning, search for mastery, self-Taylor – search for meaning, search for mastery, self-enhancement enhancement

Background 3Background 3

• LAY CONSULTATIONLAY CONSULTATION• Asking others for adviceAsking others for advice• Scambler – 11 lay consultations for Scambler – 11 lay consultations for

every doctors visitevery doctors visit• Why doctors visit – persistence, critical Why doctors visit – persistence, critical

incident (change), treatment incident (change), treatment expectationexpectation

• McDoctors – assembly line, shopping McDoctors – assembly line, shopping mallmall

Background 4Background 4• DELAYDELAY

• Appraisal (time to interpret)Appraisal (time to interpret)• Illness (realising and deciding)Illness (realising and deciding)• Utilisation (deciding and turning up)Utilisation (deciding and turning up)• Character of patient (age, gender, culture)Character of patient (age, gender, culture)• Illness related factors (site of symptom, type, speed of Illness related factors (site of symptom, type, speed of

development, embarrassment)development, embarrassment)• Health beliefs (susceptibility, examination)Health beliefs (susceptibility, examination)

• HYPOCHONDRIASISHYPOCHONDRIASIS• Overly worried about healthOverly worried about health

• MUNCHAUSENSMUNCHAUSENS• Excessive medical attentionExcessive medical attention• By proxyBy proxy

• IATROGENICSIATROGENICS• Doctor made illnessDoctor made illness

3 Short Summaries3 Short Summaries• Communication between doctor and patient is an important Communication between doctor and patient is an important

aspect of healthcare. It is made difficult by many factors, aspect of healthcare. It is made difficult by many factors, including different experiences, expectations and style of including different experiences, expectations and style of language that health workers use compared to general publiclanguage that health workers use compared to general public

• Diagnosis is difficult to make because of varied ways illness Diagnosis is difficult to make because of varied ways illness shows up in people and varied ways individuals describe shows up in people and varied ways individuals describe symptoms. Health workers make best use of available symptoms. Health workers make best use of available evidence but may also bring biases into the judgement evidence but may also bring biases into the judgement process. Diagnoses are not always welcomed by the patient process. Diagnoses are not always welcomed by the patient and there is a long process of adjustment to development of a and there is a long process of adjustment to development of a chronic illness.chronic illness.

• Our general experience of health workers is good, but it is also Our general experience of health workers is good, but it is also fair to say a significant number of patients have poor fair to say a significant number of patients have poor experience for a number of reasons. It is true that hospitals experience for a number of reasons. It is true that hospitals can make us sick and doctors can make the wrong diagnosis, can make us sick and doctors can make the wrong diagnosis, but the cost-benefit analysis suggests healthcare in the UK but the cost-benefit analysis suggests healthcare in the UK contributes massively to increasing the length and enhancing contributes massively to increasing the length and enhancing the quality of life.the quality of life.

Patient-Practitioner Patient-Practitioner Relationship – Study 1Relationship – Study 1

Kessler et alKessler et al WhoWho

19991999 Symptom attribution and recognition of depressionSymptom attribution and recognition of depression 305 (most women)305 (most women) 16-90y16-90y 8 doctors, 1 surgery8 doctors, 1 surgery InformedInformed

WhatWhat General health questionnaire (depression/anxiety) + symptom General health questionnaire (depression/anxiety) + symptom

interpretation questionnaire (symptoms + 3 causes, categorised interpretation questionnaire (symptoms + 3 causes, categorised psychologising, somaticising, normalising)psychologising, somaticising, normalising)

Seen by GP; spot symptoms anxiety/depressionSeen by GP; spot symptoms anxiety/depression ResultsResults

Patients way of thinking about own health affects way they Patients way of thinking about own health affects way they interact with GP and therefore diagnosis giveninteract with GP and therefore diagnosis given

If previously diagnosed depressive likely to be misdiagnosed with If previously diagnosed depressive likely to be misdiagnosed with it this timeit this time


SchofieldSchofield WhoWho

19971997 Agreement on preparation for breast cancer treatmentAgreement on preparation for breast cancer treatment 164 patients164 patients 5 specialists, 140 nurses, 64 doctors5 specialists, 140 nurses, 64 doctors

WhatWhat Sets of likert scales. Doctor should always do…doctors should Sets of likert scales. Doctor should always do…doctors should

never do (+ not sure)never do (+ not sure) 1. How patients should be prepared – times, jargon, sensitivity1. How patients should be prepared – times, jargon, sensitivity 2. steps to prepare – type of information, when delivered, how2. steps to prepare – type of information, when delivered, how

