Class 24

Being a Patient (finish)

Patient / Provider Communication

ANNOUNCEMENTS

Diary Study write up due today. Hand in at end of class.

Remaining classes:

4/24: Patient / provider communication

4/29: Movie: Let There Be Light

5/01: Review session

5/13: Final Exam; 11:45-2:45

Instructor Evaluation: http://sakai.rutgers.edu

Reactance

What percent of patients fall into “good patient” role?

____ Good patient ____ Average patient (minor complaints) ____ Bad patient: seriously ill and complain, not ill but complain anyway

25%

25%50%

Very bad patients: harass nurses, violate hospital rules, self-sabotage (don’t take meds, risk own health). Why?

Reactance: People have basic need for personal freedom. Work to regain freedom taken in ways that appear unfair. Hospitals can induce reactance by being arbitrary, withholdng info, treating pats. like children.

Why Hospitals Demoralize

Hospitals want to help patients. Why do they cause patients to fall into “good patient” role, or reactance?

Biomedical Model: Body is a machine—fix the parts, the body is OK, job is done. "Person" is irrelevant.

Real world constraints: Hospitals forced to do more with less. HMOs, cost cutting, related pressures.

Improving the Patient ExperienceIrving Janis “ideal anxiety” approach (1958)

Hospital hires Janis (social psych) to reduce patient stress

Janis redefines situation: Some anxiety is good. Why?

No anxiety – person not prepared for difficult outcomes. Too much anxiety – person is flooded, can’t take in information. Recommends providing pats. with enough info to emotionally prepare.

Egbert study (1964): Works with pats. undergoing abdominal surgery

Patients either told / not told what to expect post-surgery (pain, recovery, severity, etc.)

Result: Informed pats need less narcotics, leave hospital sooner. Highly replicated finding.

Social Support and Surgical RecoveryYou are about to undergo surgery. Would you prefer your hospital roommate to be someone:

____ About to undergo same surgery

____ In recovery from same surgery

Kulik & Mahler study (1996)

Patients pared with roommate who is:

* undergoing same / different surgery * Pre-operative / post-operative

* No roommate

What matters in terms of patients’ recovery?

Pared with post-op roommate: Less anxious pre-op, more ambulatory post-op, released sooner.

___ No Roommate

___Same/Pre-op ___ Diff/Pre-op

___Same/Post-op ___Diff/Post-opXXX

Effects of Responsibility and Care-Giving on Patient Outcomes

Rodin & Langer, 1977

Ss are nursing home elderly.

Cond. 1: Reminded of their own responsibilities, and given a plant to care for.

Cond. 2: Reminded of staff responsibilities to them, and given a plant that staff care for.

18 months later: Staff ratings, mortality

Cond ___ : * More positive staff ratings (happier, more sociable * Lower mortality (more likely still alive)

1

Animal Assisted Therapy (AAT): Specially trained animals plus handlers visit hospitalized patients.

Dog lies on patient's bed, is petted.

Cute, but does it work?

Experiment by Kathie Cole, RN, UCLA Medical Center

77 heart-failure patients (ave. age = 57) receive 12 minute visit from either:

a. Dogb. Human volunteerc. No visit

Animal Assisted Therapy

Anxiety:Dog: Reduced 24 ptsHuman: Reduced 10 pts

EpinephrineDog: Reduced 17%Human: Reduced 02%Control: Reduced 07%

Blood pressureDog: Reduced 10%Human: Increased 03%Control: Increased 05%

Results of AAT Study: The Paws that Refreshes

Elephant-Assisted Therapy: South Africa

Dolphin-Assisted Therapy: Israel, Florida, Ukraine

Therapeutic Riding and Cerebral Palsy

Veronic Skoczek and MacGuyver:

Skoczek suffers from cerebral palsy, affecting walking and other motion.

After years of “therapeutic riding” walks unassisted.

Rhythm of horse’s gait mimic pelvic during walking.

