Communication in Medical Settings
& Adherence to Regimes

Overview
Perceiving and interpreting symptoms

Seeking medical care
            Delaying medical care

Physician-Patient Interaction
           Basic Models of Physician Patient Care
           Physician-Patient Communication

 Intercultural Communication

Adhering to Medical Advise
           Assessing Adherence
           Frequency and Cost of Non-Adherence
           What factors Predict Adherence?
           Improving patient Adherence

Health Outcomes

Communication in Medical Settings

Issues of communication abound in Health Care and in Psychology

 They begin with being able to understand and articulate one's condition and end in receiving or maintaining optimal health. All too often challenges of communication limit the Health Care one can receive, leading to ill health and disease as well as tragedy and even death. 

Perceiving and interpreting symptoms

 Prior to reporting symptoms one must first notice or perceive them as such. While one may see or feel something for it to be understood as a symptom of a disease or condition it must be perceived as a symptom worth taking note of.

 Individual differences exist in terms of attention paid to one’s own body or condition, self-monitoring is a psychological trait that involves paying a good deal of attention to one’s own states or statuses.

 Accuracy is also important that once noticed one recognizes a real symptom as being present and not have a false alarm or miss.  Those who believe they are likely to contract a disease are more likely to notice symptoms, whether real or imagined (i.e., Woody Allan).

 Stress also may play a role here where symptoms are exacerbated or initiated.   Changes in physiological states due to stress may be mis-perceived as symptoms of some other disease or illness. 

 One’s state of mind or mood also plays a role where those who are in good spirits tend to perceive their health as better than those who are in negative moods. 

External stimulation or engagement in activities (mental and physical) tend to distract people from symptoms, unless reminded by those sources.  

 Cognitive abilities and attentional capacities may also play a role.

 Age also has been shown to play a role in noticing symptoms where older persons tend to be less vigilant of symptoms than younger people in noticing cancer symptoms.  

  After having noticed a symptom the interpretation may be hindered or enhanced by the following factors: prior experience, commonality among family, friends, and community. 

 If considered commonplace may be disregarded while some cultural expectations in terms of health and coping (stoicism) will differ (e.g., reporting vision problems Canada vs. US).

 Seeking medical care

Once noticed and interpreted as something to pay attention to, people may or may not actually seek medical advice or care.

Poole et al report that we make use of a lay referral system, influences of others around us who tells us that we look healthy or ill, need to see a doctor or not to worry.

They also report that while 75 to 90 % of people might perceived relevant symptoms, only about 30% actually seek assistance. This rate may be different for various body parts or ailments.

Lyons & Chamberlain (2006) discuss the Health Belief Model regarding seeking medical help.

             Delaying medical care

 Ambiguity over the nature of symptoms is likely to delay seeking treatment, especially for cardiac arrest which may be interpreted as gas, indigestion, ulcer, flu, or muscle (arm) pain.  Generally symptoms emerge two to fours hours prior to myocardial infarction, this leaves a good deal of time to interpret and react.

 Embarrassment may also play a role  in delaying help seeking, once symptoms have been noticed, where one may not want to talk about the symptoms (i.e., Guy LaFleur & Male ED).

Anderson et al. (1995) suggest a four-stage process for patient delay  - time between first notice of symptom and treatment of those symptoms.

1) appraisal delay – time taken to notice and interpret symptom as sign of illness
2) illness delay – time taken from realization of illness to decide to seek treatment
3) behavioural delay – time taken from decision to actually seeking treatment
4) medical delay – time taken between first making appointment to actually receiving medical care.                                <see figure 4-1>

Generally those who experience the least amount of pain are slowest to seek treatment,
while those in greatest pain demonstrate the least delay.

 Additionally those who experience new or changing symptoms are also more likely to seek treatment vs. those who have had the same symptoms for some time, along with those who imagined themselves as being severely ill. 

 Fear also plays a role here where high fear and low fear may prohibit people from seeking medical attention, while moderate levels may be most motivating to seek treatment.  Fear may involve death, disability, financial, social or marital loss.

Societal or role obligations and keeping busy with others or living day to day may also play a role in delaying the seeking of treatment (e.g., middle-age parents).

Age may play a role but studies are not consistent, although Ramirez et al. (1999) report that older women may have longer patient delay while younger women may experience longer medical delay in seeking treatment for cancer.

Gender - Lyons & Chamberlain (2006)  indicate why women tend to seek medical care more often than men.

Physician-Patient Interaction

 Patient vs. client what language is best? 