ResultsResults High level agreementHigh level agreement Only video information and previous ways of coping vary in Only video information and previous ways of coping vary in

responseresponse Doctors rated less guidelines as importantDoctors rated less guidelines as important Agrees with hypothesis that doctors lack interpersonal skillsAgrees with hypothesis that doctors lack interpersonal skills


MooneyMooney WhoWho

20012001 Predictors of satisfactionPredictors of satisfaction 345 patients345 patients 1 clinic1 clinic InformedInformed

WhatWhat Questionnaire (used before) after visit, likert scale,Questionnaire (used before) after visit, likert scale, Transferred to 0-100 scale to give scoreTransferred to 0-100 scale to give score

ResultsResults 90% rated as very good or excellent satisfaction90% rated as very good or excellent satisfaction Quality of interaction received higher rating than Quality of interaction received higher rating than

facilities/access to servicesfacilities/access to services Interpersonal skills of doctor predictor of satisfactionInterpersonal skills of doctor predictor of satisfaction


SmuckerSmucker WhoWho

19981998 Practitioner self-confidence and patient outcomePractitioner self-confidence and patient outcome Random 189 doctors & chiropractorsRandom 189 doctors & chiropractors InformedInformed

WhatWhat CorrelationCorrelation Questionnaire. I lack knowledge…I know exactly what to do…I Questionnaire. I lack knowledge…I know exactly what to do…I

feel comfortable treating. Likert, 1 Strongly agree – 5 Strongly feel comfortable treating. Likert, 1 Strongly agree – 5 Strongly disagree. 4Q self confidence, 4Q attitudes, 2Q knowledge of disagree. 4Q self confidence, 4Q attitudes, 2Q knowledge of progression acute-chronicprogression acute-chronic

Contact details 1633 patients, telephone contact made after Contact details 1633 patients, telephone contact made after 11stst visit & 2, 8, 12, 24 weeks after. visit & 2, 8, 12, 24 weeks after.

Confidence score compared to length of recoveryConfidence score compared to length of recovery ResultsResults

Strong correlation self-confidence and attitudeStrong correlation self-confidence and attitude Patient satisfaction higher for chiropractors than doctorsPatient satisfaction higher for chiropractors than doctors No correlation with length of recovery No correlation with length of recovery

Study 5Study 5 BourhisBourhis

WhoWho 19891989 Communication in hospital settingCommunication in hospital setting 40 doctors, 40 nurses, 40 patients40 doctors, 40 nurses, 40 patients

WhatWhat Questionnaire about medical language and everyday language Questionnaire about medical language and everyday language

in a hospital. Part 1 about how much of each they used with in a hospital. Part 1 about how much of each they used with the other groups. Part 2 about how much they thought other the other groups. Part 2 about how much they thought other groups used with each other. Part 3 appropriateness scale for groups used with each other. Part 3 appropriateness scale for the use of the languages in each group. Part 4 background the use of the languages in each group. Part 4 background information and attitudesinformation and attitudes

ResultsResults Doctors use ML to maintain statusDoctors use ML to maintain status Nurses will convergeNurses will converge Doctors say they use EL but not backed up by nurses or Doctors say they use EL but not backed up by nurses or

patients. Patients try to use ML if they know some. Doctors patients. Patients try to use ML if they know some. Doctors prefer patients to use EL. Nurses are communication brokers. prefer patients to use EL. Nurses are communication brokers. EL is better for patients (all agreed) and ML leads to EL is better for patients (all agreed) and ML leads to difficulties.difficulties.

Courses in communication a good ideaCourses in communication a good idea

Study 6Study 6 Savage et alSavage et al

WhoWho 19901990 GP consulting style and satisfactionGP consulting style and satisfaction Inner London practiceInner London practice 359 patients random – 200 used359 patients random – 200 used

WhatWhat Directed consultation – “you are suffering from… it is essential Directed consultation – “you are suffering from… it is essential

that…you should be better in…come and see me in…” OR that…you should be better in…come and see me in…” OR sharing consultation “what do you think is wrong…would you sharing consultation “what do you think is wrong…would you like a prescription…are there other problems…when would you like a prescription…are there other problems…when would you like to see me again…”like to see me again…”

Tape recordedTape recorded Patients 2 questionnaires – one immediately one 1 week later Patients 2 questionnaires – one immediately one 1 week later

assess satisfactionassess satisfaction ResultsResults

Overall high level satisfactionOverall high level satisfaction Directed group – higher levelDirected group – higher level Higher level of satisfaction with explanation and more likely to Higher level of satisfaction with explanation and more likely to

report ‘greatly helped’report ‘greatly helped’ Style of consultation affects patient satisfaction & contradicts Style of consultation affects patient satisfaction & contradicts

contemporary ideas about sharing decisionscontemporary ideas about sharing decisions

