PATIENT-

PRACTITIONER
RELATIONSHIP
Asim Masood
[email protected]
+923002626209
Practitioner and patient
interpersonal skills
NON-VERBAL COMMUNICATION (McKinstry and Wang, 1991)
 Aim: to investigate whether patients think the way their doctor dresses is
important, what their preference ism and whether patients think the way
the doctor dresses influences their effectiveness as a doctor

 They also wanted to explore if there were any demographic differences in

beliefs of the patients with respect to the above aim

 Sample: 475 patients (67% female) attending 30 doctors in five different

locations in Lothian, Scotland
 Method and Design: Experimental, as well as self report interview

 Procedure: Participants were asked to look at eight different photographs

of doctors (5 male, 3 female)
 Participants were asked “which doctor would you feel happiest about
seeing for the first time?” and to rate each example from 0-5
 They were asked to rate their confidence in the ability of each doctor
 They were also asked if they would be unhappy about seeing any of them
 Finally, they were asked closed ended questions about the general dress
code of doctors
 Results: The doctor in a smart suit was the most popular

 The doctor in the cardigan and casual trousers scored higher than the doctor in jeans

 The informally dressed female doctor scored lower than the other two female doctors

 Older patients gave high scores to the male doctor in a white coat or formal suit

 Older patients were more likely to give higher scores to the female doctor in a white
coat
 41% of the sample answered “yes” to the question “Do you think you
would have more confidence in the ability of one of these doctors
based on their appearance?”
 For the above, the main choices were suit and white coat for the male
doctor, followed by the tweed jacket, jeans and cardigan
 For the female doctor, the main choice was white coat, followed by skirt
and then trousers
 For the closed ended questions about general doctor dress code,
majority participants believed jeans would be too informal for a male or
female doctor
 They also believed a male doctor should wear a tie and a female doctor
should wear a skirt
 Many participants also stated their own doctor matched the smartly
dressed one in the photograph
 Data was also analysed in terms of social class and gender with higher
social class objecting more to male doctors wearing an earring and to
female doctors wearing lots of jewellery
 More male patients than female patients believed that women doctors
should wear white coats
 In general it can be seen that patients prefer formally dressed doctors,
but this is affected by age, social class and the particular medical
practice
 Patients also preferred doctors dressed in a manner similar to their own
doctor
 Demand characteristics were reduced by analysing the data and
understanding that even though initially patients stated that the dressing
of their doctor does not matter or was not important, they still gave
discriminatory scores in assessing the photographs
 To conclude, the appearance of a doctor and the way they dress can
affect the way a patient thinks about them in terms of their confidence
in their ability and whether they would be comfortable going to such a
doctor
 Controls: The expression of the male doctor was the same for all 5 photographs, as well
as for the female doctor for the 3 photographs

 The background and posture was standardized as well with the only difference being
the clothing

 All participants answered the same close ended questions on the same rating scale
VERBAL COMMUNICATIONS (McKinlay, 1975)
 Aim: to investigate the perceived and actual comprehension of medical
terms by a sample of lower working-class families in Scotland using
maternity services

 Sample: 87 families using a maternity service in Aberdeen, Scotland

 Method and Design: Interview based study

 Procedure: A total of 87 families were interviewed about the use of

maternity services 4 times during an 18 month period

 The fourth interview is the one that collected data about the patients’
comprehension of medical terminology used by doctors that could be
misunderstood by them
 57 words were initially selected that were classed as ones which either
patients would use; which patients would not understand; or those that
fell in the middle
 For the study, 13 of these 57 words were selected as they were the ones
that fell in the middle category (those that may or may not be
understood by patients)
 These words would be read out individually to the patient in the form of a
sentence and they would be asked what the word meant
 The patient was reassured this was not a test, and was being conducted
to understand if doctors use words that are commonly not understood
by patients
 Examples of words on which the patients were tested were –
ANTIOBIOTIC: If a doctor told a patient that she’s going to put her on
antibiotics, what’s she going to do?
BREECH: If a doctor told a patient that she’s going to have a breech,
what do you think is going to happen?