Traditionally in the medical model the term patient has been used which connotes a sufferer, a passive recipient of treatment, one that is acted upon.

 The term client connotes a more active role of someone who is under the protection or guidance of a professional.

 According to Poole et al, most people prefer the term patient, indicating that the term client may lead to a denial of the illness or  blaming the client for his/her condition.

             Basic Models of Physician Patient Care

 Szasz & Hollender (1956) outline three basic models of physician-patient relationship;

1)      Active-Passive model considers the patient as a passive recipient and unable to participate in his or her own care. 

2)      Guidance-Cooperation model indicates that the patient seeks advice, answering questions and relying upon the  physician  to determine the diagnosis and treatment.

3)      Mutual-Participation  model assumes that the physician and patient share the responsibility of decision making about diagnostic tests and treatment(s).

Power is an important issue here where the first model places all of the power with the physician and the last one demonstrates a sharing of power between the physician and patient.

Roter et al. (1997) offer a different model, based upon audio-taped conversations, or communication styles, between physicians and patients.

1)      narrowly biomedical – focused on closed-ended questions (i.e., does it hurt when ?)-32% of visits showed this.

2)      Expanded biomedical – still closed-ended questioning but allows for more  psychosocial exchange (i.e., how do you feel? ) (33% of visits)

3)      Biopsychosocial style - shows a greater balance of the biomedical and psychosocial styles (20%)

4)      Psychosocial - greater focus on psychosocial exchanges and advice (8%)

5)      Consumerist - approach focuses on the questions of the doctor by the patient, seeking to acquire information from the physician (8%)

Poole et al suggest that patients prefer the psychosocial or collaborative model while physicians preferred the consumerist style.

Lyons & Chamberlain (2006) discuss patient satisfaction & confidence

Question: which do you prefer? Why?  See activity 4

            Physician-Patient Communication

Various aspects for the communication process are important to consider: information, participation, patient satisfaction, malpractice claims, barriers to effective communication.

Information Giving  - is a primary role of the physician, however this does not always occur with respect to diagnosis, causes, or treatments. Patients may want to know more information and Physicians may think they are giving more information than they actually are.

Limited information giving may be due to apprehension in creating anxiety or trying to protect the patient, or through thinking the patient will not comprehend the information.

 Participation  - pertains to the desire for patients to play an active role in their healthcare. While this is the stance desired by many younger patients, many older patients may prefer less participation.                  

Physicians may also vary in their desire and degree of openness to participation not only with patients but also with other colleagues.

 General patient satisfaction  - is largely determined by the pace and style of the physician’s communication.  Personal factors like warmth, emotional expression, friendly, confident  are more likely to lead to satisfaction. 

 Malpractice claims - are more likely to occur when the patient is dissatisfied with the physician, including their communication style.  

Poole et al indicate that understanding the patient’s expectations and perspectives is crucial to avoid litigation and malpractice.

Barriers to communication

Physician behaviours  - interrupting the patients and not eliciting their concerns or perceptions.  Studies have shown that interruptions may inhibit the central concern from being reported as well as actually take longer to complete the visit.

Medical jargon – also may leads to misunderstanding and poor communication, where physicians may assume that patients understand them or they may not actually want patients to understanding them (mystery-mastery complex).  <see box 4-1> 

Poole et al suggest that the best place between jargon and baby talk is to make use of:

Non-discrepant responses – making use of the same vocabulary as being asked by the patient, as well as,

Multilevel explanations – making use of medical jargon and then clarification in lay language.

Time factors – are also important where the visit and communication may be altered by the pace and time available for the consultation.

Patient-centred or doctor centred encounters may occur, where the psychosocial or biomedical style may be found.  Poole et al report that negative visits may actually take longer than positive visits.

 Patient volume also plays a big role in time available and patient satisfaction, where big volume physicians tend to give lowered patient satisfaction.

 Patient behaviours – deception may be present where patients may hide or fail to reveal aspects about their health or behaviour. 

Failing to ask for information may also occur because of:
1) doubt or thinking it was not up to them to ask
2) afraid of what the doctor might think of them
3) afraid of a negative reaction from the doctor
4) too flustered or hurried to ask
5)  doubted the doctor could tell them more
6) forgot to ask
7) feared the truth

 Memory may cause problems where people tend to remember the gist of things, and reconstruct events of the past.

 Anxiety also can make it difficult for patients to remember or concentrate on the diagnosis or treatment.

Lyons & Chamberlain (2006) - The Active Patient

 Intercultural Communication