Class 24 Being a Patient (finish) Patient / Provider Communication. ANNOUNCEMENTS. Diary Study write up due today. Hand in at end of class. Remaining classes : 4/24: Patient / provider communication 4/29: Movie: Let There Be Light 5/01: Review session
Being a Patient (finish)
Patient / Provider Communication
Diary Study write up due today. Hand in at end of class.
4/24: Patient / provider communication
4/29: Movie: Let There Be Light
5/01: Review session
5/13: Final Exam; 11:45-2:45
Instructor Evaluation: http://sakai.rutgers.edu
What percent of patients fall into “good patient” role?
____ Good patient ____ Average patient (minor complaints) ____ Bad patient: seriously ill and complain, not ill but complain anyway
Very bad patients: harass nurses, violate hospital rules, self- sabotage (don’t take meds, risk own health). Why?
Reactance: People have basic need for personal freedom. Work to regain freedom taken in ways that appear unfair. Hospitals can induce reactance by being arbitrary, withholdng info, treating pats. like children.
Hospitals want to help patients. Why do they cause patients to fall into “good patient” role, or reactance?
Body is a machine—fix the parts, the body is OK, job is done. "Person" is irrelevant.
Real world constraints:
Hospitals forced to do more with less. HMOs, cost cutting, related pressures.
Irving Janis “ideal anxiety” approach (1958)
Hospital hires Janis (social psych) to reduce patient stress
Janis redefines situation: Some anxiety is good. Why?
No anxiety – person not prepared for difficult outcomes. Too much anxiety – person is flooded, can’t take in information. Recommends providing pats. with enough info to emotionally prepare.
Egbert study (1964): Works with pats. undergoing abdominal surgery
Patients either told / not told what to expect post-surgery (pain, recovery, severity, etc.)
Result: Informed pats need less narcotics, leave hospital sooner. Highly replicated finding.
You are about to undergo surgery. Would you prefer your hospital roommate to be someone:
____ About to undergo same surgery
____ In recovery from same surgery
___ No Roommate
___Same/Pre-op ___ Diff/Pre-op
Kulik & Mahler study (1996)
Patients pared with roommate who is:
* undergoing same / different surgery * Pre-operative / post-operative * No roommate
What matters in terms of patients’ recovery?
Pared with post-op roommate: Less anxious pre-op, more ambulatory post-op, released sooner.
Rodin & Langer, 1977
Ss are nursing home elderly.
Cond. 1: Reminded of their own responsibilities, and given a plant to care for.
Cond. 2: Reminded of staff responsibilities to them, and given a plant that staff care for.
18 months later: Staff ratings, mortality
Cond ___ : * More positive staff ratings (happier, more sociable * Lower mortality (more likely still alive)
Animal Assisted Therapy Outcomes
Animal Assisted Therapy (AAT):
Specially trained animals plus handlers visit hospitalized patients.
Dog lies on patient's bed, is petted.
Cute, but does it work?
Experiment by Kathie Cole, RN, UCLA Medical Center
77 heart-failure patients (ave. age = 57) receive 12 minute visit from either:
b. Human volunteer
c. No visit
Dog: Reduced 24 pts
Human: Reduced 10 pts
Dog: Reduced 17%
Human: Reduced 02%
Control: Reduced 07%
Dog: Reduced 10%
Human: Increased 03%
Control: Increased 05%
Dolphin-Assisted Therapy: Israel, Florida, Ukraine
Veronic Skoczek and MacGuyver:
Skoczek suffers from cerebral palsy, affecting walking and other motion.
After years of “therapeutic riding” walks unassisted.
Rhythm of horse’s gait mimic pelvic during walking.
