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Chapter 5


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Western University
Psychology 2036A/B
Bruce Morrison

CHAPTER 5: COMMUNICATION IN MEDICAL SETTINGS PERCEIVING AND INTERPRETTING SYMPTOMS: - people have difficulty deciphering and even noticing symptoms - people have difficulty assessing their internal state o people’s estimates of their own heart rate are not well correlated with physiological indices - differences account for the variability in individual’s decisions to seek medical advice - differences in the perception of symptoms o individuals who pay a lot of attention to their internal states are consistently more likely than others to notice a symptom o mood, personality traits and stress  good mood – view health more positively; report fewer illness- related thoughts  bad mood – report more symptoms, less likely to believe that any behavior they engage in will relieve symptoms and assume they are more vulnerable to future illness  negative affectivity trait have a greater proclivity to report symptoms than do those with low NA trait in the absence of any objective difference in health status • those with high NA trait, experience consistently higher levels of distress and dissatisfaction over time and across different situations • “those with high NA trait appear to be hypervigilent about their bodies and have a lower threshold for noticing and reporting subtle bodily sensations” – Pennebaker  due to pessimism, people are more concerned about the implications of the perceived symptoms  stress elevates symptom reporting – can precipitate or aggravate the experience of symptoms • experience a lot of stress are more vulnerable to illness • believe they are more attracted to illness will attend more closely to their bodies • inward focus of attention can lead to interpret acceleration of heart rate or breathing, as symptoms as illness • those experiencing a lot of stress are more likely to seek health care than those under less stress, even with equal symptoms o gender contributes to perception of symptoms  studies done into which gender is more sensitive to their internal bodily signals are equivocal  women seek health care more frequently but may delay longer in seeking the care  men attribute minor symptoms minor symptoms to major problems more readily than women o age differences in reporting symptoms  elderly people complain of physical symptoms that prompt them to seek medical intervention  older people perceive age related bodily changes as illness  tendency for symptoms to increase as one ages may be due to decreased cognitive performance that some adults experience • mild cognitive impairment is associated with the perception of poorer body functioning  older people may over report their symptoms  older patients were less likely then younger people to notice cancer symptoms – maybe because they saw less perceived risk of developing the disease than younger people did  older men delay seeking help for symptoms that might be viewed as embarrassing – such as STD o the environment is a factor when interpreting symptoms  lack stimulation – more likely to focus on internal states  boring or tedious environments leads to people amplifying bodily sensations  environments that are isolated or discourage interpersonal communication allow people time to ponder about their bodily sensations (libraries or loud factories) • may overestimate changes in their physiological functions – heart rate and nasal congestion  when environment is exciting or demands a great deal of attention or concentration, people are less likely to notice internal symptoms  engaged in physical activity, internal symptoms are unnoticed • “competition of cues” – distraction can serve as a useful short-term coping method - how a symptom is interpreted is influenced by a variety of factors o prior experience with the symptom o how common it is among someone’s family, friends, acquaintances, and culture  the fact that a symptom is widespread may lead people to attach little significance to it – sometimes unwise o cultural factors can influence interpretation  Chinese respondents were less likely to recommend enlisting emergency medical aid than English or Punjabi  Cross-cultural differences in reporting vision problems – cataract patients in Canada and Spain were less likely to report vision problems than Danish or American patients o learning how to experience the symptoms  people in different cultures learn about the experience of symptoms differently • in Western Culture, men have been taught to avoid complaining about emotional and physical symptoms of discomfort – a sign of weakness • children are taught at a young age which symptoms are important vs. trivial o our family contribute to our interpretations  we consult our family and friends for help in interpreting the meaning of a symptom  “the lay referral system” – informal network of non-practitioners who offer their own interpretations long before any medial treatment is sought; they give personal advice, when to seek medical attention or recommend home remedies SEEKING MEDICAL CARE: - when a person seeks help is a function of the specific nature of the symptoms experienced as well as of the person’s social and personal needs - most obvious determinant of when people seek help is the symptoms they experience o symptoms that are new, unexpected, painful disruptive, highly visible, or that affect highly valued body parts are interpreted as more serious and are more likely to lead someone to seek medical care o if recognizable, experienced in the past, the symptoms is unimportant and will probably be ignored o if symptom interferes with every day activity like job or athletic events, medical care is sought o symptoms also gain a