Diagnosis and style

1
Diagnosis and style

• Health Psychology

2
The Practitioners 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

3
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.

4
(Woodward and Wallston, 1987).

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

5
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).

6
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

7
How do patients impair communications?

• Not indicating distress
• Poor communication of symptoms

8
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)

9
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.

10
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.

11
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.

12
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.

13
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.
•  

14
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.
•  

15
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.
  

16
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.

17
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?

18
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.

19
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.

20
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.

21
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.

22
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.

23
Memory

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

24
Memory

• 25 more information was remembered.
• Students remembered 50 more information.
• The experiment involved list learning, so was not
  ecologically valid.

25
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.

26
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.

27
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.

28
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

29
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.

30
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).

31
The Patients 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

32
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).

33
Doctors in the dock

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

34
(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).

35
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.

36
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).

37
Medical Terms Meaning Match terms to meanings

• A hard glossy coating
• The rump or back part
• Agent to treat bacteria
• Secretion of body tissues
• Sugar produced by the body
• The navel
• A device to join separated tissue or bone
• Substance that makes up plant or animal tissue

• Antibiotics
• Breech
• Enamel
• Glucose
• Mucus
• Suture
• Protein
• Umbilicus

38
Why Physicians Use Jargon

• Habit
• Patient doesnt need to know
• Patient better off not knowing
• Keep interactions short
• Reduce emotional reactions
• Reduce recognition of errors
• Elevate practitioners status
• Not aware of jargon

39
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).

40
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.

41
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.

42
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.

43
Boyle (1970)

• Boyle (1970) 42 of patients cannot identify
  position of heart, 20 the stomach, and 49 the
  liver.

44
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 -

45
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

46
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.

47
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.

48
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.

49
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.

50
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.

51
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.

52
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.

53
So why is it that many doctors do not improve
their interpersonal skills?
54
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!

55
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.

56
(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

57
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?

58
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.

59
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.

60
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

61
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.

62
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.

63
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.

64
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.

65
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.

66
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.

67
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.

68
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.  

69
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.

70
McDoctors

• Perhaps we are getting too much into a McDonalds
  culture, where we expect a quick fix from the
  doctors using a limited range of treatments.

71
McDoctors

• Ritzer (1993) - patients are now seen as
  customers or consumers.
• Limited range of services, quick treatment -
  walk-in doctors.
• Hospitals getting more commercial.

72
The end