Interpersonal
Skills
Summary
Although
student doctors found chemistry and biology relatively easy dealing with their
patients is not so easy.
Battenburg and Gerritsma (1983) – student doctors – found it hard to:
1.
hard to initiate conversation
2.
decide on diagnosis
3.
cope with patient’s emotions
Perhaps
patients also find it difficult to talk to doctors and therefore avoid going to
see them.
Patients make 11 Lay consultations for every one consultation with a doctor (Scambler and Scambler 1984).
When patients eventually go to the doctor is usually because of one or more of three reasons
Pitts (1991) suggests there are three reasons for going to the doctor:
- Persistence of symptoms
- Critical incident - e.g. pain gets worse
- Expectation of treatment –
- Approximately six contacts per person with a US physician per year (telephone and in person)
- Common conditions seen
- Acute – flu, cold, fracture/dislocation, sprain/strain, wounds, ear infection
- Chronic – hypertension, orthopedic, arthritis, diabetes, asthma, heart disease
Who uses health services – Fig 9-1, p 277, Sarafino
- Age – under five use more, and increases linearly from middle-age on up
- Gender –
- women have higher rate of contact
- difference starts in adolescence
- some of early differences due to obstetric/gynecological contacts (pregnancy)
- however, women still have higher rate of contact
- although men have higher rates of chronic fatal illness, women have more acute illness (respiratory) and non-fatal chronic (arthritis, migraine)
- Women less hesitant to admit symptoms and seek medical care
- Men have social role to deny illness/pain, also allowed to take more risks (with health)
- Women may be more sensitive to internal sensations (Pennebaker, 1982)
- Sociocultural factors affecting use
- More income, although experience fewer symptoms, more likely to see physician when sick
- African American/low SES
- more likely to use outpatient clinics and ER
- more likely to be hospitalized, indicating more serious illness, delay in getting treatment
- Rich-poor gap has lessened with Medicaid/Medicare (25% rise in physician visits corresponding to these programs from 1968-1972)
- Low income –
- tend to see themselves as less susceptible
- less likely to have regular sources of health care
- travel longer and wait longer once at facilities
- may feel less welcome or trustful of health practitioners
- language may serve as barrier (non-English speaking immigrants)
Why people use, don’t use, and delay using health services
- People advise others, but won’t go themselves, for same symptoms (Feldman, 1966)
- Which body part affected
- Less likely-- some body parts seen as private or stigmatized (anus, genitalia)
- More likely -- some body parts seen as more important
- Fear of diagnosis
- Disease detection more distressing than treatment (implications of being ill)
- Barrier to screening
- Barrier to other treatment (BP taken every time)
- Stress
- Under stress more likely to seek care
- even when symptoms equal
- when symptoms ambiguous
- Less likely to be believed as credible when complain (Skelton, 1991)
- Iatrogenic conditions – fear health problems as the result of medical treatments
- Radiation burns
- Medication side effects (nausea, dizziness)
- Pseudomembraneous colitis
- Allergic reactions (rash, shock)
- Surgery/anethesia mortality
- Recent study calculated medical treatment related deaths would be the 4th leading cause of death among adults
- Distrust of practitioners
- Confidentiality (1/4 of survey adolescent subjects would forego Tx to avoid parent’s knowing)
- Minority group distrust
- Discrimination against African Americans (many cases true – differences in diagnosis and treatment that disadvantage the patient)
- Tuskegee Syphilis "Study"
- Distrust of allopathic medicine
- Over half of the public doubts physicians either competent or caring enough (Haug, 1988)
- Under 35 more likely to challenge MD vs over 65
- Alternative medicine (at least 1/3rd use alternative practitioners, Cowley et al., 1995)
- Folk medicine
- In study in Puerto Rico of how people got to MH treatment, most went first to relatives, then "wise" elders, then priest or traditional practitioner BEFORE going to physician
- Lack of faith in efficacy of current treatments
- Those with cancer symptoms who do not believe cancer can be helped more likely to delay getting treatment
- Social and emotional factors
- Expectations of pain –
- 5% of Americans completely avoid dentist to avoid pain
- 18% of Americans would avoid treatment for cancer because of pain associated with cancer and its treatment (Levin et al., 1985)
- Social triggers to seek treatment (Zola, 1973)
- Perceived interference of symptoms with relationships/ activities
- Interpersonal crisis – treatment to resolve/escape crisis – aversive nagging
- Sanctioning – social pressure
Stages in delaying medical treatment
