Some patients like
to participate in the decision-making but others prefer the doctor to make all
of the decisions.
Patients differ in the degree they wish to participate in their medical care The elderly are more likely to prefer having decisions made for them (Woodward and Wallston, 1987). Could be a cohort effect. If the doctor allows the patient to have an input into the decision making process than 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).
It is important to
get the correct match between doctor and patient
Physicians differ in their willingness to share authority. (Eisenberg et al, 1983). Haug and Lavin (1981) Doctors and patients described their own attitude and behaviour related to the patients health. Three conclusions
Mismatch between the doctor and patient will cause the patient stress. (Auerbach et al 1983, Miller & Mangan 1983).
Doctors need to be aware of how much the patient wants to participate in decision-making.
Preferences for participation in treatment
The approach which doctors often take is the hypothetico-deductive model of decision making. In this process a decision is arrived at fairly early on and then the doctor looks for evidence to support the hypothesis. The process involves a number of stages:
· Accessing information about symptoms.
· Developing a hypothesis
· Search for attributes – confirm or refute hypothesis
Make a management decision.
The probability of having a particular illness. This is affected by available information, which can be misleading. The more frightening the illness, can make people feel that they have contracted it. If the illness has been featured in a television drama or documentary, this causes people to feel that they have a high chance of contracting the illness themselves.
- e.g. knowing the patient to be a smoker, the doctor is more inclined to diagnose a smoking related illness.
There are other
factors that influence the decision-making process
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.
Korsch et al (1968) found that a quarter of mothers attending a paediatric (child) clinic failed to tell the doctor their major concerns. Compare with results from computer doctors. Perhaps it is a good idea for patients to fill in a form on which they write their concerns and a list of symptoms before going to see the doctor.
Weinman (1981) choice of hypotheses affected by:
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. 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.
Many people from other cultures in Britain have to put up with racism, which can trigger stress responses.
There are also
cultural differences in the way different cultures view illness and health.
Because our language refers to illnesses as if they are objects "I caught measles", then physical explanations of illness, and physical treatments are considered.
The Chinese consider medicine to be a balance of two universal forces yin and yang. Illness occurs when organs are out of balance. So the Chinese would not just treat the organ that appears to be diseased.
Horton (1967) points out that in Africa a traditional treatment would be to find out who has caused the illness. This makes sense if you consider that the removal of a source of stress can cause a person to feel better. Perhaps we should treat a patient's noisy neighbours!
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. All western countries, so does not generalise to non-western countries. Ethical considerations – confidentiality. 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. 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.
Ley et al (1973) found that information given in a structured way was better remembered than if given in an unstructured way. 25% more information was remembered. Students remembered 50% more information. The experiment involved list learning, so was not ecologically valid. Ley (1988) in a more ecologically valid experiment asked patients to recall what had been said in a real consultation. 55% was remembered. The following patterns in the errors made by the patients was found:
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.
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
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. 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). Medical schools educate future doctors to understand psychosocial factors in treating patients. Harvard's 'New Pathway' program is an example (Seligman et al, 1991).
Physicians do not like patients who criticise, ignore them or make unnecessary requests. They also do not like patients to make sexual approaches towards them!
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). Many court cases allege that doctors did not
communicate important information to their patients. Could
be that the patient claims this just to strengthen his or her case, when it is
not true.
Patients do not always give signs of their distress (Roter & Ewart, 1992).
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).
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.
The way a person interprets symptoms may affect the way they are reported.
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).
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). 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. The physicians expected even poorer comprehension, even though they used these terms often with their patients. Reasons for doctors using jargon might be: habit, forgot the client would nor understand, may feel the patient doesn't need to know, patient shouldn't know what is to happen, as there would be too much stress, could keep conversations short, less emotional response from the patient, reduce awkward questions, reduce the patient finding out an error had been made, and increases the status of the doctor.
Ley (1989) 21 surveys, 41% of patients dissatisfied with information given by hospital doctors. 28% of patients dissatisfied with information given by general practitioners. 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.
Boyle (1970) 42% of
patients cannot identify position of heart, 20% the stomach, and 49% the liver.
Could be 1970, not today, what with the national
curriculum, raised leaving age, etc.
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: -
Researchers: Bourhis,
Roth and MacQueen (1989)
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:
a the use of language between health
professionals and their patients
b
the motivation either to change or to maintain the type of language used
c the norms of communication in a
hospital, and
d the
status and power differences that categorize patients, doctors and nurses.
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. 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. 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.
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. 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. 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.
Conclusions: One of
the overall conclusions drawn from the results of the study was that doctors
used ML as a way of maintaining their status in relation to their patient
group. Their use of ML was also interpreted as a way of maintaining the power
and prestige accorded to doctors within society as a whole. Therefore there is
a strong motivation for them to maintain (or even increase) their use of ML.
The fact that nurses were prepared to ‘converge’ with the doctors and patients
is taken as an indication that they are less status conscious than doctors, as
they are trained to know ML, just as doctors are. Bourhis et al suggest
that the results show that experienced doctors and nurses, as well as students,
might benefit from courses focused on effective communication between hospital
staff and patients. They also note that a better understanding of the
motivation behind the use of language may help to avoid communication breakdown
between health workers and their patients.
So why is it that
many doctors do not improve their interpersonal skills?
Doctor's interviewing skills can be improved with training. They can be taught how and when to summarise information, ask questions and to check for comprehension. (Roter & Hall, 1989). Taylor (1986) suggests that many doctors have not been trained in communication skills, because of three reasons:
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.
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 (Thompson et al, 1990)
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?
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. 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.
Ritzer (1993) - patients are now seen as customers or consumers. Limited range of services, quick treatment - walk-in doctors. Hospitals getting more commercial.