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Chapter 9

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PSYC 328
Blaine Ditto

PSYC328 Chapter 9 Notes Patient-Provider Relations: • People vilify and praise health care professionals. • This contradictory attitude is because health is of high value to us; since everything we do depends on our health. What is a Health Care Provider? • Canadians increasingly receiving much of their primary care from individuals other than physicians, including nurse practi- tioners and complimentary and alternative medicine providers Nurses as Providers: • “Advanced-practice nursing” refers to any registered nurse with more than 2 to 4 years of basic nurse education, and with more responsibilities. • Nurse practitioner: a registered nurse (RN) with additional education in health assessment, diagnoses, management of in- juries/illness • They can order tests or prescribe drugs. • They are affiliated with physicians in private practice. • They also provide care in community clinics, health centres, nursing homes, homecare settings. • Advanced-practice nurses work both autonomously and collaboratively with other health care providers in nursing out- posts, community health centres, emergency departments, clinics, specialty units, and long-term care facilities • They emphasize health promotion and illness prevention by explaining: • Disorders and their origins • Diagnoses Prognoses • • Treatments • They screen patients before they see the physician. • They work autonomously and with other providers. • They have a complimentary role rather than replace other providers. • They can deliver advice via Telehealth. Telehealth: use of info and communication technology to connect people with health services, such as advice, info, con- • sultation, diagnoses, treatment, family visiting using audiovisual conference. Physician Assistants as Providers: • Physician assistants: skilled health care team members who perform wide range of medical services • They are supervised by physicians as part of a physician (assistant) team to complement health services • Their duties are outlined in a practice agreement with the supervising physician and the facility • Their duties vary but can be: • Take medical history • Conduct physical exams • Diagnoses and treatment of illness • Order and interpret tests • Write prescription • Assist surgery • They know their limits and seek guidance from their supervising physicians if necessary • In Canada, the Canadian Forces is their main employer, but pilot programs are introducing physician assistants in facilities in Ontario. • Physician Assistant Education Master’s programs launched in 2008 to increase their numbers. • First year of program: seminar education • Second year: clinical training Why is Patient-Provider Communication Important? • Poor patient-provider communication has been tied to non-adherence to treatment and failing to disclose concurrent use of alternative treatments. • Criticisms of providers usually centre on volumes of jargon, little feedback, and depersonalized care Judging Quality of Care: • Quality of care is often judged by criteria irrelevant to technical quality, such as the manner in which the care was delivered. • Warm, confident, friendly provider is judged nice and competent. • Cool, aloof provider is judged incompetent and less favorably judged. • If provider is uncertain about nature of the condition, satisfaction declines. • But these are unrelated to technical quality of care. Patient Consumerism: • Patients have an increasing desire and need to be involved in the decisions that affect their health.  this does not mean that patients wish to be completely autonomous in their health-related decisions or that they necessarily want to have to pay to get better treatments • Physician’s authority used to be accepted without question, but now patients have consumerist attitudes to health care: Ca- nadians choose a combination of different treatments/products and health care practitioners that they think are best. • Change in attitude is due to society’s emphasis on achieving good health • To convince patient to follow treatment regimen, giving patient a role in the planning will help their commitment. Lifestyle is major cause of illness/disability • • Patients who see their behaviour as under the control of the provider are less likely to change lifestyle So modifying lifestyle needs full patient cooperation • • Internet also encouraged active patient role by giving them an easily accessible second opinion 38% of Canadians using the internet for health info, discuss what they find with their health care provider • • Info about surgery and alternative therapies are the most commonly discussed types of health information • Internet is where patients can get a second opinion • Patients have more knowledge on their specific case/illness if it is a chronic problem. • Therefore better communication between patient-provider is important and the provider and patient’s behaviour Setting: • The average visit in the practitioner’s office lasts from 12 to 15 minutes When trying to explain symptoms, they will interrupt before the 23 second rd • • Patient: • Must endure long wait for a short consultation • Will get interrupted multiple times by provider • Will be poked and prodded • If very ill, maybe someone else has to respon for you • May be anxious/embarrassed about symptoms • Hard to articulate when in pain/fever • Provider: • Must extract significant info quickly Has tight schedule • • Over-the-counter remedies can mask/distort symptoms Patient’s idea of which symptoms are important might not be the same for provider • • This setting has many sources of strain. Structure of Health Care Delivery System: • Canadian health care has a gatekeeper system • primary health care providers including physicians are usually the first point of entry for individuals into our publicly funded health care system • Primary health care providers facilitate provision of services and make sure care continues if specialized services are needed. • When secondary health care is needed a physician referral form is required from the primary health provider. • 3.5 million Canadians do not have access to a family physician so they must use walk-in clinics and emergency rooms. • Even having a family doctor does not ensure getting access • Patients go through long wait times. • Almost 1/4 of Canadians weren’t able to see a doctor on the same day they were sick. • More than 1/3 had to wait 6 or more days to get an appointment. • The long wait for primary care creates negativity, prolonged pain, worry, stress, anxiety. • The wait is even longer for specialized care. This drives people to try complementary and alternative medicine of deal- ing with their condition. • In Ontario, the majority have a family doctor but 1/2 had difficulty getting an appointment. • Over 90% of people who had used complementary alternative medicine (CAM) said yes to the question that if they have diffi- culty accessing a physician, they would use CAM again Spotlight on Canadian Research Box 9.1 - Why Do People Use Complementary and Alternative Medicine? • Complementary and alternative medicine (CAM): a diverse group of healing therapies not yet considered integral to con- ventional medical practice. • There are 300 different types of CAM • The universal health care system doesn’t cover the