- Treatment delay – time between noticing symptoms and Tx
- Three stages of delay (Safer et al., 1979)
- Appraisal delay – time to interpret symptom as problem/illness
- Factors: Severity of symptom, pain, or bleeding
- Illness delay – time between recognizing illness and deciding to seek Tx
- Factors: new vs. familiar symptoms
- Utilization delay – time from deciding until going for treatment
- Factors: benefits (curable) vs. barriers (costs)
- Lack of pain major delaying factor
- Pain NOT symptom for many serious problems in initial stages
- Warning signs of cancer, EH
- 35-50% of those with warnings signs for cancer delay 3+ months
Sick role – after diagnosis (Kasl & Cobb, 1966)
- Illness behavior – after symptoms, before diagnosis
- Sick role – activities to get well by those who believe they are sick
- Parson’s (1978) assumptions of sick role
- Lack of blame
- Mixed – theoretically sickness is not person’s fault, but tend to blame the victim
- For some chronic disease may be partially accurate (smoking related illness)
- We tend to blame ourselves –
- 20% of reasons for illness of college students blamed themselves
- 50% of accident victims blamed themselves
- even health workers tend to blame the sick for being ill
- new age à you can cure yourself, you also are responsible for your illness
- If at fault, implies avoidable à sense of control
- Function of lack of blame à relieved from normal duties to get well
- Relief from normal responsibilities (work, school, housework, etc.)
- Along with relief may come unrealistic responsibilities of new role (Lazarus) à to be cheerful, not miserable or overly distressed
- Inability to process distress (emotion focused coping) adds to negative impact of illness stress
- Desire to get well
- Largely true, but implies curable, usually acute illness
Patient Satisfaction
Weinman (1977) – The doctor must understand the patient’s own expectations.
It’s not good enough
for the doctor to be highly efficient if they lack the personal touch. Patients expect cognitive and emotional
satisfaction.
Kent and Dalgleish (1996) two types of patient satisfaction that should be considered:
- Cognitive satisfaction – how happy the patient is with the treatment etc.
- Emotional satisfaction – how happy the patient is with the doctors level of interest and concern.
People often judge the adequacy of their care by criteria that are irrelevant to the technical quality of the care. What people do know is whether or not they liked the practitioner: whether he or she was warm and friendly or cool and uncommunicative. When people are asked what is important to them in their medical care, they rate the manner in which their care is delivered at least as high as or higher than technical quality of care (Feletti, Firman, & SansonFisher, 1986; Scarpaci, 1988; Ware et al., 1978).
Even more significant, since people
are poor judges of technical quality of care, they often judge technical
quality on the basis of the manner in which care is delivered (BenSira, 1976,
1980). For example, if a physician expresses uncertainty about the nature of
the patient's condition, patient satisfaction declines (Johnson, Levenkron,
Suchman, & Manchester, 1988). A warm, confident, friendly practitioner is
often judged to be both nice and competent, whereas a cool, aloof practitioner
may be judged less favorably, as both unfriendly and incompetent (see Buller
& Buller, 1987; DiMatteo, Linn, Chang, & Cope, 1985.
Although recent work has encouraged doctors to express their uncertainty to patients as a means to improve communication the potential impact of this on patients remains unclear. Ogden et al (2002) explored the impact of the way in which uncertainty was expressed (behaviourally versus verbally) on doctor's and patient's beliefs about patient confidence. Second the study examined the role of the patient's personal characteristics and knowledge of their doctor as a means to address the broader context. Matched questionnaires were completed by GPs (n=66, response rate=92%) and patients (n=550, response rate=88%) from practices in the south-east of England. The results showed that the majority of GPs and patients viewed verbal expressions of uncertainty such as `Let's see what happens' as the most potentially damaging to patient confidence and both GPs and patients believed that asking a nurse for advice would have a detrimental effect. In contrast, behaviours such as using a book or computer were seen as benign or even beneficial activities. When compared directly, GPs and patients agreed about behavioural expressions of uncertainty, but the patients rated the verbal expressions as more detrimental to their confidence than anticipated by the doctors. In terms of the context, patients who indicated that both verbal and behavioural expressions of uncertainty would have the most detrimental impact upon their confidence were younger, lower class and had known their GP for less time.
