Patient-practitioner relationship

PRACTITIONER AND PATIENT INTERPERSONAL SKILLS

The practitioner-patient relationship, also known as the doctor-patient relationship, is a very important factor in the healthcare industry. When people visit their doctor, they are often given information about different things. If something hinders the patient from properly processing and understanding the information, the treatment experience may not be at its best.

Interpersonal skills are those social skills that are used between people who are attempting to communicate with each other (Inter = between / Personal = people). Practitioners use different types of interpersonal skills when interacting with patients. Two main types of communication are verbal (related to speaking) and non-verbal (not related to speaking).

Non-verbal communications (NVC)

Non-verbal communication is mainly carried out through a person’s body language – no explicit speaking is involved. The recipient of non-verbal communication receives the message through vision (by looking) or touch (by feeling).

Non-verbal communication includes paralanguage (the tone, speed, volume, fluency of speech), facial expressions, gestures, appearance and physical proximity.

Michael Argyle (1975) emphasises the importance of NVC and states that it is four times more effective than verbal communication. He goes on to say that NVC does the following:

  1. Assists speech
  2. Replaces speech
  3. Signals attitudes
  4. Signals emotional states.

McKinstry and Wang (1991)

McKinstry and Wang carried out a study to investigate whether a doctor’s style of dress has any influence on their patients’ respect for their opinion. They showed eight photos (5 of a man in different styles, 3 of a woman in different styles) to 475 patients from five different GPs. Patients were asked: “Which doctor would you feel happiest about seeing for the first time?” and were then questioned about their confidence of the doctors in each picture. Their results showed that the male doctor in a smart suit and the female doctor in a skirt and jumper was preferred. Overall, 11% of patients said the dressing of a doctor was very important, 53% said it was quite important and 36% said it was not important at all. Most people who preferred formally dressed doctors were older in age or from a professional class.

Verbal communications

Verbal communication is related to speech. There are many factors involved in VC, such as the jargon used.

McKinlay (1975)

John McKinlay conducted a study of British obstetricians and gynaecologists on physicians who used medical jargon during interviews with women in a maternity ward. On average, the medical jargon and terms being used by health workers were understood by 39% of the women. This includes words like “protein”, “suture” and “umbilicus”. However, the doctors had actually underestimated the amount of people that would understand the terms, which begs the question: why did the doctors use such jargon if they did not expect the patients to understand it in the first place?

Ley (1988)

Philip Ley (1988) investigated the amount of information remembered by patients after visiting their doctor. After a consultation, the patients were asked to recall what the doctor had told them to do. After checking their answers, it was found that most patients only remember just a little more than 50% of the information given by their practitioner.

PATIENT AND PRACTITIONER DIAGNOSIS AND STYLE

Practitioners have different ways of making diagnoses; their style might be unique in the way that they consult their patient, collect information, evaluate the situation and make their conclusions.

Practitioner style: doctor and patient-centred

There are two main types of practitioner styles, namely doctor-centred and patient-centred. They are also known as “directive” consulting style and “shared” consulting style, respectively. They were discovered by Byrne and Long in 1976.

Byrne and Long (1976)

Byrne and Long analysed 2500 recordings of medical consultations in a variety of countries, including England and Australia. They discovered the two distinctive practitioner styles.

Features of the doctor-centred style:

  • Doctor asked closed questions (patient could only answer ‘yes’ or ‘no’).
  • Doctor ignored patients’ attempts to elaborate on their answers.
  • Doctor placed most focus on the first problem described by the patient.
  • Doctor made links between symptoms and their diagnosis without discussion or alternatives.
  • Everything was based on “fact” rather than two-way communication.
  • Impersonal atmosphere.
  • Patient was overall passive during the consultation.

Features of the patient-centred style:

  • Doctor asked open-ended questions.
  • Patient was given chances to give descriptions and elaborate on answers.
  • Doctor used less medical jargon; patient could understand diagnosis and treatment options.
  • Patient had the chance to participate in decision-making.
  • Personal atmosphere.
  • Patient was very active during the consultation.

Savage and Armstrong (1990)

Savage and Armstrong compared a patient-centred style (sharing consultative process) with the doctor-centred style (traditional doctor-led process). All the patients involved in the study reported that they were highly satisfied with the consultation. However, straight after the consultation and one week later, it was found that they preferred the doctor-led style. It is possible that this is due to people being more familiar with the traditional method; adjusting to a newer consultation style could take time for patients and their doctors.

Practitioner diagnosis: type I and type II error

While these are rare occurrences, there are times where a doctor will get things very wrong. There are two main types of errors (which have previously been discussed in the Rosenhan study during AS).

  1. Type I error – Doctor diagnoses a physically/psychologically ill person as “healthy”.
  2. Type II error – Doctor diagnoses a healthy person as “ill”.

The Type I and II errors are also known as the “false positive” and “false negative”, respectively.

Disclosure of information

To “disclose” something means to reveal. It is necessary for a patient to disclose certain information to their doctor in order to determine the correct diagnosis. However, every patient is different; they have different styles of communicating.

