Patient/Practitioner Interaction
INTRO
Effective communication between patient and practitioner is vital to health promotion, disease prevention and treatment, and is an essential skill that can greatly improve the quality of care. It may also facilitate better relationships that can improve intermediate outcomes such as, treatment adherence, self management, trust and support within the health care system (Mauksch et al 2008).
One problematic behaviour in patients is not adhering to advice from their doctors. Some types of request can be easier to adhere than others. For example a short term request like taking a course of antibiotics is a lot easier to adhere than a long term request regime like diabetes. Individuals with social/ economic support from family, friends or caregivers, prove better adherence to treatment. However unstable living environments, lack of financial resources and cost of medication are all associated with decreased adherence to treatment.The relationship between doctor and patient is key to high adherence. All methods of measuring adherence have their strengths and weaknesses. Therefore in order to measure it accurately its best to use a range of methods. (Kalogianni 2011). Some methods used to measure compliance and adherence could include pill counting, electronic monitoring devices and data reviews (LaFleur et al 2004).
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Non-verbal communication factors can make a significant difference to the levels of adherence in patients. Psychologists Mckinstry and Wang (1991) showed pictures of doctors to patients attending surgeries, in both a formally or informally dressed manner. The results suggested the formally dressed doctors received higher ratings than the casually dressed professionals (Mckinstry et al 1991). The study, however, had low ecological validity as the pictures show to the patients did not relate to real life situations. The age of patient’s affect the rating of results, as older patients may care more towards the appearance of the practitioner than younger patients. Factors such as, pain, stress and anxiousness are confounding variables affecting the outcome of the results. Although the study has a rating scale that can be interpreted in different ways, it collected quantitative data, meaning that it could not be affected by subjectivity. This makes the study more reliable. If the study were to be qualitative the results would of not been reliable, as individuals have different interpretations of the meaning quality. overall, the study shows clear consistency throughout and has fairly reliable results.
Doctors use two types of medical communication, Patient-centred and Doctor-centred. A patient-centred communication style makes use of the patients experience and knowledge through techniques such as listening and reflection; whereas a doctor-centred style makes use of the doctors skills and knowledge with small input from the patient. Medical jargon is used within doctor-patient communication and is one of the reasons for low adherence in patients. Psychologist Mckinlay (1975), studied ‘lower class’ patients and their understandings of 13 different terms used by doctors on a maternity ward. Each word was understood by only 39% of patients on average. The doctors were asked to use words that they believed the women would have a higher understanding of. However they still used the same medical jargon even though they expected low comprehension (Mckinlay 1975). This study shows poor generalisation as the survey only included women of the lower-class and was only carried out in a British maternity ward. Therefore, the results cannot be applied to men, women in other countries and people of other social classes. Even though confidentiality was kept, the women may have felt distressed having to admit they did not understand the doctor, making this study unethical. Despite this, the experiment is non-bias as the doctors who marked the definitions of the terms did not know each other’s scores, making the study slightly reliable as there was no pre-set words.
One considerable contributing factor in the breakdown of Patient Practitioner Interaction (PPI), is the verbal language practitioners use. Practitioners may use Medical Language (ML) when in consultation with patients which create unnecessary barriers, often leading to misunderstanding of treatment. This can affect the level of satisfaction from the patient, which in turn decreases the level of adherence to medical advice (Farrington 2011). Bourhis et.al. (1989) researched into observing the ML and everyday language (EL) in a hospital setting. The psychologists considered the following; the motivation to either change or to maintain the language used, the norms of communication in a hospital setting and the status and power difference between the three. A questionnaire was given to 40 doctors, 40 nurses and 40 patients with an overall conclusion that doctors used ML as a way of maintaining status and power rather than using EL to promote better understanding for patients. The study had a small sample group so not widely representative nor generaliable to the population, as was only conducted in one hospital setting. The use of a questionnaire has good measure, producing reliable data. However, the questions may be bias as it is set by the researcher so the demand characteristics may be higher. The questions also are more likely to be closed questions, giving less scope for people to express their true feelings. Nurses and patients may feel they want to please the doctor, therefore not answer truthfully; increasing the social desirability. The hawthorne effect could have an impact on the outcome of the study due to the doctors communication skills being investigated causing them to act differently. Although the study was small, it could be replicated in other hospitals of the health service, as it has relatively high reliability.