Barnett (2002) has found that a quarter of surgeons are brusque, unsympathetic or impatient when they break bad news to patients. Family doctors are better at breaking bad news, but most patients are told by surgeons (86%). 106 cancer patients were interviewed. 94 of these had been told by doctors and the rest by family members. The patients were asked to rate the way the news was delivered in four categories: positive, neutral, negative and very negative. In 26 per cent of the cases, memories of the moment were negative or very negative. There were also complaints about the lack of clear, simple information. (The Times 01-07-02)
Cartwright and Windsor (HMSO 1992) found that
8% of patients who were referred to hospital by their general practitioner
would have liked the doctor to explain more about why he or she wanted them to
go to hospital. At the clinic rather more, 19%, wanted more information. The
things they wanted to know about included
the diagnosis:-
· · just what they, felt it was and what they'd ruled out.'
the cause:-
· · 'I'd like to know why it started in the first place and why it's
growing deformed' (A woman whose foot had become distorted and painful.)
the condition:-
· · 'I'd like to see a diagram of what is wrong with my ears and the
blockage in my nose, and what causes the discharge and makes me spit. They say
it's a middle ear problem.'
the investigations:-
· · 'They don't explain why they are looking at you, just do a check each
time. Don't tell you what they are looking for.'
the treatment:-
· · 'About the operation - what exactly they did.'
'They changed my
pills without saying why.'
the side or after effects:-
· · 'No one explained the after effects of an exploratory with anaesthetic
and air pumped inside. I had only asked for a day off work but I had to have a
week off.'
the prognosis:-
· · 'What is going to happen eventually - what stages, if there are stages,
whether you go into hospital and deteriorate (I don't want that.) It's not
knowing.'
(woman with
emphysema)
Doctors are sometimes accused of not listening
Beckman and Frankel (1984) studied 74 visits to the doctor. In only 23% of the cases did the patient have the opportunity to finish his or her explanation of concerns.
In 69% of the visits, the doctor interrupted, directing the patient towards a particular disorder.
Moreover, on average doctors interrupted after their patients had spoken for only 18 seconds.
Doctors therefore need
training in active listening
Active listening – eye contact, open-ended questions, responding positively to patients whilst listening to their description of their problems. Taught through role-play and observation with patients.
An important interpersonal skill, for which doctors can be trained is Non-Verbal Communication
Birdwhistell (1970) estimated that only 30 to 35% of the social meaning of a conversation is carried by words alone.
Non-verbal communication includes features of speech such as:
- tone of voice,
- inflection,
- rates of speaking,
- duration and pauses.
Other forms of non-verbal communication are conveyed by gestures, dress, physical proximity, facial expressions, posture and orientation.
Argyle (1975) four major uses:
- To assist speech, for example in synchronising conversation or supplementing speech by putting stress on certain words, or pausing between words or varying the tone and speed of speech
- As a replacement for speech
- To signal attitudes, e.g. trying to look cool
- To signal emotional states, i.e. we can tell how a person is really feeling by looking at their facial expression or posture.
· It is difficult to convey emotion; try this exercise.
This exercise may be done in a group or in pairs.
As a group.
Count the number of people in the group. On the same number of cards, or pieces of paper, write an emotion, e.g. Fear, Disbelief, Sadness, Dominance, Boredom, Disgust, Interest, Shame, Anger, Surprise, Love, Embarrassment, Admiration, Happiness etc. Distribute the cards to the members of the group face down. Give the following instructions:
· On the card in front of you is written an emotion. You have to stand up in front of the group and communicate this emotion nonverbally, that is you must not use any words. You can communicate vocally by altering such things as the pitch, tone and volume of your voice by counting from 1 to 5 whilst using any other nonverbal channel. Other members of the group write down the emotion they think is being demonstrated as each member takes his turn.