Improves allignment, muscle symmetry, postural control
Children in Hospitals Outcomes
Hospitals are frightening to children.
a. Place associated with pain
b. Weird looking people
c. Sad/Scary looking patients
d. Parents are not in control
a. Fear, anxiety
b. Anger, rebellion
c. Shame (esp. at adolescence)
Being left overnight in hospital esp. upsetting.
a. "Setting" anxiety
b. Age 3-6: fear rejection c. Age 4-6 develop new fears (e.g., darkness)
d. Age 6-10 free-floating anxiety
e. Separation anxiety: deserted? punished?
a. Parental visits study (Branstetter, 1969)
Cond 1. Mom at visiting hours only
Cond 2. Mom for extended periods
Cond 3. Surrogate mom
b. Kids in Cond 2 & 3 do better than Cond 1
c. Hospitals now let parents stay with kid all times
d. Story telling
a. Kid in hosp. movie --> less anxiety
b. In gen., informed kids show less anxiety
c. Encourage kids to ask questions
d. Provide kids with coping skills * Self-talk * Relaxation skills
Excerpts from A. Boyard Essay Outcomes
Intoxicated by My Illness
“Suddenly there was in the air a rich sense of crisis…”
“I had been given a real deadline at last”
“I’m filled with desire--, to live, to write, to do everything”
“I now feel as concentrated as a diamond, or microchip”
Why these positive reactions to fatal condition?
Class 24 Patient / Provider Communication
Why Providers Are Often Poor Communicators Patient / Provider Communication
Situation: Time pressed, competing demands (“Jerusalem to Jericho”)
Communication and compassion not emphasized
Communication skills not modeled. MD training is itself inhumane.
Motives for becoming MD sometimes contrary to compassion/listening
prestige, wealth, status, authority
Some MD skills contrary to compassion/listening:
Analytic / time-efficient / detail oriented
Personality qualities needed to get into med school
Competitive: (Steve Leonodakis, UCSF)
MD Failure to Listen Patient / Provider Communication
Beckman & Frankel (1984) study of MD initial response to patients
MDs know they are being observed, 74 patient visits
Patient given opportunity to explain problem:
MD interrupts, directs pat. to particular disorder:
MD interrupts pat. after ______ seconds.
1. Patients don’t get a chance to fully explain symptoms, concerns.
2. MD doesn’t get all vital information
MD Communication Problems Patient / Provider Communication
1. Failure to listen
2. Use of jargon:
Hmm. Seems you have Ulag's Syndrome, which voraciously perturbs the ipsilateral medulla of the flatabuloig.
I suggest we immediately begin ripsaw radiation and perhaps implode the ventral sinus of your gronus.
Arnold of Villanova (1235-1311): Say that he has an obstruction of the liver, and particularly use the word obstruction because patients do not understand what it means.
MD Communication Problems (contin.) Patient / Provider Communication
3. Baby talk: “Is you got a boo-boo on your spleen?”
MD sees pat. as condition, not a person
Refer to pat. in third person, in front of pat. “Need to get his name and address, and what’s his primary symptom”
Functions: Manages pat., improves efficiency in emergency
Effect on Pat:
Can calm: help dissociate Can alarm: “I see this condition terminating in negative status”
Inappropriate Emotions Patient / Provider Communication
MD looks frightened, distressed, frustrated.
“Holy Toledo, look at that spot on your X-ray!!!!”
Women who get mammogram, if MD appears worried, they:
a. Remember less b. See situation as worse
c. Higher pulse rates
ANNOUNCEMENTS Patient / Provider Communication
4/29: Finish Pat/Provider Communication
Movie: Let There Be Light
5/01: Review session , Papers returned
5/13: Final Exam; 11:45-2:45
a. Will be fewer, possibly no short-answers
b. Not displaying Quiz 2 questions—too close to final.
COURSE EVALUATIONS Patient / Provider Communication
Stereotypes Interfere with Treatment Patient / Provider Communication
Ethnic status: Black, Hispanic, low SES get
Less info., less emotional support, less proficient TX
Elderly: Less often resuscitated in ER
Women: Taken less seriously
Mr./Ms. Kendler has sudden, sharp headaches
Possible stroke? Yes for Mr., no for Ms.