Improves allignment, muscle symmetry, postural control

Children in HospitalsHospitals are frightening to children.

a. Place associated with pain b. Weird looking peoplec. Sad/Scary looking patients d. Parents are not in control

Emotional reactions

a. Fear, anxietyb. Anger, rebellionc. Shame (esp. at adolescence)

Being left overnight in hospital esp. upsetting. a. "Setting" anxiety b. Age 3-6: fear rejection

c. Age 4-6 develop new fears (e.g., darkness) d. Age 6-10 free-floating anxiety e. Separation anxiety: deserted? punished?

Social-Psychological Tx for Hospitalized ChildrenSocial Support

a. Parental visits study (Branstetter, 1969)Cond 1. Mom at visiting hours onlyCond 2. Mom for extended periodsCond 3. Surrogate mom

b. Kids in Cond 2 & 3 do better than Cond 1c. Hospitals now let parents stay with kid all timesd. Story telling

Psychological Control

a. Kid in hosp. movie --> less anxietyb. In gen., informed kids show less anxietyc. Encourage kids to ask questionsd. Provide kids with coping skills * Self-talk

* Relaxation skills

“Suddenly there was in the air a rich sense of crisis…”

“I had been given a real deadline at last”

“I’m filled with desire--, to live, to write, to do everything”

“I now feel as concentrated as a diamond, or microchip”

Excerpts from A. Boyard Essay Intoxicated by My Illness

Why these positive reactions to fatal condition?

Class 24 Patient / Provider

Communication

Situation: Time pressed, competing demands (“Jerusalem to Jericho”)

Medical Training:Communication and compassion not emphasizedCommunication skills not modeled. MD training is itself inhumane.

Self SelectionMotives for becoming MD sometimes contrary to compassion/listening

prestige, wealth, status, authoritySome MD skills contrary to compassion/listening:

DetachmentAnalytic / time-efficient / detail oriented

Personality qualities needed to get into med schoolCompetitive: (Steve Leonodakis, UCSF)CerebralTechnical

Why Providers Are Often Poor Communicators

MD Failure to Listen

Beckman & Frankel (1984) study of MD initial response to patients

MDs know they are being observed, 74 patient visits

Patient given opportunity to explain problem:

MD interrupts, directs pat. to particular disorder:

MD interrupts pat. after ______ seconds.

23%

69%

18

Consequences?

1. Patients don’t get a chance to fully explain symptoms, concerns.

2. MD doesn’t get all vital information

MD Communication Problems

1. Failure to listen

2. Use of jargon:

Hmm. Seems you have Ulag's Syndrome, which voraciously perturbs the ipsilateral medulla of the flatabuloig.

I suggest we immediately begin ripsaw radiation and perhaps implode the ventral sinus of your gronus.

Arnold of Villanova (1235-1311): Say that he has an obstruction of the liver, and particularly use the word obstruction because patients do not understand what it means.

3. Baby talk: “Is you got a boo-boo on your spleen?”

4. Depersonalization: MD sees pat. as condition, not a person

Refer to pat. in third person, in front of pat. “Need to get his name and address, and what’s his primary symptom”

Functions: Manages pat., improves efficiency in emergency

Effect on Pat: Can calm: help dissociateCan alarm: “I see this condition terminating in negative

status”

MD Communication Problems (contin.)

Inappropriate Emotions

MD looks frightened, distressed, frustrated.

“Holy Toledo, look at that spot on your X-ray!!!!”

Women who get mammogram, if MD appears worried, they:

a. Remember lessb. See situation as worsec. Higher pulse rates

ANNOUNCEMENTSRemaining classes:

4/29: Finish Pat/Provider Communication

Movie: Let There Be Light

5/01: Review session , Papers returned

5/13: Final Exam; 11:45-2:45

a. Will be fewer, possibly no short-answers

b. Not displaying Quiz 2 questions—too close to final.

COURSE EVALUATIONS

http://sakai.rutgers.edu

Ethnic status: Black, Hispanic, low SES getLess info., less emotional support, less proficient TX

Elderly: Less often resuscitated in ER

Women: Taken less seriously

Mr./Ms. Kendler has sudden, sharp headaches

Possible stroke? Yes for Mr., no for Ms.Possible emotional problem? Yes for Ms., no for Mr.

