Using and misusing health services

Summary

Patient-practitioner relationship

The hospital

"I was astounded when four technicians from four different departments took four separate and substantial blood samples on the same day. That the hospital didn’t take the trouble to coordinate the tests, using one blood specimen, seemed to me inexplicable and irresponsible. When the technicians came the second day to fill their containers with blood for processing in separate laboratories, I turned them away and had a sign posted on my door saying that I would give just one specimen every three days and that I expected the different departments to draw from it for their individual needs." (Cousins, 1985, pp. 55-56)

"I had a fast-growing conviction that a hospital was no place for a person who was seriously ill." (Cousins, 1985)

History

• Until 20^th century, hospitals had well-deserved bad reputation for miserable care, ministering exclusively to poor, who often died of infections they didn’t have when they entered.
• Middle and upper classes treated at home
• End of 19^th century, revolution in medicine
• In 1873, 178 hospitals in US, in 1909, over 4300, 7X the population growth
• Hospitals gained reputation for good care, treated all classes
• 1995, about 31 million people treated as inpatients
• Infections still problem, about 5% (2 million) will contract nosocomial (hospital) infections, of which at least 15,000 die
• Data show physicians less likely to follow sterile procedures and Infection Control Nurse less likely to challenge physician (see Patients fight back against the superbugs)
• Since 1980, marked decrease in number of admits/discharges and in length of stay (Fig 10-1, p 305, Sarafino)
• More outpatient procedures (day surgery, single day tests)
• More efficient procedures (microscopic orthopaedic surgery, laparoscopy, better and faster diagnostic tests)
• Patients released at earlier point in recovery
• Many changes due to changes in health care financing -- Managed care, DRGs

Hospital patient role

• Nonperson treatment – depersonalization (Goffman, 1961)

"Recently when I was being given emergency treatment for an eye laceration, the resident surgeon abruptly terminated his conversation with me as soon as I lay down on the operating table. Although I had no sedative or anaesthesia, he acted as if I was no longer conscious, directing all his questions to a friend of mine – What’s his name? What’s his occupation? .. As I lay there, these two men were speaking about me as if I was not there at all. The moment I got off the table and was no longer a cut to be stitched, the surgeon resumed his conversation with me, and existence was conferred on me again." (Zimbardo, 1970, p. 298)

• Hip fracture in 202B
• Comments ignored, not wanted or solicited
• Not spoken to directly, conversations occur as if not present
• Expected to cooperate, to be passive
• Emotional needs often not assessed, noticed or met
• Reasons for depersonalisation
• Hectic, unpredictable days, often with risks (contagion, exposure to dangerous chemicals)
• Protection from emotional pain when patients die or get worse
• Under high, prolonged stress à burnout
• Emotional exhaustion
• Depersonalisation
• Feelings of professional inadequacy
• Maslach & Jackson reported among health practitioners about equal exhaustion, nurses showed less depersonalization, physicians less inadequacy

Lack of information

• Patients often do not possess critical knowledge of diagnosis, tests, procedures, treatments, prognosis
• Lack of knowledge often leads to anxiety and stress
• Part of problem, poor communication, non-reciprocal communication
• Physicians may inform only partially, indirectly or with jargon, often in attempt to protect patient form alarm or misunderstanding (McKinlay, 1975)
• Without direct communication, patients may seek alternate info sources (look at chart, ask other patients)
• Information may be misleading or not fully understood

Loss of control

• Loss of normal control over body (when, how, what to eat, when, how to toilet, dressing, what to wear, what medicines you put into your body)
• Loss of control over activities (recreation, leisure, work)
• Loss of control over future – predict what will happen
• Problems associated with loss of control
• Stressful
• Increased discomfort
• Heightened physiological responses
• Patients may respond with reactance (Brehm, 1966) à bad patients
• Petty acts of mutiny (drinking/smoking in room, off diet foods, not taking medicines)
• Angry, complaining, questioning (which may indeed be good)
• Attempts to re-establish control, however, maybe self-defeating (noncompliance)

Good patients

• Patient, passive, compliant, noncomplaining
• May be disguised learned helplessness secondary to perceived loss of control
• Learned helplessness also may lead to depression à immunosuppression
• Also may be passive-aggressive – way to get even by withholding info, making less effort to help

 WRITING OFF BAD HEALTH
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Writing about positive experiences you've had could benefit your health.
That's the message from Chad Burton (Southern Methodist University, USA)
and Laura King (University of Missouri, USA) who recruited 90 undergrads
(average age 18.58 yrs) to participate in a writing exercise for 20
minutes/day for three days.

Half the students wrote about an intensely positive experience they'd had.
Their instructions were taken from the founder of humanistic psychology,
Abraham Maslow (1908-70), the first line reading: "Think of the most
wonderful experiences in your life, happiest moments, ecstatic moments,
moments of rapture...". The other half of the students wrote about mundane
things: their plans for the day, their shoes or bedroom contents.

For three months before the exercise, there was no difference in the number
of health-centre visits made by the students who went on to write about
mundane things compared with the students who went on to write about their
positive experiences. By contrast, for the three months following the
writing exercise, the mundane-writing students made significantly more
health-centre visits than the positive-writing group. The mundane group's
visits had gone up since before the exercise but the positive-writing group
's hadn't, their health seeming to have been protected during the winter
period.

Attempts to identify factors - mood effects following writing, for
example - that might have mediated the apparently observed health benefit,
all failed. The authors' speculated positive writing benefited health
because it was a way of "obtaining self-understanding, of gaining a more
clearly articulated sense of self, and of discovering and creating one's
life goals".
_______________________________________

Burton, C.M. & King, L.A. (2004). The health benefits of writing about
intensely positive experiences. Journal of Research in Personality, 38,
150-163.

Journal weblink: http://www.sciencedirect.com/science/journal/00926566