person’s attention if they attack a visible part of the body like the face or eyes or if important to self-identity (lump on women’s breast) o the symptom that leads people to seek medical care the most is pain - females seek more care than males - rural residents visit their health practitioner more than those in an urban dwelling o urban dwellers are more likely to seek specialists - symptom recognition is the major factor in seeking medical care Delaying Medical care: - delaying in seeking diagnosis and treatment is linked to increases in morbidity and mortality of cancer patients - in medical emergencies, people seek help with minutes or hours o most heart attack victims are initially confused with their symptoms and attribute them to a wide variety of causes  arrive at hospital or seek the care between 2.5-4 hours after the onset of their symptoms  victims spend about 65% of their time deciding whether their symptoms require medical attention  even after correctly attributing the symptoms to a serious condition, people will waste a substantial amount of time before taking direct action to receive treatment - a model that outlines different stages of delay: - patient delay is the period between one’s first awareness of a symptom and treatment for that symptom - patient delay occurs in stages… o (1) appraisal delay – time it takes for a person to decide that a symptom is a sign of illness o (2) illness delay – the time between recognizing one is ill and deciding to seek medical care o (3) behavioral delay – time that elapses between the decision to seek medical care and acting on this decision by making an appointment o (4) medical delay (scheduling and treatment) – interval between making an appointment and first receiving medical care - researcher interviewed patients in a waiting room to see a physician o least delay meant they were in the most pain o total delay was longer when the patients had other problems in their lives, read about their symptoms, who were older, waited for symptoms to go away o best predictor of illness delay was whether the person had a new symptom (see old symptom as normal and could tolerate it) o patients who imagined they were severely ill and imagined negative consequences of being ill had length illness delays o people who believed they could not be cured delayed treatment - this study should be interpreted with caution because of its methodological limitations o study only included people who already came to the doctors office o study uses retrospective data – asked to recall specific points - most research investigates delay behaviors on cancer patients o important because delay has an impact on survival rate o 20-30% of women with breast cancer symptoms delay seeking medical advice for three months or more  prospective and retrospective research reveals that appraisal delays account for the majority of the total delay time  high and low levels of fear are associated with longer delay times in reporting breast cancer symptoms – doctors, hospitals, cancer, embarrassment, chemotherapy, disfigurement, pain, loss of femininity, and loss of control • these fears will lead to delays in reporting symptoms in order to avoid having to deal with these issues  those with little fear are likely to delay seeking medical advice because they feel it is unnecessary  those that are trustful with others are less likely to delay seeking medical advice - social influences affect delay behavior o women feel if they are diagnosed with breast cancer their men will leave them o role responsibilities of married women with children influence delay behavior  “devoting time and attention to the needs of others, making domestic arrangements prior to biopsy, arranging for child care during the summer and school holidays and dealing with work related demands all receive priority over discovered breast cancer symptoms” - the age of the patient is a factor o said to affect patient delay o older age is associated with longer symptom reporting delay by breast cancer patients - these types of studies divide the time between onset of symptoms and start of treatment (total) into two main phases: delay by patients (time between onset of symptoms and time of first medical consultation); delay by providers (any delay between first medical consultation and treatment) o based on this definition, many older women engage in patient delay o younger women also delay in reporting symptoms and experience more delay by their health care provider o based on study done by Richards et al. we can conclude that health care providers were less likely to delay treatment of older women because the older women were at a more advanced stage of cancer (delay in seeking advice) o delays by providers do not associate with decrease survival in patients presented with breast cancer - studies done on heart attack patients show that older patients and women tend to delay seeking medical care longer - in Canada, 3.5 million people do not have a regular physician – contributes to patient delay PHYSICIAN-PATIENT INTERACTION Basic models of physician-patient interaction: - the active-passive model describes a relationship in which patients are unable to participate in their own care or to make decisions for their own welfare because of the severity of the condition o Example: patient has a severe injury or are in coma - the guidance-cooperation model applies when patients seek advice from the physician. The patient answers questions of physician about symptoms, but the physician is responsible for determining the diagnosis and treatment. Physician is responsible for the thinking and decision making o Example: an infection or sprain - the mutual participation model the patient has more responsibility than in the other models. The physicians and patient