[From Health Psychology, Marks et al, Communication: Messages and Meanings, p272]
3 approaches to study of doctor patient communication: ‘Deviant patient’, ‘authoritarian doctor’ or ‘interactive dyad’.
Health communication is a means through which health promotion is achieved. Health psychologists involvement with health promotion has been primarily concerned with health communication, so from health psychologist point of view they are largely the same thing. Public health communication e.g. media campaigns, and activities of health care professionals, e.g. doctor-patient communication.
Communication as route to information about the patient’s physical and/or mental state, and route to provide patient with ‘crucial information about necessary adjustments in lifestyle as well as treatment directives’. Also, has been suggested that effective communication can have a therapeutic effect in itself.
Doctor-patient communication is not always effective – according to Ley (1982) communication is the least satisfactory aspect of the doctor-patient encounter, ~1/3 of patients in UK say they are dissatisfied. Furthermore, patients’ understanding and memory of what they have been told by the doctor is limited. In addition, and possibly as a consequence, 1/3 to 1/2 of outpatients do not comply with doctors’ advice. And a substantial portion of patients problems remain undisclosed and undetected.
Ideas of patient-centred and doctor-centred communication
“Byrne and Long observed that doctors adopted a habitual style that they tended to use with most patients. Some doctors were more controlling than others. Suggested that patient-centred styles increase adherence to treatment, as well as satisfaction. -> training medical students in communication (from mid 80s). But limited success from this approach. Kreps advocated a consumer orientation to health care and heath promotion in order to address the imbalance of power between providers and consumers. Meeuwesen argues that until this imbalance is corrected, training in communication skills is unlikely to succeed.
Interactive dyad perspective, looking at the ‘communicative event’ to which both doctor & patient contribute.
There are a wide range of factors that influence doctor patient interaction – gender, culture, patient groups, age, stage of illness, disability. AIDs patients are often very informed, sometimes more than their doctors, as are disabled patients. Patient adherence to treatment, understanding, and satisfaction, as proxy outcome measures – true measure might be long term health status and quality of life.
Methods used to study doctor-patient communication:
- Interaction analysis systems – allow researcher to identity, categorise and quantify features of the doctor-patient encounter, e.g. analysing audio or video recordings – predominantly used to study doctor’s communication styles.
- Questionnaire studies – measure patients perceptions of doctor’s communication styles, and patient satisfaction.
- Qualitative textual analysis – e.g. discourse or conversation analysis – linguistic analysis of transcripts of doctor-patient interactions.
- Triangulation – combining methods of analysis – allow researcher to explore same topic from different perspectives.
Compliance – ‘the extent to which the patient’s behaviour … coincides with medical or health advice’ – notion of a dependent layperson and a dominant professional – fails to understand the complexity and legitimacy of patient behaviours that differ from clinical prescriptions. In a study of 54 rheumatology patients Donovan and Blake found that non-compliance was largely the result of reasoned decision-making – patients experimented with drug dosages and timing in order to manage side effects and effectiveness of drugs, and made decisions based on info from GPs, media, family and friends, as well as the consultant – ought to be concerned with provision of information that would allow patients to make informed decisions, rather than compliance per se – ‘concordance’.
Computer guided consultations
Through prompts and fixed sequencing of questions, the computer directs the flow of the interview, interviews can be longer and more detailed, but with less space for ‘small talk’ that may reveal psychosocial concerns on the part of the patient, and impacts on non-verbal communication, with doctors attention split between computer notes and patient, and more focus on computer than had been previously on prescribing pad and pen.
Role of communication in coping with illness
Ways in which communication mediates the illness experience itself, e.g. coping with illness and prognosis, informed consent, patient choice, decisions about testing
Treatment adherence and Patient empowerment [p291]
“Non-compliance is an unavoidable by-product of collisions between the clinical world and other competing worlds of work, play, friendship, and family life. (Trostle 1998, p1305)”
“The assumptions underlying the term compliance implies an authoritarian stance on the part of the physician or other health professional that are challenged by recent changes within health care systems”. In general, most people do not adhere to specific medical or health-care directives – at least not fully – estimates 50-75% or patients do not adhere to medical advice. 14-21% do not fill their prescriptions, 60% cannot identify their own medications, 30-50% of all patients ignore or compromise medication instructions, 12-20% of patients take other people’s medication. ~125,000 people with treatable ailments die each year in the USA die due to inappropriate medication usage. Asthma as particular problem with non-compliance.