Stereotypes Interfere with Treatment

Gender Differences in MD Communication

Who communicates better?

X

Female doctors: 1. Conduct longer visits2. Ask more questions3. Show more support

Training Physicians to Communicate: The Standardized Patient

http://www.youtube.com/watch?v=vM3su8ZcriY

http://www.youtube.com/watch?v=JvCVg4MrhUE

Patient Non-Adherence

Treatment Non-Adherence Rate

Antibiotics 33%

Drugs in general 66%

Preventive care appts. 55%

Child's ear infection 95%

Overall non-adherence 15%-93%

When patients do not follow the behaviors and treatments that their providers recommend.

Reasons for Non-AdherenceFailure to understand treatment

Difficulties maintaining treatment

Besides obtaining five prescriptions and getting to the pharmacy to fill them (and that’s assuming no hassles with the insurance company, and that the patient actually has insurance), the patient would also be expected to cut down on salt and fat at each meal, exercise three or four times per week, make it to doctors’ appointments, get blood tests before each appointment, check blood sugar, get flu shots – on top of remembering to take the morning pills and then the evening pills each and every day. Added up, that’s more than 3,000 behaviors to attend to, each year, to be truly adherent to all of the doctor’s recommendations. Viewed in that light, one can see how difficult it is for a patient to remain fully compliant.

Danielle Ofri, MD, NY Times, 11/115/2012

Protease Inhibitors and AIDS

Increase life expectancy,Miss 1 dose—now non-effective!but:

Take 4X dailySide effects: nausea, diarrheaMust refrigerate

Reasons for Non-Adherence

Personality / demographics

Political, ideological orientation

Depression, stress, avoidant coping

Creative non-adherence

Change dose to preserve med

Mix with home remedies

Altruism: Polish rescuer

Michele Bachmann says HPV vaccine can cause

mental retardation9/13/2011

Reactance and Non-AdherenceDr. Rusty Needles:

Condescending: Well, if you weren’t eating like a swine and exhausting yourself chasing money, you wouldn’t have this condition.

Infantalizing: Take the ittle, yittle blue pills with wahhhter!!!

Demeaning: Get off that rolly-polly duff and exercise!

Dilemma for patient:

Compliance = accepting insults; Non-compliance = self-assertion, self-respect.

Reactance against situation: Restricted behavior = reduced freedom

Reactance against negative self-label: Weak, limited

Failure to hear

a. 33% can't recall diagnosis after seeing MD 50% don't understand important details

b. Reasons for failure to hear

* Too anxious* Too embarrassed* Ignorant, uninformed

Failure to speak

a. Don't say why they're there.b. Wait till last minute, mention problem offhandedly

Patient Contribution to Poor Communication

Improving Adherence: Tips for MDsCare more

Basic politeness

Greet by nameExplain purpose of procedures / medsDon't appear desperate to leave (door handle effect)Say "goodbye" after exam

U. Mass 3 points (from Schrof article)

1 Don’t interrupt: MD 18 secs / pat 2.5 min2 Ask “what were you hoping I could do for you?”3 Don’t intimidate into silence

1. Spend real time in explaining:a. Repeat instructions 2 + timesb. Have patient repeat instructions back to you.c. Break complicated treatment into sub-goals

2. Probe for real-world barriers to adherence

3. Obtain verbal commitment

4. Prescribe behavior change like medication. e.g., Don't advise new diet, prescribe it.

5. Tell patient to "Get better." (According to Kent's MD)

Addressing Adherence Directly

Tips for Patients

Ask questions at the outset, not at the end

Prepare a written list for your visit.

1. Helps you remember issues and specifics

2. Acts as social prop, makes it hard for MD to leave until all items are addressed.

Let There Be Light

http://www.youtube.com/watch?v=kDNoaSMKx0g

John Huston, 1946

Purpose: To inform public about PTSD among WW II vets.To counteract stigma of psychiatric woundsFilmed at Edgewood State Hospital, Long Island

US Military bans filmFears it will demoralize potential recruits

Film finally released in 1980sJohn Huston, 1906-

1987