Possible emotional problem? Yes for Ms., no for Mr.
Gender Differences in MD Communication Patient / Provider Communication
Who communicates better?
Female doctors: 1. Conduct longer visits
2. Ask more questions
3. Show more support
Training Physicians to Communicate: Patient / Provider Communication
The Standardized Patient
Patient Non-Adherence Patient / Provider Communication
When patients do not follow the behaviors and treatments that their providers recommend.
Reasons for Non-Adherence Patient / Provider Communication
Failure to understand treatment
Difficulties maintaining treatment
Besides obtaining five prescriptions and getting to the pharmacy to fill them (and that’s assuming no hassles with the insurance company, and that the patient actually has insurance), the patient would also be expected to cut down on salt and fat at each meal, exercise three or four times per week, make it to doctors’ appointments, get blood tests before each appointment, check blood sugar, get flu shots – on top of remembering to take the morning pills and then the evening pills each and every day.
Added up, that’s more than 3,000 behaviors to attend to, each year, to be truly adherent to all of the doctor’s recommendations. Viewed in that light, one can see how difficult it is for a patient to remain fully compliant.
Danielle Ofri, MD, NY Times,
Protease Inhibitors and AIDS
Increase life expectancy,
Miss 1 dose—now non-effective!
Take 4X daily
Side effects: nausea, diarrhea
Reasons for Non-Adherence Patient / Provider Communication
Personality / demographics
Political, ideological orientation
Depression, stress, avoidant coping
Change dose to preserve med
Mix with home remedies
Altruism: Polish rescuer
Michele Bachmann says HPV vaccine can cause mental retardation
Reactance and Non-Adherence Patient / Provider Communication
Dr. Rusty Needles:
Condescending: Well, if you weren’t eating like a swine and exhausting yourself chasing money, you wouldn’t have this condition.
Infantalizing: Take the ittle, yittle blue pills with wahhhter!!!
Demeaning: Get off that rolly-polly duff and exercise!
Dilemma for patient:
Compliance = accepting insults; Non-compliance = self-assertion, self-respect.
Reactance against situation: Restricted behavior = reduced freedom
Reactance against negative self-label: Weak, limited
Patient Contribution to Poor Communication Patient / Provider Communication
Failure to hear
a. 33% can't recall diagnosis after seeing MD
50% don't understand important details
b. Reasons for failure to hear
* Too anxious
* Too embarrassed
* Ignorant, uninformed
Failure to speak
a. Don't say why they're there.
b. Wait till last minute, mention problem offhandedly
Improving Adherence: Tips for MDs Patient / Provider Communication
Greet by name Explain purpose of procedures / meds Don't appear desperate to leave (door handle effect) Say "goodbye" after exam
U. Mass 3 points (from Schrof article)
1 Don’t interrupt: MD 18 secs / pat 2.5 min 2 Ask “what were you hoping I could do for you?” 3 Don’t intimidate into silence
Addressing Adherence Directly Patient / Provider Communication
1. Spend real time in explaining:
a. Repeat instructions 2 + times
b. Have patient repeat instructions back to you.
c. Break complicated treatment into sub-goals
2. Probe for real-world barriers to adherence
3. Obtain verbal commitment
4. Prescribe behavior change like medication. e.g., Don't advise new diet, prescribe it.
5. Tell patient to "Get better." (According to Kent's MD)
Tips for Patients Patient / Provider Communication
Ask questions at the outset, not at the end
Prepare a written list for your visit.
1. Helps you remember issues and specifics
2. Acts as social prop, makes it hard for MD to leave until all items are addressed.
Let There Be Light Patient / Provider Communication
John Huston, 1946
Purpose: To inform public about PTSD among WW II vets.
To counteract stigma of psychiatric wounds
Filmed at Edgewood State Hospital, Long Island
US Military bans film
Fears it will demoralize potential recruits
Film finally released in 1980s
John Huston, 1906-1987