Patient characteristics of non-adherent patient -less social support, more socially isolated, unstable families, certain cognitive deficits or emotional upsets may reduce adherence, type and severity of psychiatric disorder, environment, resources, expectations and attitude toward treatment, competing sociocultural and ethnic folk concepts of disease and treatment. no consistent relationship by age, sex, marital status, education, number of people in the household, social class and adherence. Strong association between patients health beliefs and adherence – Health Belief Model – perceived disease severity, susceptibility to the disease, benefits of the treatment recommended and barriers to following the treatment. But varying degrees of support for this model, different studies find different factors have greater or lesser influence on adherence. Social Learning Theory showed that patients with internal locus of control have better adherence.
Severity of disease and visibility of symptoms, and prognosis linked to adherence – non-linear relationship – patients with asymptomatic chronic diseases frequently do not comply with treatment – when symptoms frequent and unwanted, patients more likely to comply with treatment that offers the promise of removing them.
Treatment factors: lengthy or inconvenient waiting times, inconvenient clinic locations or organisation, complicated treatment, treatment methods that individual patients don’t like (e.g. calcium powders!), information overload causing patients to get confused, forget, or simply ignore much of the information. (Ley found that patients forget at least 1/3 of the information given by their physician) all decrease treatment adherence. Adherence declines with an increasing number of medications or doses and with the length of recommended treatment. It is estimated that adherence with long-term therapy declines to ~50% irrespective of illness or setting. Lack of feedback for the patient in terms of improvement in symptoms – e.g. when patients with hypertension are able to identify symptoms of their disease that are controlled by medication they are more likely to comply with it. Social side effects of a treatment in terms of stigma are shown to be just as important to adherence as physical side effects, and the extent to which the treatment disrupts the patient’s everyday life is also a factor.
Patient-physician relationships, classified as ‘patient-centred’ or ‘affiliative’ (interest, friendliness, empathy) or ‘authoritarian’ (physician controlled), affect adherence. Studies have shown that patients are more satisfied with those physicians who had high job satisfaction and who felt more secure in their work, e.g. when faced with conditions responsive to standard medical interventions. The more understanding the physician has of the patients system of illness-beliefs, and cultural norms and practices, the more compliant the patient is. Physicians view of the patient has an important effect, and there is a well-established social class effect that upper– and middle-class patients receive more information and attention from physicians and physicians frequently report more frustration with and less interest in lower- and working-class patients.
Meichenbaum and Turk (1987) identified 10 setting characteristics potentially associated with non-adherence: adherence is greater when the referral to a specialist is seen as part of the assessment rather than as a last resort, when care involves follow-up and is personalised, when appointments are individualised and waiting times are reduced, when treatment is available on site, when treatment is carefully supervised with home visits, special nursing care, etc, when there are good links between inpatient and outpatient services and when staff have a very positive attitude towards the treatment. In particular with long-term therapy there is evidence that regular follow-up by the physician increases adherence. Family members reminding and assisting the patient increases adherence, and it has been suggested that the patient’s partner’s views of the medication is the most important factor explaining adherence. Adherence is higher in cohesive families and lower in families in conflict.
In western society medicine has been based upon power and authority. Since it is founded on the assumption that it has the monopoly on truth, it follows that patient non-adherence is a result of ignorance and/or deviance. Trostle (1998) argues that the increasing research interest in medical compliance is a reflection of ‘a concern for market control combined with a concern for therapeutic power’. However this very concern with maintaining power may carry with it an equal and opposite reaction evidenced by a reluctance of patients to comply – reactance theory – patients feel they have a right to control their own behaviour and when they feel this right is threatened they resist. The more extensive and complex the treatment prescribed, the greater the threat to perceived freedom. This threat might be accepted if it was seen as worthwhile, but may still sensitise the patient to additional threats to their freedom such that patients become resistant to additional demands. Non-compliance can thus be interpreted as a means of resisting medical dominance.
