D503 Behavioral Sciences - Final Exam

Four standards for effective doctor-patient communication (define each)

Complete (all relevant info, nothing unnecessary); Clear (no jargon, standard terminology); Brief (less is more, be direct); Timely (dependable in providing info to patients, colleagues, families, communities)

Swarbrick (2006) — eight domains of wellness

Emotional, Environmental, Financial, Intellectual, Occupational, Physical, Social, Spiritual — healing addresses all eight, not just disease

Swarbrick — which domains are easiest to confuse?

Intellectual = recognizing creative abilities and expanding knowledge/skills; Occupational = satisfaction and enrichment derived from one's work; Emotional = coping with life and creating satisfying relationships

Nine barriers to effective dentist-patient communication

Language; distractions; physical distance; personalities; workload; varied communication styles; conflict; shift or personnel change; professional training differences

Hampton (2003) — why communication matters

Satisfied patients report more effective consultations, fewer complaints, less litigation; positive communication yields fewer errors, better outcomes, higher morale, lower burnout, better staff retention

Oculesics

The study of eye contact — signals attention and regulates the conversation; breaking it reads as disinterest

Why might a patient not make eye contact?

Shy, ashamed, avoidant, or deceptive — do not assume any one

Kendon (1967) — four functions of eye contact

Cognitive (information about another's perspective); Monitor (are they receptive, do they like what we're saying); Regulatory (averting gaze when acknowledging someone); Expressiveness (emotions of sadness or happiness)

Proxemics — and why dentistry is a special case

The study of the use of space; dentistry necessarily works inside the patient's intimate zone, so you ask before entering and explain before you move in

Hall (1959) — four spatial zones with distances

Intimate up to 18 in (personal, friends); Personal 18 in to 4 ft (colleagues in clinics); Social 4 to 12 ft (business transactions); Public 12+ ft (public speaking)

Hall (1959) — two caveats to know

Sample was White middle-class US men and women; the study guide asks for five zones but the slide lists four (some versions split public into close and far phases) — ask Dr. Schrader

Space as power

Whoever can spread out has the power; slides note women tend to give up space while men become aggressive when space is taken away

Territoriality vs. territorial markers

Territoriality is the sense of ownership ("those are my hand pieces"); territorial markers are how we mark a desk, cubicle, or operatory

Mirroring / being in synch — what it is and is NOT

Adapting to the patient's frame of reference: match tone when appropriate, reuse their descriptive language, adjust pace and manner. NOT verbatim repetition and NOT agreeing with everything they say

WHO (1946) definition of health — all four parts

A state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity

Illness vs. disease

Illness = social and psychological — perceptions, behaviors, experiences (stress raising cortisol); directly influences disease. Disease = cellular or sub-cellular pathological process of determining abnormalities

Kleinman on illness

Illness is the socio-cultural context in which disease is experienced, which the patient and family label and explain so it becomes personally and socially meaningful

Doctor-centered care

Body is mechanical, living is mechanical, generally one central cause per disease, providers act as detached observers

Patient-centered care — who, when, premise

Balint, early 1960s; multiple inseparable influences on health, etiology is a complex web of systemically interacting relationships, and the dentist stands within and participates in healing with the patient

Person-centered care — definition and origins

Putting people, patients, and care partners at the heart of every decision and partnering with them to improve care; origins in Carl Rogers, term first used by Kitwood in 1988 for dementia care

Relationship-centered care — who, when, premise

Beach and Inui (2006); healer/doctor and patient are not divisible

ATTRIBUTION DRILL: match name to model — Balint, Rogers/Kitwood, Beach and Inui, Stewart et al., Baxter and Montgomery

Balint = patient-centered (1960s); Rogers/Kitwood = person-centered (1988); Beach and Inui = relationship-centered (2006); Stewart et al. = six dimensions of PCC (1995); Baxter and Montgomery = relational dialectics (1996)

Three dimensions of relationship-centered care

Patient-Practitioner; Community-Practitioner; Practitioner-Practitioner

RCC Patient-Practitioner dimension — components

Comprehensive biomedical care; be critically reflective; be caring; preserve dignity and integrity; actively listen; openly communicate; address power inequities (race, sex, education); encourage collaboration of patient and family

Stewart et al. (1995) — six dimensions of patient-centered care

Exploring the experience of the illness; understanding the person as a whole; agreeing to the plan for health care management; including prevention and promotion of health; focusing on the doctor-patient relationship; being realistic about personal limitations

Picker Principles — where dental literature falls short

Needs stronger emphasis on involvement of family and friends, co-ordination and integration, and physical comfort

Strengths perspective

Shifts from problem-centered diagnosing to collaborative, solution-focused interviewing, promoting belonging, healing, and relationship building

Resilience (RCC)

Not static — arises from the interplay of risk vs. protection, barriers vs. motivators, demands vs. opportunities, challenges vs. possibilities

Five forms of Presence

Being-there, being-with, being-for, being-in-relation, being-in-transcendence

Wood (2006) definition of empathy

The ability to feel with another person — to feel what he or she feels in a situation, adopting a dual perspective so you adapt your communication to other people's frames of reference

Expressing empathy — do more of / do less of

More: less jargon, listen for specific descriptive language, match tone when appropriate, express appreciation for unique events, words, symptoms. Less: talking, and advice-giving on non-oral-health matters

Empathy phrasing — express, rephrase content, rephrase feelings

Express: "I can see that..." / "I can appreciate how difficult..." / "I can sense how angry you must feel..." Content: "Are you saying..." / "So the point you are making seems to be..." Feelings: "So you seem to be feeling..."