Study 7Study 7 SaferSafer et al et al

WhoWho 19791979 Determinants of delayDeterminants of delay 4 clinics, 1 hospital4 clinics, 1 hospital Interviewer approached patients (new), questions 45 minutes. Black Interviewer approached patients (new), questions 45 minutes. Black

female nurse + white male undergraduatefemale nurse + white male undergraduate 93, ~44y, 60% black93, ~44y, 60% black

WhatWhat When did first symptom occur…when decided il…when decided to When did first symptom occur…when decided il…when decided to

seek help. Range of questions open/closed to discover factors seek help. Range of questions open/closed to discover factors contributing to decisioncontributing to decision

ResultsResults Factors operate independently as no correlation (appraisal, illness, Factors operate independently as no correlation (appraisal, illness,

utilisation)utilisation) Mean delay 14.2 daysMean delay 14.2 days Appraisal variable – severe pain, reading about symptoms, bleeding. Appraisal variable – severe pain, reading about symptoms, bleeding.

Pain and bleeding speeds up process, reading is passive monitoringPain and bleeding speeds up process, reading is passive monitoring Illness variable – new symptom, negative consequences of illness, Illness variable – new symptom, negative consequences of illness,

gender. Old symptoms delay more, negative imagery delay more, gender. Old symptoms delay more, negative imagery delay more, females delay more.females delay more.

Utilisation variable – cost increases delay, pain decreases delay, belief Utilisation variable – cost increases delay, pain decreases delay, belief in cure delay less longin cure delay less long

Personal problems lead to a longer delay in all areasPersonal problems lead to a longer delay in all areas

General ReviewGeneral Review ReductionismReductionism

All rely on numerical scalesAll rely on numerical scales Statistical analysis possible but excludes rich dataStatistical analysis possible but excludes rich data

GeneralisationGeneralisation Smucker generalisable to rest of geographic areaSmucker generalisable to rest of geographic area Others use convenience samples so findings restrictedOthers use convenience samples so findings restricted

Determinism/Free willDeterminism/Free will Kessler; the diagnosing behaviour is influenced by attribution style Kessler; the diagnosing behaviour is influenced by attribution style

of patientof patient Schofield; preparedness of patients determined by doctorsSchofield; preparedness of patients determined by doctors

UsefulnessUsefulness Implications, benefit health servicesImplications, benefit health services Kessler/Mooney suggest ways doctors need to be trained Kessler/Mooney suggest ways doctors need to be trained

(attributional styles, interpersonal skills)(attributional styles, interpersonal skills) Schofield guidance on how to consultSchofield guidance on how to consult

Questions…Questions…• Describe what psychologists have discovered about the relationship Describe what psychologists have discovered about the relationship

between patients and practitioners (10)between patients and practitioners (10)• Evaluate what psychologists have discovered about the relationships Evaluate what psychologists have discovered about the relationships

between patients and practitioners (16)between patients and practitioners (16)• One colleague in a group practice finds the elderly patients prefer to One colleague in a group practice finds the elderly patients prefer to

go to her colleagues than make an appointment to see her. Suggest go to her colleagues than make an appointment to see her. Suggest how she might change her behaviour to encourage more elderly how she might change her behaviour to encourage more elderly patients to make appointments with her. Using your knowledge of patients to make appointments with her. Using your knowledge of psychology, give reasons for your answer (8)psychology, give reasons for your answer (8)

• Suggest an intervention that will encourage people not to delay Suggest an intervention that will encourage people not to delay seeking help when they have serious symptoms. Give reasons for the seeking help when they have serious symptoms. Give reasons for the suggestion.suggestion.

• Describe one study of patient-practitioner interpersonal style (6)Describe one study of patient-practitioner interpersonal style (6)• Discuss ethics of research into patient-practitioner interactions (10)Discuss ethics of research into patient-practitioner interactions (10)• Describe one piece of research into using health services (6)Describe one piece of research into using health services (6)• Discuss usefulness of research into using health services (10)Discuss usefulness of research into using health services (10)• Describe one piece of research into mis-using health services (6)Describe one piece of research into mis-using health services (6)• Discuss problems of researching mis-use of health services (10)Discuss problems of researching mis-use of health services (10)

Health Psychology Patient-Practitioner Relationships.

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