Late 20th century saw public opposition to idea of powerful doctor and demands for greater control over health care (partly as a result of publicity about medical negligence and sexual harassment). Younger patients often more resisting and consumerist towards patient-doctor encounter, while older patients often more accepting of authority and may prefer a passive patient role. The more consumerist stance of certain patients is not always welcomed by physicians, who are sometimes reluctant give patients the information they request about their condition. Bertakis et al (1991) estimated that as many as 85% of patients who came to see their family doctor have some degree of psychosocial distress, but this is often ignored by the doctor – power of the doctor to define what is sickness, and lack of medical language and medical treatment for these social issues
Royal Pharmaceutical Society of Great Britain (1997) report described compliance as appropriate for welfare state and 1930s society rooted in benign paternalism, but suggests ‘concordance’ as an alternative model for doctor patient relationship based on mutual respect. “The price of compliance was dependency – it belongs to an older world. The price of concordance will be greater responsibility” both for the doctor and the patient.
To reduce non-adherence requires a reassessment of the contemporary medical-dominated health-care system, and an understanding of what it means to the patient to be ill.
Self-regulation – individuals with chronic illness actively monitor and adjust their medication on an ongoing basis. Non-adherence as a rational process and patient as rational problem solver. Testing the impact of varying dosages, controlling dependence and asserting to themselves and others that they are not dependent on prescribed medication, de-stigmatising and rejecting the illness label, a feeling that reducing the medication meant they were ‘getting better’, concern to control the harm a medicine might cause, modifying treatment regimes to fit symptoms, side effects and lifestyle. Many people have a range of fears abot medication.
Asthma – Horne and Weinman (1999) Those patients with strong medication necessity beliefs also perceived asthma as having a lengthy timeline and that its consequences were serious. Adams et al – deniers/distancers deny they have asthma, say they just have a bad chest, and so take relievers which help their bad chest, but not prophylaxic medicines which are a symbol of being asthmatic. Acceptors reluctantly accept they have asthma and take their medications, while still holding negative associations of people with asthma.
Medical error, iatrogenic illness, US Institute of Medicine report (2000) estimated that 44,000 – 98,000 Americans die each year as a result of medical error. That is more than die each year from motor-vehicle accidents, breast cancer or AIDS. UK Health Foundation report estimates 40,000 iatrogenic deaths each year in UK. 10-20% of these thought to be due to medication errors. In hospitals it is junior doctors who do most of the prescribing. They are the ones with the least knowledge, and who make most mistakes. One common problem raised by all of the recent reports has been medical silence: the reluctance of medical professionals, especially physicians, to report errors.
Empowerment – process whereby people gain mastery over their lives. Patients lay health beliefs and knowledge considered of equal or greater value than physicians health knowledge. Opportunityfor patients to tell their story. Medicine has the power not only to rewrite the patient’s story of illness but also to replot its course. If the story that is handed back is widely different to the patient’s own story, or irrelevant to their life, and the physician fails to recognise the distance between them, the interaction founders, leading to non-adherence.
Empowerment connects with the identification of the patient as responsible in some way for both their illness and their treatment, especially for illnesses associated with lifestyle practices such as smoking, diet and exercise. Transformation of patient from passive sufferer to active manager of their own suffering – from which it is a small step to locating with the patient the moral responsibility to become well. This provides the physician with the opportunity to evade responsibility for treatment of those problems for which they have limited insight, e.g. chronic illness and mental illness. E.g. doctors promoting the “fighting spirit” among cancer patients – can be disempowering when patient feels they cannot control the disease. Also Patient Controlled Anaesthesia – can be perceived as encouraging patients not to bother the staff.
Lord and McKillop Farlow note: “people mistakenly talk about “empowering families” or “empowering professionals” as if empowerment is something one person does to another – empowerment as paternalism. Within a capitalist state this promotion of empowerment has a hidden agenda, allowing questions of oppression to be reframed as free individual choices among predetermined alternatives, allowing health care workers to blame the patient when strategy fails, and making health education a technology, a way to get people to think they are taking charge of their own health and exercising their rights instead of being dependent.
“The move towards empowerment is especially directed at those people who do not conform to mainstream values and practices rather than attempting to promote broader changes in social structures. The physician and other health care professionals can now continue to disparage the most deprived and marginalised not for their non-compliance but rather for their refusal to accept responsibility for self-management.”
PBL Notes 