 The participants were scored by two independent doctors (for inter-rater

reliability), one male and one female, both did not know the rating given
by the other, in terms of four scores
 Score A: The patient did not recognize no understand the word

 Score B: The patient had an incorrect understanding of the word

 Score C: the patient recognized the word but did not understand it

 Score D: The patient had a good idea what the word meant

 Patients were split into two groups – Utilizers (those who avail the
maternity services regularly) and Underutilizers (those who do not avail
services regularly)
 A year later, a separate group of doctors rated each of the words on
what they expected the patients to understand

 Results: For nearly all 13 words, the utilizer group had a higher Score D
(understanding of the word) than the under-utilizer group, suggesting
that those patients who avail maternity services regularly are more likely
to comprehend medical terminology used by doctors

 Furthermore, the study also showed that the doctors underestimated the
level of medical terminology comprehension in their patients
 Controls: The same questions were asked to all the patients, making it a
structured interview
 The same 13 words were used making it a standardized procedure
 The scores were rated on the same scale
 Two independent doctors scored each participant for inter rater
reliability
 Only those words were selected which had a possibility of both being
understood and not understood (rather than selecting those words
which definitely would not be understood, or those which definitely
would be understood)
 Other factors that can affect verbal communication in interactions as
noted by Ley (1988) include:
 Volume of information provided by the doctor, as it is believed that just over
50% of the information provided by doctors to patients is remembered
 Primacy effect plays a part as patients tend to remember more of the
information provided to them at the start of a consultation
 Patients with some medical knowledge tend to understand better, and
therefore remember more information
 Instructions provided verbally tend to be forgotten and therefore, written
instructions should also be provided
PATIENT AND PRACTITIONER
DIAGNOSIS AND STYLE
PRACTITIONER DIAGNOSIS
 There are three main aspects to a practitioner diagnosis which include:
making a diagnosis, presenting a diagnosis, and coping with diagnosis

 Making a diagnosis requires disclosure of information which means that the

patient should tell the doctor information about their symptoms and
experience for the doctor to make a correct diagnosis and avoid any
errors

 Some patients may struggle to communicate effectively which can lead to

errors in diagnosis
 Sarafino (2006) discusses some reasons as to why patients may not
accurately disclose information to doctors which include factors such as:
the patient may become angry at the doctor, they may ignore what the
doctor is saying, they may insist on medication or tests which are not
necessary or required, they may want to be given a certificate for an
illness they do not have, and lastly, they may make inappropriate
remarks towards the doctor

 One study to learn about diagnosing patients is that by Robinson and

West (1992) who conducted a study to investigate how much
information was disclosed by 69 patients attending a genito-urinary clinic
via a computerized interview compared to a paper questionnaire, that
would be passed on to a doctor or nurse
 They were split randomly into one of the two conditions and were asked
to disclose information relating to the number of sexual partners within
the past few weeks, the number of previous visits to a genito-urinary
clinic, and the number of symptoms reported

 The results showed that they were more likely to disclose information via
a computerized interview as opposed to a paper questionnaire, and
both these methods gathered more information than the doctor was
able to when speaking to them directly during the consultation
 Talking further about diagnosis, as mentioned earlier, errors and mistakes can
be made while diagnosing patients

 There are two main types of misdiagnoses that can be made which are false
positive (aka Type 1 error) or false negative (aka Type 2 error)

 A false positive is when the doctor incorrectly diagnosis a patient as being

unwell when they are in fact, healthy

 A false negative is when the doctor incorrectly diagnosis a patient as being

healthy and well, when in reality, they are unwell, and this is the more serious of
the two errors, as the patient may not take medication and their condition may
worsen, or they may spread to the illness to others
 Cooke and Colver (2016) carried out a study where 77 patients with
suspected skin cancer were asked how they would prefer to be
informed of their diagnosis, following a biopsy