Empathy — the phrase to avoid, and why

"I know how you feel, I have a friend who also..." — it recenters the conversation on you

Five levels of communication, innermost outward

Cognitive/Intrapersonal; Interpersonal; Group; Organizational; Public/Mass-mediated

Five levels — the slides' own examples

Intrapersonal = statements inside the patient's or dentist's mind; Interpersonal = sharing a treatment plan with a patient; Group = hygienist, assistant, dentist discussing a diagnosis; Organizational = training the allied team on dental insurance codes; Public = teaching oral hygiene at a primary school

Social constructionism — definition

A social theory of knowledge: jointly constructed understandings of the world form the basis for shared, often normative, assumptions about reality (e.g. "I view my dentist as ___")

Eight key elements of social constructionism

Symbolic; Systemic and Processual; Layered Systems; Language Co-Creates Realities; Culture Influences Meanings; Makes Multiple Meanings; Taken for Granted; Content AND Relationship

Constructionism element: Symbolic

By convention we label abstract experience — "I'm in pain!"

Constructionism element: Systemic and Processual

Communication is always ongoing and in motion; you cannot stop or forget it

Constructionism element: Language Co-Creates Realities

Language does not mirror reality; it in part helps shape it (Fairhurst and Grant)

Constructionism element: Culture Influences Meanings

Bi-directional — e.g. regional diets and caries risk

Constructionism element: Makes Multiple Meanings

Meaning is not in the dentist or the patient, but between them

Constructionism element: Content AND Relationship

Understanding is created by both levels of meaning (Watzlawick, Beavin, and Jackson, 1967)

Taken-for-grantedness — definition and two examples

Taken-for-granted realities emerge from everyday, routine, moderately conscious interactions among people. Hippocampus = Greek hippos (horse) + kampos (sea monster), named for shape; the white coat's link to purity, intelligence, caring, honor, hygiene, professionalism only formed around the 1890s

Nested hierarchy

Communication happens within layered systems: dentist-patient relationship inside a clinic, inside a local geographic community, reporting to and responding to state, regional, and national conditions (State Health Department, CDC)

Constructionism vs. constructivism

Constructionism is about MEANING — facts exist (histology of blood) but their meaning, value, or categorization is socially constructed through relationally sharing language. Constructivism is about LEARNING — people cognitively and actively construct knowledge for themselves rather than passively absorbing it (e.g. flossing instruction), scaffolded by social and cultural environments

Relational dialectics — who, when, core premise

Baxter and Montgomery (1996); we live and work within opposing, continuous tensions — relationships are "and/both," never "either-or"

Three relational dialectic contradictions with their poles

Integration = autonomy vs. connectivity; Expressiveness = disclosure vs. privacy; Stability = predictability vs. novelty

Relational dialectics — the clinical examples

Integration: wants your guidance but also to decide for themselves. Expressiveness: wants you to know about their anxiety but not to chart it. Stability: wants the familiar routine but something new tried

Four dimensions in which relational dialectics are embedded

Context, temporal, spatial, psycho-socio-cultural

Vocalics / paralanguage — definition and three categories

Non-utterances that signify continuance and fluency. Vocal qualities (volume, rhythm, pitch, inflection, rate, tempo, pronunciation); vocal segregates ("ummss, errrss" and silence); vocal characterizers (crying, laughing, groaning, muttering, whispering)

Session 1 paralanguage additions

Speech rate (slow, fast, deliberate); pauses (long, short, inappropriate); tone (flat, nasal, breathy); articulation (clear, precise, slurred)

Chronemics — definition and four themes

The study of how we perceive and use time to define identities (Wood, 2005). Status and power; expectations of time (cultural meaning of being on time); morality (moral weight of being on time or late); consumerism ("time is money")

Kitwood (1988) — contribution

First used the term "person-centered care," distinguishing it from medical and behavioral approaches to dementia

Kitwood's model of dementia

An interplay between neurological impairment and psychosocial/environmental factors related to health, individual psychology, and the social environment

Kitwood (1997) on identity

To have an identity is to know who one is, in cognition and in feeling — a sense of continuity with the past, and hence a narrative, a story to present to others

Kitwood's depersonalizing processes — number, and the four on the slides

Ten total; slides name Disempowerment (removing agency), Labeling (language drives perception, perception drives care), Infantilism (treating an adult as a child), Objectification (treating the person as a body to be processed)

Kitwood and Bredin on personhood

Personhood can be ensured only within a mutually recognizing, respecting, and trusting relationship

Sabat and Harre (1992), and Sabat and Collins

Sabat and Harre: selfhood persists despite significant cognitive impairment — it is NOT intact autobiographical memory that constitutes personal identity; the self persists far into advanced dementia. Sabat and Collins: publicly presented personae can be lost partly because of how others treat and view the person

Unconditional positive regard — definition

The generally non-judgmental accepting attitude of the dentist; it does not imply approval of destructive patient behavior, but acceptance of its existence and that its roots lie in the patient's bio-psycho-social history. Moralistic evaluation is neither necessary nor desirable for comprehensive quality treatment

Three core qualities of UPR

Positive unconditional self-regard (accept a patient as they are); being yourself as person and professional (set the agenda, clearly outline expectations); understanding their experiences and demonstrating that understanding back to them

Respect and perspective-taking in UPR

Introduce yourself, greet them, ask their name, explain your role, develop rapport, find common ground, ask about comfort before starting, set an agenda. Don't argue about whether they are in pain; don't minimize their position. Test case: 9-12% of cancer patients may still smoke — separate feelings from behavior