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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

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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

5/13: Final Exam; 11:45-2:45

Instructor Evaluation: http://sakai.rutgers.edu


Reactance

What percent of patients fall into “good patient” role?

25%

____ Good patient ____ Average patient (minor complaints) ____ Bad patient: seriously ill and complain, not ill but complain anyway

50%

25%

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.


Why Hospitals Demoralize

Hospitals want to help patients. Why do they cause patients to fall into “good patient” role, or reactance?

Biomedical Model:

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.


Improving the Patient Experience

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.


Social Support and Surgical Recovery

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

___Same/Post-op ___Diff/Post-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?

XX

X

Pared with post-op roommate: Less anxious pre-op, more ambulatory post-op, released sooner.


Effects of Responsibility and Care-Giving on Patient Outcomes

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

1

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:

a. Dog

b. Human volunteer

c. No visit


Results of AAT Study: The Paws that Refreshes Outcomes

Anxiety:

Dog: Reduced 24 pts

Human: Reduced 10 pts

Epinephrine

Dog: Reduced 17%

Human: Reduced 02%

Control: Reduced 07%

Blood pressure

Dog: Reduced 10%

Human: Increased 03%

Control: Increased 05%


Elephant-Assisted Therapy: South Africa Outcomes

Dolphin-Assisted Therapy: Israel, Florida, Ukraine


Therapeutic Riding and Cerebral Palsy Outcomes

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

Emotional reactions

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?


Social-Psychological Tx for Hospitalized Children Outcomes

Social Support

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

Psychological Control

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”)

Medical Training:

Communication and compassion not emphasized

Communication skills not modeled. MD training is itself inhumane.

Self Selection

Motives for becoming MD sometimes contrary to compassion/listening

prestige, wealth, status, authority

Some MD skills contrary to compassion/listening:

Detachment

Analytic / time-efficient / detail oriented

Personality qualities needed to get into med school

Competitive: (Steve Leonodakis, UCSF)

Cerebral

Technical


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:

23%

MD interrupts, directs pat. to particular disorder:

69%

18

MD interrupts pat. after ______ seconds.

Consequences?

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?”

4. Depersonalization:

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

Remaining classes:

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

http://sakai.rutgers.edu


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?

X

Female doctors: 1. Conduct longer visits

2. Ask more questions

3. Show more support


Training Physicians to Communicate: Patient / Provider Communication

The Standardized Patient

http://www.youtube.com/watch?v=vM3su8ZcriY

http://www.youtube.com/watch?v=JvCVg4MrhUE


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,

11/115/2012

Protease Inhibitors and AIDS

Increase life expectancy,

Miss 1 dose—now non-effective!

but:

Take 4X daily

Side effects: nausea, diarrhea

Must refrigerate


Reasons for Non-Adherence Patient / Provider Communication

Personality / demographics

Political, ideological orientation

Depression, stress, avoidant coping

Creative non-adherence

Change dose to preserve med

Mix with home remedies

Altruism: Polish rescuer

Michele Bachmann says HPV vaccine can cause mental retardation

9/13/2011


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

Care more

Basic politeness

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

http://www.youtube.com/watch?v=kDNoaSMKx0g


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