 They could choose to be informed face to face, by telephone, or via a

letter

 They were explained the pros and cons of each option mentioned in a
leaflet provided to them

 One month after receiving the biopsy result, a questionnaire was sent
 This questionnaire asked various closed questions about how they
received their diagnosis, whether they had been given the information
leaflet, and if they were satisfied with the method at the time and in
hindsight

 From the 77 patients, 48% chose to receive the diagnosis by letter, 37%
opted for telephone, 11% face to face, and 5% chose a combination of
two methods

 89% received their diagnosis via their chosen method, with 11% being
sent a letter because they could not be contacted by phone
 94% patients were happy with the way they received their diagnosis ,
and when asked if they would change in hindsight, 80% said no

 The pros for the letter method include:

 It can be re-read at any time
 Avoids having to go to the hospital
 Contact number of specialist nurse is present

 The cons for the letter method include:

 It takes longer to by typed and posted
 Impersonal
 Can’t ask questions right away
 The pros for the telephone method include:
 Quickest method
 Avoids having to go to the hospital
 Can be in your own home

 The cons for the telephone method include:

 May find it difficult to have a conversation over the phone
 You may not be available when you receive the call
 If contact cannot be made, a letter will be sent instead
 The pros for the face to face method include:
 More personal
 Opportunity to ask questions
 A relative can be with you for support

 The cons for the face to face method include:

 Have to attend hospital
 May have to wait for your turn once at the hospital
 Research by Karri (2009) found that 52% patients diagnosed with skin
cancer preferred to receive diagnosis by letter rather than face to face

 Despite these findings, it is reported that most skin care centers do not
believe it is necessary to offer alternative methods to the traditional face
to face approach

 Schofield (2003) investigated whether the way the diagnosis is presented

to patients affects how they cope with the diagnosis

 He sent out a questionnaire to 131 patients four months after they

received a diagnosis of skin cancer
 This was done to find out the relationship between the communication
from doctors and the patients’ satisfaction, anxiety and depression levels

 Results showed that 32% of the patients received diagnosis via telephone
as opposed to face to face, and there was no significant difference in
satisfaction, anxiety or depression levels between patients who received
diagnosis by phone or face to face

 However, some factors which could influence this include points such as
patients who were prepared for the diagnosis, had been presented
information clearly, and told everything about what to expect with
respect to the disease, experienced higher satisfaction, and lower
depression and anxiety as well
KEY STUDY: DIRECTING AND SHARING STYLES (Savage and Armstrong, 1990)

 Aim: To compare the effects of ‘directing’ and ‘sharing’ styles of

consultation on patients’ satisfaction with a consultation

 Sample: A random sample of 359 patients aged between 16 and 75

years presenting any symptoms at an inner London general practice,
with results being analysed of 200 patients

 Consent was taken from the patients for their consultation to be

recorded
 Method and Design: The patients’ satisfaction was measured through
two questionnaires – one immediately after the consultation, and
another, one week later

 Procedure: The general practitioner did not know which style to adopt
for each patient until they had entered the consultation room

 The practitioner would then turn over a card allocating one of the two
styles (directing or sharing)
 An independent observer listened to a selection of 40 recordings of the
consultation and confirmed that all aspects of each consultation
conformed to the style allocated on the card

 The consultation had 5 parts to it:

 Judgment on the consultation (judgment usually on the symptoms described by
patient)
 Diagnosis (identification of nature of illness or problem)
 Treatment (course of action to take to heal illness)
 Prognosis (the likely course of the illness)
 Follow up and closure (when to return for a follow up check up/appointment, if
needed)
 The assessment provided to the patients to complete immediately after
the consultation, and one week later included the following points:
 I was able to discuss my problem well
 I received an excellent explanation
 I perceived the GP to have complete understanding
 I felt greatly helped
 I felt much better

