Psychology 2151 - Module 9

Patient-Provider Relations

Health Care Provider

Broad term to describe the various individuals that provide health care services

Nurse practitioners

a type of advanced practice nurse that is becoming increasingly more common in Canada. They have additional education in areas like assessment, diagnosis, and treatment, and have the ability to order tests and prescribe medication

Telehealth

refers to the providing of a variety of health services through the use of communication technologies like phone or video calls (usually by nurses); useful for rural/remote areas - especially in Indigenous communities

Physician assistants

skilled healthcare providers who can perform a wide range of medical services under the supervision of a physician. They can have many responsibilities and capabilities, depending on where they are employed - used to be most common in military setting

Common duties of physician assistants

• Taking patient histories

• Conducting physical exams

• Diagnosis and treatment

• Ordering and interpreting tests

• Writing prescriptions

• Assisting in surgical procedures

Other professionals involved in providing healthcare

• physiotherapists

• social workers

• occupational therapists

• nutritionists

• psychologists

often take part in inter-professional teams that deal with complex, specialized health issues in a comprehensive way

Potential problems with collaborative health care

communication - It may be the case that the providers attending to a single patient are not communicating with each other about diagnoses, treatment plans, or important medical decisions, which could decrease the quality of care provided

jargon

most common issues mentioned in criticisms of health care providers include the use of excessive _______

Issues with the use of excessive jargon

decreases understanding, too little feedback from providers, and a feeling that care is impersonal

Importance of patient-provider communication

not only impacts the judgement from patients, but can also lead to problematic outcomes like non-adherence to treatment and failure to disclose important information if it is judged to be poor

Self-determination theory

defines autonomy as one of our three basic needs as human beings - people have a desire, and even feel a need, to be involved in decisions that affect their health

Patient Consumerism

physician’s authority would be accepted without question before, but now consumerist attitudes that see healthcare as more of a transaction have been increasing

more, less

when patients feel their behaviour has been put under the control of a physician, they will be ____ resistant and ____ adherent to treatments

less, more

if a patient believes their behaviour is under their personal control, they will be ____ resistant and ____ adherent to treatments like a healthy diet and exercise when prescribed by a physician

Internet as a healthcare tool

a third of Canadians who find health information on the internet will then take this information to their provider for further discussion

Problems with using the internet as a healthcare tool

risk that information found by patients will not be accurate or appropriate for their health issue, and an excessive use of the internet for health information has been shown to be unhelpful, sometimes even increasing health anxiety

Role of setting in quality of patient-provider communication

• often limited amount of time (physician’s busy schedule)

• often a stranger (embarrassing/uncomfortable to reveal personal information)

• harder to discuss/disclose issues when in pain/discomfort

Issues with publicly funded healthcare

• Primary physician needs to be first point of contact for other specialists/services

• Many people don’t have a family doctor (primary care physician) thus have difficulty accessing secondary specialists/procedures (Indigenous communities in particular)

• Difficult to get same-day care (Canada ranks low compared to other industrialized countries)

• Low physician-to-patient ratio

• Long waits

• Physicians have difficulty accessing diagnostic tests for their patients

Low physician-to-patient ratio

physicians have too many patients and are too busy to provide timely consultations

Complementary and Alternative Medicine (CAM)

refers to treatments that are not considered to be typical or conventional medical practices; may be delivered by a health care provider, or they may be more like self-care in nature

common in:

• breast cancer patients

• people with chronic issues (e.g. asthma or migraines)

Examples of CAM

• Chiropractic

• Massage therapy

• Homeopathy

• Acupuncture

Common Characteristics of individuals who use CAMs

• more likely to be female

• middle-aged

• highly educated

• have a large number of chronic health complaints

• more consumeristic

• proactive about their health

Holistic health

the idea that health is a positive state, not merely achieved through the absence of disease; involves both psychological and spiritual influences, and places responsibility on the patient to achieve health through their attitudes, behaviours, and beliefs; emphasizes health education, self-help, and self-healing, often through the use of CAMs;

• better communication between patients and providers

• more egalitarian and reciprocal - patient feeling supported by and cared for by their provider - leads to empowerment and feelings of greater symptom relief among patients

Problematic Provider Behaviours and Communication

• Not listening

• Use of jargon

• Baby talk

• Elderspeak

• Patient Stereotypes

18-22 seconds

patients only speak for about ___________ before being interrupted by their provider

less

When male and female report the same symptoms, such as chest pain, medical intervention is seen as _____ important for females

gender pay gap

There also exists a _______ ____ ____ among physicians, whereby male physicians make more on average than female physicians (by almost $100,000)

mortality, less

female physicians have lower _______ rates and their patients typically require ____ treatment than male physicians

Problematic Patient Behaviours and Communication

• Neuroticism

• Anxiety

• Linguistic barriers

• Attitudes

• Misleading information

Neuroticism

________ has been shown to lead to an exaggerated picture of a patient’s symptoms, which can compromise a physician’s ability to gauge the seriousness of a condition

Patient Behaviours and Communication: Anxiety

can impact communication, as the patient will likely be less able to focus

less, more

Dissatisfied patients are ____ likely to use medical services in the future, ____ likely to turn to CAMs