A psychologist Grenness (2014) conducted a two part study at an audiology rehabilitation center on PPI. Study one consisted of interviews with adults that owned hearing aids to gain the patients definition of patient-centered care. This provided qualitative data to enable focus for the second study. The second study analysed and filmed 63 consultations between patient and practitioner. 17 of the consultations had companions with them. A method called The Roter Interaction Analysis System (RIAS) was used to examine the presence and nature of patient-centered communication. The second part of the study consisted of two phases, the first focused on the history taking of the consultations and the second on the counselling. Both results showed that the audiologists asked closed-ended questions and biomedical questions limiting the amount of input from the patient (Grenness, 2014).
In this study, there is relatively low reliability as the interviews and observations are unstructured. Not all individuals will have the same interpretation of PPI, and the circumstances may be unsettling. There is relatively low generalisability, as there is a low number of participants and therefore does not support the population. However the study is aimed at the older generation with hearing aids so it is representative to this.
There are other major factors in PPI on the rise, including violence against healthcare professionals. Mackin (2000) conducted research to assess the level of violence against trainee paediatricians. A telephone questionnaire was used for 25 specialist practitioners from three regions of the United Kingdom; Northern Ireland, south thames and Northwest England. More than 10% mentioned that an attempted assault had taken place and 5.3% had been victims of actual physical assault. Results showed that less than 10% of individuals questioned had received training in managing violent people, although 99% of those questioned thought that this would be a good idea.
Mackin used a telephone questionnaire,making this study unreliable as you cannot be certain the individuals are honest with their answers. The study also has low generalisation as only 25 specialist practitioners were questioned, which does not support the population. Although the quantity of the study is low, the quality is relatively good, as it is conducted in 3 different regions in the United Kingdom, it also is in real life scenes increasing the ecological validity.
A study conducted by Kinmouth et al (1998) focused on the impact of giving GP’s and practise nurses additional training in patient-centered care. A sample group of 250 nealy diagnosed diabetics attended 41 practices across Southern England. The practices were split up into two groups. The first group consisted of 20 GP practices and the second was an intervention group of 21 practices, where doctors and nurses received 1.5 days of training in patient centered care. Results showed that after 1 year the patients who received care from practices within the intervention group reported greater satisfaction with treatment, better communication with the doctors and increased well-being. However knowledge of the disease was found lower from the doctors in the intervention group. This showed the psychologists that practitioners find it difficult to create a patient-centered approach to patients in order to manage the disease effectively. Although its good for doctors to use the patient-centered approach, it then also proves difficult for them to deliver important points across to patients at a critical time.
This study has high ecological validity as the research is based upon 40 practices across Southern England. It also has relatively good reliability because its longitudinal over 2 years, and compares two groups. On the other hand the study has bad generalisation as it is only in Southern England, not collecting data from around the United Kingdom and its only based upon diabetic patients.
In some situations doctors can use The Health Belief Model (HBM) to support service users with personal decisions. The HBM is a psychological model focusing on the attitudes and beliefs of individuals to attempt to predict and explain their health behaviours. A recent study conducted by Harrmann et. al. (2018) looked in to using the HBM to explore why women decided for or against the removal of their ovaries, to reduce the risk of developing ovarian cancer. The Qualitative study consisted of 18 semi-structured interviews with women who have attended a cancer treatment centre or counselling. Results showed that the more anxious women felt about getting ovarian cancer, the more likely they were to get a oophorectomy. The women also reported a lack of decision support from their doctor when discussing treatment plans and personalised information (Harrmann et al 2018).
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The study uses qualitative data, this is unreliable as each individual has their own interpretation of how qualitative the study is. The study also has low ecological validity as there was only 18 interviews which does not support the whole population. However, using the HBM allows the psychologists to look at the patients behaviour to medical advice and treatment.
PPI could be improved with more time being allocated to GP appointments, with the practitioner ensuring the patient has understood the medical advice given, especially instructions for treatment plans. A follow up consultation would also help to encourage patient adherence. However, this improvement would cost private practices a high amount of money as the doctors would have a reduced amount of consults per day. This would also impact the NHS as, the demand of the public requiring medical treatment would be significantly higher as the doctors would have restricted time.