 Results: Overall satisfaction levels were higher for the directed group who
reported more satisfaction with explanation provided by the doctor
compared to the sharing group
 The directed group also reported greater satisfaction with regards to the
perception that the GP had a complete understanding
 For the aspects of ‘I was able to discuss my problem well’, ‘I felt greatly helped’,
and ‘I felt much better’, there was no real significance between the directed
group and the sharing group
 The comparison showed that 45% of patients in the directing group, but only
24% in the sharing group felt they received an excellent explanation, and one
week later after they took the assessment again, these figures dropped to 33%
and 17% respectively
 A total of 62% patients in the directing style, but only 37% in the sharing style felt
the GP had a complete understanding of their health issue, and one week
later, these figures dropped to 39% an 18% respectively
 It can therefore be concluded that a more directing style of consultation brings
about more satisfaction in patients
MISUSING HEALTH SERVICES
DELAY IN SEEKING TREATMENT
 For many patients, there is a delay between noticing a
symptom and seeking treatment, and this can have serious
implications

 There are many reasons as to why patients delay seeking

treatment including emotional factors, behavioural factors,
beliefs about the symptoms they are experiencing, type of
symptom, and sociodemographic (e.g. age, sex, education,
ethnicity etc.) factors
 Key study: Safer et al. (1979) conducted a study to investigate the reasons for
delaying seeking medical care as well as factors that influence this

 Safer found there were three stages that make up the delay in seeking
treatment which include:
1. Appraisal delay: the time the patient takes to appraise or judge a symptom, an is
commonly the duration from when they first notice a new symptom, up to the time
they realize they are unwell
2. Illness delay: this is the duration of time from when the patient realizes they are
unwell, up to the time they decide to seek medical care
3. Utilisation delay: this is the duration of time from when the patient has decided to
seek medical care, up to the time that they actually access the services
 Safer investigated the effect of the following predicting factors on each
of the stages of delay:
 Sensory or perceptual experience of the symptom, e.g. pain or bleeding
 Self-appraisal processes, e.g. observing the symptom for signs of change
 Coping response to symptoms, e.g. home remedies
 Emotional reactions to the health threat, e.g. fear and distress
 The imagined consequences of the symptoms, e.g. imagining that surgery is
required
 The situational barriers to receiving care, e.g. cost of services
 The first three factors were considered to be the most probable
predictors of appraisal delay

 The next two were considered to be the most probable predictors of

illness delay, and the last (situational barriers), was considered to be the
most probable predictor of utilisation delay

 The patients of the study were attending one of four clinics and had
come to present a new illness they developed, and were approached
by the researchers to take part in a 45 minute questionnaire and
interview
 93 patients completed the interview, all who were presenting a new
symptom for an illness, and included people of different ages, ethnicities,
and both males and females (slightly more females)

 They were interviewed and given a questionnaire for 45 minutes through

which both open and close questions were asked

 Data was collected on the reasons as well as length of each type of

delay

 Results: The mean total delay was 57 days

 There were 6 variables that correlated with total delay:
 The first and more significant was a recent problem or change in life
that was unrelated to the medical condition (e.g. marriage or
divorce) – mean of 7 days who did not experience any such problem,
but a mean of 23 days for those who did
 The second most significant variable that correlated with total delay
was how painful the symptom was – mean of 8 days for those with a
painful symptom, compared to a mean of 23 days for those without
 Third was whether the patient had read about the symptom, and if
this was the case, the mean delay was 50 days if they read a lot
about it, 26 days if they read a bit, and 11 days if they didn’t read at
all
 The fourth variable was age, as those under 45 years had a mean
delay of 9 days, but those over 45 had a mean delay of 23 days
 Fifth was whether patients waited to see if their symptom went away
or changed, in which case the mean was 9 days, but those who did
not wait, had a mean delay of 23 days
 Lastly, patients who felt their symptoms would be cured – mean delay
of 9 days for those who did feel this, whereas a mean of 15 days for
those who did not
 There average length of appraisal delay was 4.2 days, and the presence of a
painful symptom such as bleeding (sensory factors) reduced the delay,
whereas reading about the symptom (appraisal strategy) increased the delay