Trait of effective communicator

a single trait possessed by these individuals: their interest in people. Rather than being a personality trait, this is more of a motivational factor, suggesting that any practitioner who is motivated to do so can become an effective communicator

Patient-centered communication

This method enlists the patient to be involved in decisions about their health care and encourages the provider to try to see disorders and treatments from the patient’s point of view; leads to more cooperative patient and health outcomes

Two interview techniques used in communication education

1. the NURSE model

2. the WEMS model

The NURSE Model

Naming, Understanding, Respecting, Supporting, and Exploring; which promotes empathy

The WEMS Model

Waiting, Echoing, Mirroring, and Summarizing; which promotes active listening

Treatment non-adherence

when a patient does not adopt the behaviours or follow the treatment prescribed by their physician

prescription medications as prescribed

In Canada, it has been found that the most common form of non-adherence is not taking ___________ ____________ __ __________

fill their prescriptions

one in three Canadians fail to ____ ____ ________ after receiving them from their physician

financial barriers

just under 10% of Canadians face _______ _______ that prevent them from filling their prescriptions

highest

adherence is _______ among those with diseases like HIV, arthritis, gastrointestinal disorders, and cancer

lowest

the ________ adherence levels are found among those with diseases such as diabetes, pulmonary disease, and sleep disorders

Commonly used self-report survey

Medical Outcomes Survey

Medical Outcomes Survey

uses a Likert scale to assess patient adherence to treatment

Alternate ways to measure adherence other than self-report

• measuring treatment outcomes

• the number of appointments attended by the patient

• measuring their dose count

• checking pharmacy records

• Medication Event Monitoring Systems (MEMS)

• assessment of biomarkers

Creative non-adherence (intelligent non-adherence)

occurs when a patient does not simply fail to follow a treatment regime, but instead will modify or supplement their treatment programs

Examples of creative non-adherence

• a patient lowers their dosage of a medication to make it last longer or to keep a reserve for another time they may need it, or perhaps a family member may need it

• patients will take more of a medication than they were prescribed as a way to heal themselves more quickly (not how it works)

Physician beliefs about patient non-adherence

• uncooperative attitudes

• patient ignorance

• lack of motivation

• forgetfulness

poor communication

One of the greatest causes of non-adherence is _____ _________

High quality communication that leads to better adherence

• jargon-free explanations of their diagnosis

• etiology

• treatment options

lower

Treatment over a long period of time and complex regime have _____ adherence

Protease inhibitors

used to treat HIV/AIDS, must be taken four times a day, and must be refrigerated. One missed treatment can lead to permanently unsuccessful treatment. All of these factors lead to decreased adherence

Four categories to increase adherence

1. technical

2. behavioural

3. educational

4. multifaceted/complex

Technical interventions

includes things like simplifying treatment regimes, have been found to be the most effective at encouraging adherence

Placebo

a medical procedure that produces an effect in a patient because of its therapeutic intent and not its nature

less

there is ____ mortality in groups such as newborns and young children in modern times

Middle Ages

treatments became less lethal to the patient but still ineffective

Treatments in Middle Age Europe

• unicorn horn (ground ivory)

• animal gallstones

• ground snakes

• even powdered Egyptian mummies

Treatments from 17^th and 18^th centuries

• bloodletting

• freezing

• induced vomiting

Placebo effect

the medically beneficial impact of an inert treatment

Brain imaging studies

shown that placebos can mimic the brain activity seen with non-placebo treatments, such as decreased activity in pain regions or release of opioids, the body’s natural painkillers

stronger

providers who express warmth, confidence, and empathy typically get ______ placebo performance outcomes than those who are more remote and formal in their interactions

Influence of provider’s attitude toward a treatment

legitimate drugs and effective treatments can suffer if providers do not convey confidence in their efficacy:

• In one study, the effectiveness of a sedative, chlorpromazine, was found to be influenced greatly by the attitudes of the provider. When providers expressed doubt about its effectiveness, the normal effectiveness level of 77% dropped to just 10%

Effects of patient characteristics on placebo effect

people who are optimistic respond better to placebos that produce positive effects, because their nature makes them more likely to expect positive effects. Conversely, individuals who are pessimistic report better results with placebos that produce negative side effects

Effects of the Big Five personality traits

People who score high on the traits of agreeableness, openness, and extraversion are more responsive to placebos, as found in studies examining patients with irritable bowel syndrome. Out of these three traits, extraversion is the only one to uniquely predict placebo response. Openness to experience and high emotional awareness have also been linked to placebo effects in studies examining patients with chronic back pain

Effects of setting on placebo effect

If a placebo is administered in a more formal medical situation, like a hospital with nurses, medical equipment, and other patients, it will likely have a more powerful effect

contextual healing

Some researchers argue that placebos are so dependent on the context in which they occur, they should be renamed _________ _________

Blue and green pills

associated with sedation

White pills

associated with pain reduction

Yellow and red pills

associated with stimulation

mortality

Adherence to placebos is even correlated with lower ________ from illness

Double blind studies

two experimental groups — one that receives the legitimate treatment that is under study, and another that receives a placebo treatment; both the participant and the experimenter are unaware of who has received which treatment

• This type of design is used to prevent bias, both on the part of the participant in terms of expectations of treatment efficacy, and the experimenter with regards to their expectations for the results as well as how they interact with each patient