The results from Bhouris et. al. (1989) study can be used to reduce less use of ML from doctors which would ensure better understanding from the patient. Also using a patient-centered style of consultation can allow the patient to feel involved in decisions. A practitioner simply introducing themselves in the first instance, and establishing how each patient like to be addressed, improves the building of a relationship.
Mckinstry and Wangs study (1991) can encourage health care practices to set formal dress code guidelines for doctors. This would be at no cost for the NHS or private practises. However only a small percentage of the service users have a view on informally dressed doctors
Mckinlay’s study (1975), can be used to improve and prevent the use of medical jargon from HCP’s. Encouraging trainee doctors to avoid medical jargon from the offset and by showing them the possible outcomes for using this type of communication can assure better levels of adherence from patients. And to encourage the use EL so that patients have more input in treatment choices. On the other hand, some service users prefer doctors to use medical jargon as they come across more professional and experienced. Doctors may also disagree because they could argue how they would be able to deliver medical advice in a professional manner without using medical jargon.
Another improvement for PPI could include offering nurses a higher position in their careers, to improve the language barrier between doctors and patients with regards to ML. This would in turn increase the levels of adherence. This could also increase the amount of applicants applying for a nursing degree, as there would be another opportunity for career development. However, individuals who hope to become a doctor may strongly disagree with nurses helping them with communication, as it can affect the doctors reputation and the feeling of being high in the health system.
Another improvement to PPI could be the added additional training in patient-centred care from both trainee and qualified doctors. This would improve communication barriers, by breaking down factors causing the decrease of adherence and the increase of confusion in the delivery of health advice. Although, some individuals may disagree as they could have a number of other responsibilities they have to adress, resulting in less time for them to attend the extra training. This could also be a high cost for the organisation organising the training and would need secure funding.
In conclusion, effective communication is imperative for high satisfaction and adherence to treatment from patients. PPI is greatly achieved through patient-centred communication and both patient and practitioner play equal roles. The practitioner should avoid medical jargon and closed ended questions where possible, adopt good listening skills, introduce themselves and be open minded to body language. ML should not be used during the delivery of medical advice as patients can become confused, which in turn can affect adherence. More time should be appointed to consultations to enable good interaction from both patient and practitioner, however due to such high demand on the services this may not be possible.
References
- Bourhis, R. R. (1989, December). Communication in the hospital setting: A survey of medical and everyday language use amongst patients, nurses and doctors. Retrieved from ResearchGate: https://www.researchgate.net/publication/46499443_Communication_in_the_hospital_setting_A_survey_of_medical_and_everyday_language_use_amongst_patients_nurses_and_doctors [Accessed on: 12th November 2018]
- Epstein., M. D. (2008). Health care professional-patient communication. In D. M. Marks, Health psychology (p. 277). Sage Publications. [Accessed on: 29th of November 2018]
- Farrington, C. (2011, June). Reconciling managers, doctors, and patients: the role of clear communication. Retrieved from PMC: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110963/ [Accessed on: 1st December 2018]
- Kalogianni, A. (2011). Factors affect in patient adherence to medication regimen. Health Science Journal, pp. 157-158. [Accessed on: 22nd November 2018]
- LeFleur, J. e. (2004). Methods to measure patient compliance and medication regimens. Retrieved from Pub Med: https://www.ncbi.nlm.nih.gov/m/pubmed/15364635/ [Accessed on: 22nd November 2018]
- McKinlay, J. (1975). Who is really ignorant: Physician or patient? Retrieved from APA PsycNET: http://psycnet.apa.org/record/1975-23957-001 [Accessed on: 25th November 2018]
- Mckinstry, B. W. (1991, July). Putting on the style: what patients think of the way their doctor dresses. Retrieved from Pub Med: https://www.ncbi.nlm.nih.gov/pubmed/1747264 [Accessed on: 25th November 2018]
- Proietto., H. H. (2018, November). Using the Health Belief Model to explore why women decide for or against the removal of their ovaries to reduce their risk of developing cancer. Retrieved from Pub Med: https://www.ncbi.nlm.nih.gov/pubmed/30428865 [Accessed on: 29th of November 2018]
- Rowlands, G. P. (2014). Health Literacy . Royal College of General Practitioners. [Accessed on: 1st December 2018]
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