Medical Communication

What are the functions of psychological communication

What are two lines of thinking that support SDM?

Ethics (it’s increasingly being seen as more ethical to involve the patient in the decision-making process)

Treatment variation: Treatment is often influenced by doctor’s preferences, not evidence, so SDM can help patients make better informed choices for themselves

What essential elements are there in SDM?

1. The professional informs the patient that a decision is to be made and that the patient’s opinion is important;

2. The professional explains the options and the pros and cons of each relevant option

3. The professional and patient discuss the patient’s preferences; the professional supports the patient in deliberation

4. The professional and patient discuss patient’s decisional role preference, make or defer the decision, and discuss possible follow-up

Are the four SDM steps implemented into clinical practice?

No, in a study it was shown that the elements of SDM are often ignored. Furthermore it was shown that patients often want more information than they are given

What are the positive aspects of patient communication aids in SDM?

They were shown

to improve knowledge and expectations, improve patient involvement in decision making, decrease decisional conflict and the number of postponed decisions, and improve the agreement between patient choice and patient values

Bounded rationality

The idea that human decision-making is influenced by biases and the like

however, this is an argument for SDM, as doctors also have these biases

What methods do we use in studying medical communication?

Surveys, interviews, focus groups, experiments, record what's happening in the consultation room

 

How does communication influence health outcomes?

Both directly: Communication → Improved health and wellbeing

And indirectly: Communication → Proximal outcomes (understanding, satisfaction, trust) → Health outcomes

Or: Communication → Proximal outcomes → Intermediate outcomes (access to care, commitment to treatment, quality decision making) → Health outcomes

What dimensions of trust are there in the client / clinician relationship?

• Competence: Having relevant knowledge

• Honesty

• Fidelity: Having patients' best interest at heart

• Confidentiality (in the US, not NL)

• Caring: Care and sympathy

What was shown in the test where they manipulated different outcomes (gender, verbal and non-verbal uncertainty) and showed how it influenced patient trust?

Nonverbal uncertainty caused less trust, but verbally expressed uncertainty didn't (more honest? Or because it wasn't strong enough)

What influences amount of patient trust?

Outfit

Tested: The relationship between eye gaze on trust

Does looking at computer screen (vs patient) decrease trust?

More face gaze towards patients associated with lower trust

What interactional functions do gaze shifts have?

Gaze shifts have various interactional functions (introducing a different topic or entering data)

Indicator for patients that it's time to stop talking

 

Gaze shifts highly variable --> Need to think of different ways it can be used

What things does providing information to the patient affect?

Relationship

Participation in decision making

Treatment adherence

Emotions (sense of control, uncertainty, dysfunctional cognitions)

Why is it important how the clinician provides information to the patient?

The person needs to be able to hear, understand, recall and use the information

What are cognitive deficits that could prevent you from remembering what was said to you by the clinician

• Selective attention: Remembering things that are important to you

• Limited memory capacity: Forget things easily (esp. in elderly patients)

  • Emotions

Prognostic awareness

The awareness of a patient of their prognosis - providing information helps improve this

What was shown in the test where they wanted to find out about how much patients want to know what their prognosis is, and how accurately they estimate their prognosis?

Around 1/3rd of patients don't want to know their prognosis, goes up the lower the prognosis is -- want to be in denial

Relationship between denial and fatigue: Lower fatigue if you have high denial

20% of patients who think they will be cured when they won't be

Agreement low: clinicians can't predict if they want to know the prognosis, and the agreement between physicians and patients' prognoses is low

Physicians should explicitly ask whether patients want to know prognosis

What were the results of the test where it was tested how clinicians communicate uncertainty to parents of patients in neonatal / intensive care wards?

Large variety of topics: Uncertain diagnosis, process of dying

Wide array of communication strategies

Mostly implicit uncertainty

What three phases were there in the intensive care unit test and what different communication?

Phase 1: Unstable condition, additional diagnostic testing and care planning

Communication: Uncertainty related to diagnosis and diagnostic procedures, physicians providing short-term action plans and explanations

Phase 2: Deteriorating condition, limited treatment options

Communication: Uncertainties related to short-term prognosis, choice of treatment efficacy and risks, emphasizing uncertainties and sketching scenarios (providing reassurance)

Phase 3: Imminent death, treatments become futile

Communication: Eliminating uncertainties, except the process of dying

In the intensive care test, it was shown that the parents don’t respond that much to the uncertainty that is conveyed. What three things do parents respond to?

• Checking their perspective on uncertainty

• Providing emotional support

• Acknowledging psychological impact of uncertainties.

When should patients be involved in the decision making process?

Only in case of a:

Preference-sensitive decision (best treatment

depends on subjective trade-off)

Not in case of

Effective decision (evidence-based consensus

about best treatment)  treatment advice

What were the results in the test that tried to improve SDM?

Communication aid: Did not help in how much doctor involved patient, patients sometimes also felt burdened by having to make the choice

Physician training: Helped