 The average length of the illness delay was 3.1 days, and if it was a new
symptom (sensory factor), this reduced the delay, as compared to an old or
recurring symptom. Furthermore, if the patient imagined a negative
consequence such as having to receive surgery (imagery factor), this increased
the delay

 The average length of utilisation delay was 2.5 days, and those who were
worried about the cost had a longer delay (situational factor), but those who
felt that their symptom could be cured, or experienced pain (sensory factor)
had a shorter delay
Alternative explanations for delay:
Health Belief Model:
 The health belief model helps to explain health-related behaviours, including delay in
seeking treatment and includes the following factors:
 Perceived severity: the likelihood of a person changing their health behaviours depends
on how serious they think the consequences are
 Perceived susceptibility: a person is more likely to change their health behaviour if they
feel they are particularly at risk
 Perceived benefits: people are less likely to change a behaviour if they don’t think the
change will benefit them
 Perceived barriers: barriers such as expense, effort, discomfort and inconvenience can
lead to delays
 Cues to action: an external event such as an ad advising people to get symptoms
checked, can act as a trigger to make someone take action
 Self-efficacy: Someone who believes they are capable doing something is more likely to
do it, such as believing one can go through the diagnosis and treatment process is more
likely to not delay seeking treatment
MUNCHAUSEN SYNDROME vs MALINGERING
 Munchausen syndrome is a mental disorder where someone pretends
to be unwell deliberately, and this can be done so by hurting
themselves

 Usually a pre-existing disorder is present, but this is often aggravated,

or new symptoms are made up

 Malingering on the other hand is when someone deliberately makes

themselves unwell or pretends to be unwell for an obvious incentive
such as avoiding criminal prosecution, or receiving money
 These incentives are not involved in Munchausen syndrome

 The essential features of Munchausen syndrome are pathological lying

(compulsive and frequent lying about illness), peregrination (wandering
such as from one hospital to another), and recurrent, feigned or
simulated illness

 Other support features include antisocial personality traits, deprivation in

childhood, equanimity (sense of composure in a difficult situation),
evidence of self-induced physical signs, knowledge of medical field,
multiple scars, police record, unusual or dramatic presentation, and
multiple hospitalisations
Example study: Aleem and Ajarim (1995)

 Ajeem and Ajarim report a case of a 22 year old female who attended a
hospital in Saudi Arabia with a painful swelling over her right breast
 She had a history of similar recurrent swellings and needed surgical
drainage
 From the age of 17 she had been seen by many hospitals regularly for
issues relating to her menstrual cycle during which she developed
symptoms that suggested deep vein thrombosis (blood clot) which did
not respond to the medication
 The patient came from a supportive family and did not have any
financial problems
 Her mother had breast cancer
 Soon after the swelling, she presented complaints of swellings in the groin
area and weakness in lower limbs
 She had physical examinations such as a CT scan, and the doctors
suspected haemotoma (swelling of clotted blood within the tissue)
 She was an intelligent individual but lacked much medical knowledge
 She was treated with antibiotics, but the surgical drainage had to be
completed to remove an abscess she had developed
 After four days in the hospital, she developed a similar abscess on the
opposite breast
 It was found that the abscess contained several different bacteria
 At this point the doctors started suspecting a case of factitious disorder
and a psychiatric consultation was made after counselling her without
giving her a hint about suspicion of a factitious disorder
 One day when she was not in the bed in the hospital, nurses found a
syringe full of faecal material along with needles
 When she returned, another patient had told her about what the nurses
had found
 She became very angry and hostile and left the hospital and did not
return
 At this point she was officially diagnosed with Munchausen Syndrome