Module: Health Psychology

Lecture: Consultation

Date: 9 February 2009

Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick

Tel: +44(24) 761 50222 Email: C.Bridle@warwick.ac.uk www.warwick.ac.uk/go/hpsych

Aims and Objectives Aim: To provide an overview of the psychological

influences within the consultation context Objectives: By the end of this session you should be

able to describe the following: the psychological factors relevant to the consultation

context; the behaviours that contribute to poor consultation; the effects / consequences of poor consultation; unconscious psychological processes that contribute to

consultation / communication inequalities.

Consultation Quality People judge adequacy of care by criteria that are

irrelevant to its technical quality

Key criteria relate to manner in which care is delivered Warmth, listening and empathy = communication skills

Satisfaction declines when Drs express uncertainty about a condition/diagnosis, etc.

Uncertainty expressed in >30% of consultations

Technical quality of care and the manner in which it is delivered are not necessarily related

Consultation Context

The patient must answer questions, be

poked/prodded, whilst in pain and unwell

may feel anxious, stressed and/or embarrassed

will want a clear diagnosis, answer and/or explanation

has expectations about the consultation and the Dr

The Doctor: must identify, elicit and

evaluate significant information quickly

may feel anxious, stressed and/or embarrassed

will be acutely aware of the need to find ‘the answer’

has expectations about the consultation and the patient

Consultation Factors … just some …

ConsultationContextDoctor Patient

Experience

Personality

Training

Targets

Evidence

The last patient

Litigation

Healthcare experience

Health status

Personality

Health literacy

Beliefs, Fear

Consulting motivation

Social network

Rapport Language Time

Ethnicity SES Gender

Bottom Line?

The consultation context is not naturally conducive to effective communication or patient and Dr satisfaction Realistic expectation is that good consultation should be

regarded as the exception and not the rule Surprising that consultation does not go ‘wrong’ more

often Nevertheless, patients describe Drs as poor communicators

What do patients highlight has indicators of poor communication?

Poor Communication

Behaviours that block patient disclosure Not listening / interrupting (Beckman & Frankel, 1984)

Depersonalisation (Shapiro et al, 1992)

Explaining away distress as normal (Edwards et al, 2002)

Attending to physical aspects only (Maguire & Pitceath, 2002)

Jollying patients along (Erenes et al, 2001)

Use of jargon (Samora et al, 1991)

An Example

Not Listening / Interrupting 74 GPs had 5K+ consultations recorded In 23% of the consultations patients finished

explanations, i.e. ¾ were interrupted before finishing

Average time to interruption = 18 seconds

(Beckman & Frankel, 1984;Dale et al. 2008)

But does it matter?

Beyond ‘satisfaction’ are there any ‘real’ consequences for a patient’s health that

derive from poor communication?

Effects of Poor Communication

1. Diagnosis2. Treatment3. Dose frequency4. Duration

(Bain et al, 1977) 1 2 3 40

102030405060

Not known or Incorrect

% o

f Pat

ient

s

Poor Communication Effects: Summary

Less likely to adhere to medical regimens … and not just because they are dissatisfied

Less likely to use health care services / seek medical help in the future

Less likely to attend check-ups, screening or other forms of preventive health care

More likely to experience negative, but largely preventable, health outcomes

(Rutter et al., 1996;Erenes et al, 2001)

Does it matter? YES!

Quality of communication in consultation can, and should, be

considered a risk factor for patient health

Hey, … I told you the first thing is to do no harm!

Iatrogenic harm

What can be done to improve communication, and will this improvement

lead to better health outcomes?

Understand the problem Intervene in the process

Evaluate the effects

Understanding the Dr’s Perspective

Why do Drs block? Pandora’s box effect Fear of increasing patient distress Limited time available Threat to one’s own emotional well-being Unaware patients fail to disclose important

information

Understanding the Patient’s Perspective

Why do patients fail to disclose? Drs’ blocking behaviour Belief that nothing can be done Worry that fears will be confirmed Reluctance to burden healthcare provider Desire not to seem ungrateful or critical Concern that it is not appropriate / legitimate to

disclose some problems

Intervening to Improve Communication

Providers: Med Ed – communication

as a core clinical skill Modelling – shadowing

effective communicators Ongoing assessment and

feedback Peer support Self-reflection

Patients: Preparation – planning

questions in advance Change attitudes –

personal responsibility Realistic expectations -

medicine and the certainty of uncertainty

Effects of Good Communication

Increased patient satisfaction, greater recall of advice, and higher adherence (Hall et al, 2005)

Improvements in disease control markers such as HbA1c, blood pressure and circulating stress hormones (Stewart, 2005)

Increased Dr satisfaction and amelioration of burnout (Roter et al, 2003)

If interventions are effective in promoting better communication between Drs and

patients, does that mean the ‘communication’ problem has been solved?