In pairs.
Take turns to demonstrate the emotions to each other, writing down what you think they are.
[Source health psychology by Neil Niven; published by Churchill Livingstone, 1989, and excellent easy to read text suitable for students]
Doctors could get
their patients to smile and thus increase their positive feelings towards the
illness.
Smiling a lot can make people happy.
Zuckerman et al (1981) divided males and females into three groups.
- The first group saw a film of a pleasant scene.
- The second group were shown a film of a neutral scene.
- The third group were shown a nasty film.
Within each group
- a third were asked to suppress their facial expressions,
- a third were asked to exaggerate their facial expressions
- and the other third were not asked to do anything apart from watching the film.
The people who exaggerated their facial expressions showed higher levels of arousal and reported stronger positive or negative emotional reactions, compared with the other two groups. So making patients smile will make them feel happier about themselves. Learning to suppress facial expressions at times of stress could reduce stress.
The way the doctor dresses matters.
McKinstry and Wang (1991) Pictures of same doctor dressed formally or informally. Pictures of formally dressed doctors rated higher for the amount of confidence the patients had in them, and on how happy they would be to see them. Older and professional-class patients particularly preferred the formally dressed doctors.
Stewart (1980) found that the law courts were influenced by the attractiveness of the defendant; and unattractive defendants were much more likely to receive a prison sentence than attractive ones.
Esses and Webster (1988) presented subjects with photographs of adults who had been identified as sex offenders. The least attractive offenders were rated as more dangerous and more likely to commit a further crime than were attractive and average looking offenders. Perhaps we pay too much attention to appearance at the expense of more reliable indications of character.
Patients are touchy
about touch. You have to know somebody
pretty well before you can put your paws on them.
It would be well to remember that touching other
people is subject to many "unwritten" rules (and written ones for
that matter). Who touches whom?, where? For how long and under what
circumstances ? are all questions that need to be considered.
Jourard (1966) considered where it is acceptable to be touched and by whom. Doctors need to be careful not to alarm the patient by touching them in a 'no go' area without their permission.
Jourard (1966) also found cultural differences in the amount of touching.
Observing people in cafes around the world he counted the number of times
people touched each other during the course of one hour. His results were:
|
Place |
Number of times touched |
|
San Juan (Puerto Rico) |
180 |
|
Paris |
110 |
|
London |
0 |
Davitz & Davitz (1985) report that American patients' perceptions of British nurses might be influenced by different cultural norms:
· The expression of a range of emotions on the part of American patients, in many situations, often made the British nurses uncomfortable and even more reserved. It is interesting to note that a number of patients whom we interviewed judged this discomfort as dislike, insensitive, and hard-boiled. 'They're efficient,' noted one patient, 'but they're not sympathetic.'
A reluctance to respond to patients' emotions and to engage in bodily contact might contribute to this view of British nurses.
A second piece of research highlights the status differences involved in touching. Whitcher & Fisher (1979) arranged for nurses to either touch or not touch patients while providing them with information about impending operations. The nurses in the'touch condition'touched the patients on the hand whilst showing them a booklet describing the operation, whereas those in the 'no touch' condition did not touch the patients at all. All the nurses were female. The patients were asked for their views about the hospital and the prospective operation.
After the operation, the patients'
blood pressure was measured. Female patients touched by nurses reported lower anxiety,
more positive feelings to the hospital and had lower blood pressure after the
operation than those not touched. On the other hand, male patients who were
touched reported greater anxiety, more negative feelings and higher blood
pressure after the operation than those who were not touched. Whitcher &
Fisher (1979) suggest that one explanation for these results stems from status
differences. Higher status individuals are at liberty to touch lower status
individuals, but not vice versa. Thus females perceived the touching as a sign
of caring and warmth; males perceived it as a threatening gesture, which
communicated the nurses' superior status in the hospital setting.
questioning
1.
the most important part of questioning is listening
2.
determine the reasons for asking the questions
3.
do not asked too many questions
questions fall into the following categories
- closed questions
- open questions
- affective questions
- probing questions
- leading questions
closed questions are questions which require very short answers and are useful for anxious or nervous people so that tension can be reduced. Asking too many closed questions means that the doctor has to ask lots of questions to get information and they spend less time listening to the patient. As an exercise try asking a friend a series of closed questions for as long as possible and observe
- How difficult it is
- How stilted it sounds
open questions give the respondents the opportunity to respond in anyway they wish. There is no correct answer. A disadvantage is curtailing rambling irrelevances, though the use of well timed closed questions can bring a wandering conversation back to the issue at hand.