Robinson and West, 1992

Robinson and West conducted a study on patients at a genito-urinary clinic. They discovered that the patients gave more information to a computer than to the doctor they met afterwards. For example, they admitted to having more sexual partners and revealed more symptoms. This suggests that computers can be used to help patients communicate more comfortably and openly.

MISUSING HEALTH SERVICES

Some patients may misuse health services. We will look at three types of misuse: treatment delay, hypochondriasis and Munchausen syndrome.

Delay in seeking treatment

Instead of seeking immediate solutions to their issues, some patients delay treatment for various reasons.

Safer (1979)

After interviewing patients, Martin Safer and his fellow researchers attempted to explain why people delayed treatment by creating a model. They outlined three sequential stages of treatment delay:

  1. Appraisal delay – The time taken for a personal to interpret their physical symptoms as an indication of an illness.
  2. Illness delay – The time taken between discovering the illness and deciding to seek medical assistance.
  3. Utilisation delay – The time taken between deciding to seek medical attention and then actually getting it.

Misuse: hypochondriasis

Sarafino (2006) defines hypochondriasis as a “tendency of individuals to worry excessively about their own health, monitor their bodily sensations closely, make frequent unfounded medical complaints, and believe they are ill despite reassurances by physicians that they are not.” This specific behaviour may also lead to a misuse of health services.

According to Fallon (2010), there are three types of hypochondriasis:

  1. Obsessive-anxious – Sufferer believes that their doctor is “missing something” and continue to believe that they are ill even when their doctor declares them healthy.
  2. Depressive – Sufferer simply refuses to visit a doctor or ends up crying to a doctor about the hopelessness of their condition.
  3. Somatoform – Sufferers always assume the worst when they are experiencing certain symptoms.

PRACTITIONER AND PATIENT INTERPERSONAL SKILLS

The practitioner-patient relationship, also known as the doctor-patient relationship, is a very important factor in the healthcare industry. When people visit their doctor, they are often given information about different things. If something hinders the patient from properly processing and understanding the information, the treatment experience may not be at its best.

Interpersonal skills are those social skills that are used between people who are attempting to communicate with each other (Inter = between / Personal = people). Practitioners use different types of interpersonal skills when interacting with patients. Two main types of communication are verbal (related to speaking) and non-verbal (not related to speaking).

Non-verbal communications (NVC)

Non-verbal communication is mainly carried out through a person’s body language – no explicit speaking is involved. The recipient of non-verbal communication receives the message through vision (by looking) or touch (by feeling).

Non-verbal communication includes paralanguage (the tone, speed, volume, fluency of speech), facial expressions, gestures, appearance and physical proximity.

Michael Argyle (1975) emphasises the importance of NVC and states that it is four times more effective than verbal communication. He goes on to say that NVC does the following:

  1. Assists speech
  2. Replaces speech
  3. Signals attitudes
  4. Signals emotional states.

McKinstry and Wang (1991)

McKinstry and Wang carried out a study to investigate whether a doctor’s style of dress has any influence on their patients’ respect for their opinion. They showed eight photos (5 of a man in different styles, 3 of a woman in different styles) to 475 patients from five different GPs. Patients were asked: “Which doctor would you feel happiest about seeing for the first time?” and were then questioned about their confidence of the doctors in each picture. Their results showed that the male doctor in a smart suit and the female doctor in a skirt and jumper was preferred. Overall, 11% of patients said the dressing of a doctor was very important, 53% said it was quite important and 36% said it was not important at all. Most people who preferred formally dressed doctors were older in age or from a professional class.

Verbal communications

Verbal communication is related to speech. There are many factors involved in VC, such as the jargon used.

McKinlay (1975)

John McKinlay conducted a study of British obstetricians and gynaecologists on physicians who used medical jargon during interviews with women in a maternity ward. On average, the medical jargon and terms being used by health workers were understood by 39% of the women. This includes words like “protein”, “suture” and “umbilicus”. However, the doctors had actually underestimated the amount of people that would understand the terms, which begs the question: why did the doctors use such jargon if they did not expect the patients to understand it in the first place?

Ley (1988)

Philip Ley (1988) investigated the amount of information remembered by patients after visiting their doctor. After a consultation, the patients were asked to recall what the doctor had told them to do. After checking their answers, it was found that most patients only remember just a little more than 50% of the information given by their practitioner.

PATIENT AND PRACTITIONER DIAGNOSIS AND STYLE

Practitioners have different ways of making diagnoses; their style might be unique in the way that they consult their patient, collect information, evaluate the situation and make their conclusions.

Practitioner style: doctor and patient-centred

There are two main types of practitioner styles, namely doctor-centred and patient-centred. They are also known as “directive” consulting style and “shared” consulting style, respectively. They were discovered by Byrne and Long in 1976.

Byrne and Long (1976)

Byrne and Long analysed 2500 recordings of medical consultations in a variety of countries, including England and Australia. They discovered the two distinctive practitioner styles.