No

Communication Inequalities

Providers give less information, are less supportive and less clinically proficient with certain patients: Ethnic minorities (Cooper, 2002) Low SES groups (Schmelkin et al, 1998) The elderly (Haug, 1987) Females (Hall et al, 1993) Chronic illness (Wilcox, 1992) Psychological symptoms (Hall, 1993)

Why?

Widely regarded as being a consequence of Drs beliefs about members of various social

groups?

i.e. Stereotypic knowledge

Recall from Lecture 1: Stroop, and person perception

New methodologies:Stroop & Person-perception

Race of Person

Colour

Of Ink B

W

Match

Mismatch

African-american (Black)

Mismatch

Match

Caucasian (White)

(Karylowski, et al., 2002)

Stroop and Person-Perception

Race of Person

Colour

Of Ink B

W

Bill Cosby

Oprah Winfrey

African-american (Black)

Rosie O’Donnell

Jerry Seinfeld

Caucasian (White)

(Karylowski, et al., 2002)

Name/read the colour of the ink Mis-match

Match

Slower to name ink colour in the mismatch condition Mismatched info requires

additional processing time What is the mismatched info?

Ink and skin colours are mismatched - not the name

Mismatch can only occur if reading name generates racial category information

Info generated in milliseconds

Stroop and Person-Perception

Reac

tion

Tim

e (m

s)

Ink Color(Karylowski, et al., 2002)

Racial categories come to mind automatically

Just because some stereotypes are automatically

activated doesn’t mean they necessarily influence

our behaviour, ability, judgment, etc.

Three experiments to convince you otherwise

Automatic Effects on Behaviour University students - mean age 24 years Prime: Words presented without awareness (<20ms)

Elderly stereotype words, e.g. wrinkle, old, knitting Neutral words, e.g. thirsty, clean, telephoneYou were just primed – ‘wrinkle’ – were you aware?

Told experiment is over Outcome measure: Time taken by the participant to

walk to the lift – 9.75m Design: Randomised cross-over (7 days)

(Bargh et al 1996)

Study 1 Study 20

2

4

6

8

10

12

14

16

18

20

10.5 10.1

19.4 19.8

Neutral

PrimedSe

cond

s

ResultsParticipants exposed to the elderly prime took

significantly longer to walk to the lift …

… compared to unexposed participants and

themselves, i.e. cross-over in Study 2

Explanation: Behaviour unconsciously adjusted to be

consistent with primed stereotype

Mdif = 9.3 secondsAlmost twice as long!

Automatic Effects of Performance

UK gen pop: N=1000; M age = 35; 53% female Prime: Write about the behaviour, lifestyle and

attributes of the typical X University professor or football support No prime/writing, or 2 or 9 mins prime

Outcome: Score on a 60 question general knowledge test

Results

No Prime 2 Mins 9 Mins20

25

30

35

40

45

50

55

60

No Prime 2 Mins 9 Mins20

25

30

35

40

45

50

55

60

Prime: ProfessorImproved performance – stereotype consistent

Prime: HooliganImpaired performance – stereotype consistent

Automatic Effect on Interaction White students unknowingly screened for relevant

stereotype belief – black males more aggressive Participate in ‘response task’ study – very boring Prime: Black male or white male faces presented without

awareness (<20 ms) Near end of ‘task’, message appears - ‘Warning: Fatal

Error Restart Computer’ Told they must re-do the entire (boring) task

Outcome: Hostility towards the experimenter - videotaped

Results

0123456789

10

2.8 3.1

8.29.1

Level of hostility rated by experimenter and blinded assessor

Greater hostility among stereotype-activated participants black face prime

Behaviour became consistent with stereotype belief

ExperimenterRating

Blinded Assessor

Host

ility

Ratin

g

Once activated, stereotypic knowledge influences behaviour, performance and judgements about, and

interaction with, other people

Helps us understand evidence showing that, for certain social groups, clinicians offer less information, less

support and are less clinically proficient

… of course, patients do it too!

Conclusions Patients judge quality of care by how satisfied they are with

the consultation interaction – especially communication Quality of communication is linked strongly to clinical

outcome across wide range of illnesses Quality compromised by both Dr and patient factors, as well

as contextual demands Interventions for Drs and patients can improve consultation

quality, satisfaction and clinical outcomes Behaviour, communication and decision making can be (are

often) influenced by stereotypic beliefs Awareness of stereotype influence is a necessary but not

sufficient precondition to prevent their negative effects

Summary This session would have helped you to understand …

the psychological factors that are relevant to the consultation context

the behaviours that contribute to poor consultation / communication between Dr and patient

the effects / consequences on patient behaviour and health of poor consultation / communication

unconscious psychological processes that help to explain consultation / communication inequalities

Any questions? What now?

Obtain / download one of the recommended readings

In your small groups consider today’s lecture in relation to tutorial tasks:

a) integrated template b) ESA question