Questions are asked in sequences, so that people do not become disorientated; there are three main types of sequences:
- Funnelling. Beginning and interview with an open question and gradually becoming more specific.
- Inverse funnelling. Going from specific details to general topics.
- The Tunnel. Asking a series of closed questions.
Jesudason (1976) compared open and closed questions in finding out what foods were taboo during lactation (mothers producing milk for their babies) for Indian women. The sample consisted of 1151 women who were asked either to name the foods that were taboo (open) or were read out a list of 12 foods and asked whether they ate each food during lactation (closed). About 53% did not report any food taboos when given the question in open form. When these women were read the list of 12 foods, 32% considered five or more items taboo.
affective questions. These are questions about the patients feelings and emotions and help to communicate concern and empathy.
probing questions. These questions are used to get a patient talking when they are not forthcoming. They are also used for tariff occasion. Hackney and Cormier (1979) suggests the use of the "accent" and "minimal" prompt. The accent is a short re-statement that echoes and focuses a previous statement. The minimal prompts use a large number of non-verbal responses such as "uh-huh", "mmm", "ah", and "yes, I see." Non-verbal behaviours such as leaning forward would also act as prompts. A problem with using too many probing questions is that the interview can become an interrogation.
there are three main types of leading question:
- conversational lead. This type of leading question is used to anticipate agreement with the patient and thus convey the impression of friendliness and attentiveness. An example would be "isn't she a marvellous cook?".
- pressurised agreements. This type of question puts pressure on people to agree with the questioner. For example "you do, of course, brush your teeth every day?". These types of questions should be avoided by doctors because it leads to invalid responses.
- hidden subtleties.this type of question leads the respondent without their knowledge. Loftus (1975) interviewed 40 people about headaches and headache products, ostensibly for market research. They were asked either "do you get headaches frequently, and if so, how often?" Or "do you get headaches occasionally, and if so, how often?" The average number of headaches in the "frequently" group was 2.2; whereas in the "occasionally" group it was 0.7 headaches a week.
The subjects were also asked how many products they had tried for the headaches. One group was given a choice of one, two, or three; another the choice of one, five, or ten. The first groups average was 3.3, the second's 5.2. Similar effects can be used by substituting "short" with "tall" or "the" with "a".
Loftus and Zanni (1975) found that the question "did you see the broken headlights?" Produced fewer uncertain responses than "did you see a broken headlights?"
Savage and Armstrong (1990) found that patients were more satisfied with a ‘directed consultation’ rather than a ‘sharing consultation’.
Directed consultation – statements made such as “You are suffering from…”, “It is essential that you take this medication”, “You should be better in …. Days”, “Come and see me in …. Days”.
Sharing consultation – “What do you think that is wrong?”, “Would you like a prescription?”, “Are there any other problems?”, “When would you like to come and see me again?”
359 randomly selected patients – free to choose their doctor. 200 results used.
2 questionnaires – one immediately and one a week later.
Results – overall a high level of satisfaction, but higher for directed group. Higher for ‘satisfaction with explanation of doctor’ and with ‘own understanding of the problem’. More likely to report that they had been ‘greatly helped’.
Comment – the results might reflect the individual choices of the patients studied; perhaps a sample from a different area would show a preference for a ‘sharing consultation’.
Use of Video in training (Maguire and Rutter 1976).
Experimental group – video feedback of student interviewing a patient and notes on interviewing by Maguire.
Control group – with neither of the above
One week later the students interviewed a second patient.
Results – experimental groups extracted three times the amount of relevant information from the patient.
Keeping quiet about an awkward problem could be the
last mistake you ever make, says Ann Robinson