Features of the doctor-centred style:

  • Doctor asked closed questions (patient could only answer ‘yes’ or ‘no’).
  • Doctor ignored patients’ attempts to elaborate on their answers.
  • Doctor placed most focus on the first problem described by the patient.
  • Doctor made links between symptoms and their diagnosis without discussion or alternatives.
  • Everything was based on “fact” rather than two-way communication.
  • Impersonal atmosphere.
  • Patient was overall passive during the consultation.

Features of the patient-centred style:

  • Doctor asked open-ended questions.
  • Patient was given chances to give descriptions and elaborate on answers.
  • Doctor used less medical jargon; patient could understand diagnosis and treatment options.
  • Patient had the chance to participate in decision-making.
  • Personal atmosphere.
  • Patient was very active during the consultation.

Savage and Armstrong (1990)

Savage and Armstrong compared a patient-centred style (sharing consultative process) with the doctor-centred style (traditional doctor-led process). All the patients involved in the study reported that they were highly satisfied with the consultation. However, straight after the consultation and one week later, it was found that they preferred the doctor-led style. It is possible that this is due to people being more familiar with the traditional method; adjusting to a newer consultation style could take time for patients and their doctors.

Practitioner diagnosis: type I and type II error

While these are rare occurrences, there are times where a doctor will get things very wrong. There are two main types of errors (which have previously been discussed in the Rosenhan study during AS).

  1. Type I error – Doctor diagnoses a physically/psychologically ill person as “healthy”.
  2. Type II error – Doctor diagnoses a healthy person as “ill”.

The Type I and II errors are also known as the “false positive” and “false negative”, respectively.

Disclosure of information

To “disclose” something means to reveal. It is necessary for a patient to disclose certain information to their doctor in order to determine the correct diagnosis. However, every patient is different; they have different styles of communicating.

Robinson and West, 1992

Robinson and West conducted a study on patients at a genito-urinary clinic. They discovered that the patients gave more information to a computer than to the doctor they met afterwards. For example, they admitted to having more sexual partners and revealed more symptoms. This suggests that computers can be used to help patients communicate more comfortably and openly.

MISUSING HEALTH SERVICES

Some patients may misuse health services. We will look at three types of misuse: treatment delay, hypochondriasis and Munchausen syndrome.

Delay in seeking treatment

Instead of seeking immediate solutions to their issues, some patients delay treatment for various reasons.

Safer (1979)

After interviewing patients, Martin Safer and his fellow researchers attempted to explain why people delayed treatment by creating a model. They outlined three sequential stages of treatment delay:

  1. Appraisal delay – The time taken for a personal to interpret their physical symptoms as an indication of an illness.
  2. Illness delay – The time taken between discovering the illness and deciding to seek medical assistance.
  3. Utilisation delay – The time taken between deciding to seek medical attention and then actually getting it.

Misuse: hypochondriasis

Sarafino (2006) defines hypochondriasis as a “tendency of individuals to worry excessively about their own health, monitor their bodily sensations closely, make frequent unfounded medical complaints, and believe they are ill despite reassurances by physicians that they are not.” This specific behaviour may also lead to a misuse of health services.

According to Fallon (2010), there are three types of hypochondriasis:

  1. Obsessive-anxious – Sufferer believes that their doctor is “missing something” and continue to believe that they are ill even when their doctor declares them healthy.
  2. Depressive – Sufferer simply refuses to visit a doctor or ends up crying to a doctor about the hopelessness of their condition.
  3. Somatoform – Sufferers always assume the worst when they are experiencing certain symptoms.

Barlow and Durand (1995)

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Munchausen syndrome

This syndrome, also known as a “factitious disorder”, was named after Karl Freidrich Hieronymus Baron von Munchhausen, an 18th century German officer. In the 1700s, he would tell wild and exaggerated tales of travels and adventures. According to Turner and Reid (2002), there are three main features of this syndrome:

  • Simulated illness (artificial symptoms)
  • Pathological lying (pseudologia fantastica)
  • Wandering from place to place (peregrination).

People with MS may purposely create, induce or exaggerate their symptoms. They may lie or fake symptoms, hurt themselves to induce symptoms, or even alter test results to support their claims.

Not to be confused with MS is the Munchausen syndrome by proxy (MSBP). This involves a carer (such as a nurse or mother) deliberately exaggerating or inducing illness in another person, usually a child. Criddle (2010) outlined three levels of MSBP:

  1. Mild – Fabrication of symptoms.
  2. Moderate – Tampering of evidence.
  3. Severe – Inducing symptoms to cause an illness.

Aleem and Ajarim (1995)

Aamer Aleem and Dahish Ajarim carried out a case study on a 22-year-old female university student with Munchausen syndrome. When she was 17, she had a case of amenorrhea (absence of menstrual period in women). Over the years, she had many other medical problems, including thrombosis and painful swellings. After a round of treatment, she developed an abscess on her left breast. Because there was no explanation for this, doctors became suspicious and decided to offer psychiatric help. One day, when the patient was out of her room, a nurse found needles and a syringe full of faecal matter under the patient’s bed. When the patient found out about this discovery, she became angry and left the hospital. She never returned to this hospital again.

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