costs of CAM • Use of CAM continues to rise in developed nations • 3/4 of Canadians have used at least one CAM in their life and 54% had used CAM in the past year • General population use of CAM is only 20%, but 57% for breast cancer patients • Those who use CAM tend to be female, middle-aged, highly educated, with a lot of chronic health complaints and also use a lot of conventional health services. • Most chronic illnesses can only be managed, not cured and physician don’t like dealing with chronic illness is- sues. • Many conventional treatments have unpleasant side effects. • CAM users are more proactive about their health. • CAM providers give longer, more in depth consultations and consider psychosocial aspects of patient’s life • CAM users also receive benefits beyond symptom relief • A study showed that CAM users reported symptom relief, improved physical functioning, coping, em- powerment, hope, etc. • CAM users also made healthy lifestyle changes. Initial CAM use is usually be due to dissatisfaction with conventional care, but beliefs in more holistic/em- • powering health care will sustain CAM use. • With increased use of CAM, some people may simply be raised in a family where CAM use is the norm. Changes in the Philosophy of Health Care Delivery: • The role of the physician is changing • Use to be characterized by dominance and authority and this is changing due to the growing use of CAM and the rais- ing number of women in the medical profession • These changes promote more egalitarian attitudes among physicians, they also challenge the physicians' dominance, autonomy and authority • Responsibilities exclusive to physicians are now shared with other authorities, including other health care providers Holistic Health Movement and Health Care: • Western medicine is increasingly incorporating Eastern Approaches to medicine and nontraditional therapies such as meditation and biofeedback • Holistic health: idea that health is a positive state to be actively achieved, not merely the absence of disease now new concept in W medicine • Acknowledges psychological and spiritual influences on achieving health and curing illness through their behaviours, atti- tudes and spiritual beliefs. • It emphasizes health education, self-help, and self-healing • CAM (complementary and alternative medicine): herbal medicine, acupuncture, massage, dance therapy, etc. can be added or substituted for traditional care • Gaining popularity among Canadians as treatment options and increasing the demand for acceptance among conventional medicine providers • The biopsychosocial approach to health advocated by CAM use provides patients with a very different way of viewing their health • This change alters the provider-patient relationship. The latter becomes more open, equal and reciprocal. • CAM patients rate the quality of their interpersonal care and communication higher than do patients of conventional medicine physicians. • Therefore patient feels more empowered which was linked to greater symptom relief Provider Behaviours That Contribute To Faulty Communication: Not listening: Is a problematic behaviour • • Beckman and Frankel study (1984) Studied 74 office visits • • ¼ of patients were able to finish their explanation • Most of the patients were interrupted after 18-22 seconds • Prevents patients from discussing their concerns which leads to a loss of important information • Study: 31-45% of patients did not have their symptoms mentioned in physician’s notes • 31% with chest pain • 38% with shortness of breath • 45% with cough • Some physicians are suggesting that less attention should be given to physician’s impression of patient symptoms, and more attention be given to patients’ firsthand experience of their symptoms Use of Jargon: • Another important factor in poor communication • Why use jargon? • Keep patients from asking too many questions • Hide the fact that provider is not certain what the problem is • Impress gullible laymen • May be carryover from provider’s technical training • Often find it hard to remember that patients don’t share this expertise • the use of jargon may also stem from an inability to gauge what the patient will understand and an inability to fig- ure out the appropriate non-technical explanation • Arnold of Vllanova (13th century) wrote that the word 'itis' such as "stomachitis" would stop additional questions from the patient Baby Talk: A way to make patient understand their illness and its treatment (underestimate patient’s ability to understand) --> resort in • baby talk and symplistic explanations Overly simple explanations coupled with infantilizing baby talk can make the patient feel like a helpless child • • such behaviour can forestall questions Elderspeak: • A communication issue that is unfortunately common between health care workers and their patients • Elderspeak: Overly caring and infantilizing communication issue that sends the message that elderly people are incompet- ent • Use of overly familiar terms like “dear” , “sweetie” to elderly strangers • Can negatively impact health • Study: Elderspeak was linked to an increase probability of patients resisting care compared to normal communication, sug- gesting that elderspeak may create barriers to delivering needed health care • Also reinforces negative age-related stereotypes to both • May also have long-range health consequences for the person using elder speak --> one longitudinal study followed adults for 38 years found that those who held negative age stereotypes as younger adults had an increased risk of having a cardic event later in life • Communication training may be one way to effectively reduce this problem and its consequences Education and interventions designed to target ageism among health care workers may also be necessary to held address • this widespread issue since a recent review shows that physicians' attitudes towards the lederly tend to be more negative than not Nonperson Treatment: • Non person treatment may be employed intentionally to try to keep patient quiet during test, examination ,etc. or because pa- tient (as object) has become the focus of the provider’s attention. • Don’t want the patient to actually be there and fuss, give unhelpful suggestion, ask questions • Would be nice if patient could simply drop their bodies off like they do with a car in the garage • The emotion communicated by a provider in interaction with a patient can have a substantial impact on the patient's attitude toward the provider, the visit and his or her conditions • Study: women getting their mammogram results from worried physician experiences higher levels of anxiety, recalled less in- formation, percieved more information to be more severe, and higher pulse rates vs women who received info from less wor- ried physicians Stereotypes of Patients: Negative stereotypes of patients may contribute to problems in communication (ie Native people are seen as...) it can lead • to social distancing in health care encounters Satisfaction with treatment tends to be higher when person is seen by provider of same race/ethnicity. • • So it’s important to increase number of minority physicians • Health care needs to be delivered in the cultural appropriate way • Nova Scotia has set up provincial cultural competency guidelines to help health care professionals tailor health care so tha
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