make joint decisions about every aspect of care, from deciding what diagnostic tests the patient should undergo to the choice and implementation of treatment. Input and responsibility are shared equally. - Assertiveness and active involvement on the part of the patient are the precursors of an effective partnership with the physician - The mutual participation model is seen as the ideal relationship between physician and patient - The typical relationship is one which the physician possesses a greater degree of power than the patient - Roter et al. used audiotape analysis to describe communication patterns and revealed five distinct communication patterns: o Narrowly biomedical characterized mainly by biomedical talk (Medication may make you sleepy), closed-ended medical questions (Are you in pain when you walk), and very little discussion of psychosocial factors (problems of daily living, emotions…etc) – 32% of the visits o Expanded biomedical includes closed-ended medical questions, more moderate levels of biomedical talk and psychosocial exchange between the physician and patient – 33% of visits o Biopsychosocial suggests that biological, psychological and social factors are all involved in any given state of health or illness – 20% of visits o Psychosocial includes a substantial amount of psychosocial exchange between the physician and patient – “it is important to get out and do some exercise” – 8% of visits o Consumerists the use of the physician as a consultant who answers questions rather than asking them – 8% of visits - Szasz and Hollender said that the mutual participation model was “essentially foreign to medicine” o 50 years later and this does not seem to be true - according to patients the collaborative model is preferred (more psychosocial) - physicians were satisfied with the consumerist pattern – the visits made more use of their time - in Roter et al study, the consumerist pattern occurred in only a small proportion of visits o might think that this pattern will increase as younger cohorts get older and need more health care - least preferred by patients and physicians was the biomedical approach o biomedical patterns were used most often with younger male physicians and by those physicians interacting with patients who are sick, older and have lower income - “what people want from their family physician” 1. always honest and direct 2. listens to me 3. encourages me to lead a healthier lifestyle 4. does not judge; understands, supports 5. someone I can stay with as I grow older 6. tries to get to know me 7. acts as partner in maintaining health 8. treats both serious and non-serious conditions 9. attends to emotional and physical health 10. can help with any problem - Patient-Centred care model: o Exploring the disease and illness experience  What the patient believes is wrong with them  Their feelings about being ill  Impact of the illness on their daily functioning  How they believe the physician should proceed o understanding the whole person  understand the disease and the experience of illness in the context of the patient’s life o finding common ground  the specific problems and priorities  goals of treatment  role of both the physician and patient o incorporating prevention and health promotion  physician and patient must work together to enable the patient to take the steps required to control and improve his or her own health o enhancing the patient-physician relationship  relationship will aid the physician in recognizing the specific approach that should be taken with the patient in order to meet the patient’s needs o being realistic  physician must recognize their own limits  manage their time and emotional energy in a way that provides the most benefit to their patients Patient-Physician communication: Information giving – - in order to participate in decisions, patients need information - researchers have found that “patients tend to be more dissatisfied about the information they receive from their physicians than about any other aspect of medical care” - physicians overestimated the amount of time they thought they gave the information o in a 20 minute interview, they estimated taking 9 minutes giving information, but really they took 1 minute - physicians sometimes choose to withhold information to protect them from worry o this could be why the elderly have less education or a poor prognosis receive less information - in a study on the diagnosis of parkinson’s disease, the physicians had difficulty deciding how, when and whom to tell and difficulty in deciding just how much information to share about the patient’s diagnosis and prognosis o the physician was positive and overly optimistic o they avoided details about medication, side effects and did not explore problems with long term medication use - patients want to be given as much information as possible o lowered blood pressure, and less psychological distress as well as improvement of symptoms when the information presented is coupled with emotional support Participation – - generally, healthier, younger, and better educated patients prefer greater involvement in health related decisions - those in a lower social class prefer a more passive roles - compared to Whites, Hispanics, African-American and Asians were less satisfied with the involvement allowed them by their physicians - providing the amount and type of participation that patients want in their health care enhances patients’ adjustment to and satisfaction with medical treatment - patients who prefer an active role in their treatment tend to recover faster than those who prefer an inactive role - some physicians are more inclined than others to share their authority and decision making - when determining how much in
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