Level 3 - Semester 5 - PSYC BEHAVIORAL SCIENCE 2021 - 2022 Lec1: The Physician-Patient Relationship TTC) teleBehavioral science lecture notes © ° The Physician—Patient ER Pe Reetoos © Seeking medical care: <> Only about one-third of Americans with symptoms seek medical care; most people contend with illnesses at home with OTC medications and home management. ~> Patients’ behavior when ill are influenced by: Y Culture Y previous experiences with medical care Y physical ond mental conditions Y personality styles Y coping skills. © Seeking psychiatric care: ~> many patients fail to seek help AWE As There is a stigma to having a psychiatric illness (Psychiatric symptoms ore considered a moral weakness or a lack of self-control). <> Morbidity rates and mortality rates } between psychological illness and physical illness in patients who need psychiatric attention. © The “sick role”: Described by | T. Parsons Y A person assumes a particular role in society and certain behavioral patterns when he or she is ill characters Y The sick role includes exclusion from usual responsibilities and expectation of care by others. objection | it applies only to middle-class patients with acute physical illness By/ Mokhtar &Behavioral science lecture notes © Patient Personality Styles and Behavioral Characteristics during Illness Personality Style Behavioral Characteristics During Illness Paranoid Blames the physician for the fact that he or she is ill Schizoid Becomes even more withdrawn during illness Schizotypal _| Bizarre behavior may mask serious illness Dee May be dramatic, emotionally changeable, and approach the Histrionic ees 4 : ae physician in an inappropriate sexual fashion during illness ae Has a perfect self-image, which is threatened by illness and may Narcissistic ; ; refuse needed treatment which can alter his or her appearance Antisocial May self-write or alter prescriptions and lie to the physician Idealizes the physician at first, may make gestures of self-harm Borderline ; when ill Interprets physician health suggestions as criticisms, fears Avoidant rejection by the doctor, is overly sensitive to a perceived lack of attention or caring Obsessive- _| Fears loss of control and may in turn become more controlling compulsive | during illness Becomes more needy during illness and wants the physician to Dependent = oa make all decisions and assume all responsibility Passive-aggressive | Asks for help but then does not adhere fo the physician's advice © Telling patients the truth: In the United States: Y adult patients must be told the medical information directly (not relayed to the patient through relatives). v The patient is told the complete truth about the diagnosis, the Adult management and its side effects, and the prognosis of their illness. Y Falsely reassuring in response to patient questions is not appropriate (e.g., “Do not worry, we will take good care of you” or “You can get pregnant again” [after a miscarriage]). By/ MokhtarParents decide if , how, and when such information will be given to an el ill child. v With the patient’s permission, the physician can tell relatives this information in conjunction with, or after, telling the patient. relatives Y Relieving the fears of close relatives of a seriously ill patient > encourage the support system — help the patient. @ Special situations: <> Patients may be afraid to ask questions about distressing issues (e.g., sexual problems) or fear provoking (e.g., laboratory results). HOW TO DEAL? - A physician should not fry to guess what is troubling a patient; address them truthfully and fully with the patient. +> Physicians have the primary responsibility or dealing with adherence issues as well as with angry, seductive, or complaining behavior by their patients. ~ Referrals to other physicians should be reserved only when a medical and psychiatric problems outside of the treating physician’s range of their knowledge. © Definition: It refers to the extent fo which a patient follows the recommendations of the physician, such as taking medications on schedule, having a needed medical test or surgical procedure, and following directions or changes in lifestyle, such as diet or exercise. + Patients need to recognize that their behavior or condition (e.g., obesity) is problematic before they are motivated to change or seek medic care. | + Patients’ unconscious transference reactions fo their physicians, which are based in childhood and parent-child relationships, can affect adherence. | ~ Only about one-third of patients adhere fully to management recommendations, one-third adhere some of the time, and one third do not adhere to such recommendations. By/ Mokhtar 3 |Behavioral science lecture notes © + Factors that increase and decrease adherence ~> Adherence is not related to patient intelligence, education, sex, religion, race, socioeconomic status, or marital status. ~ Adherence is most closely related to how well the patient likes the doctor. ~ The strength of the doctor-patient relationship is also the most important factor in whether or not patients sue ala, their doctors when an error or omission is made or when there is a poor outcome. Factors assossiated with adherence Factors 4’ Adherence Factors |, Adherence (295 lll nse Fo WUE) Comments Liking the physician is the most important factor in Good physician-patient Poor physician-patient adherence; it is even more important than the physician's relationship Relationship technical skill Physicians perceived as unapproachable have low adherence from patients I tomatic illnesses, such as hypertension, only about Patient feels ill and usual Patient experiences few ee are eee nn ee pat a half of the patients initially adhere to management Many activities are disrupted by symptoms and little a. é ue © ___ | asymptomatic patients who initially adhered have stopped the illness disruption of usual activities adhering within 1 yr of diagnosis Short time spent in the waiting room Long time spent in the waiting room Patients kept waiting get angry and then fail to adhere Belief that the benefits of care outweigh its financial and time costs Belief that financial and time costs of care outweigh its benefits The “Health Belief Model” of health care By/ MokhtarFactors * Adherence Factors |, Adherence Comments Written diagnosis and instructions for management Verbal diagnosis and instructions for management Patients often forget what is said during a visit to the physician because they are anxious Asking the patient to repeat your verbal instructions can improve understanding and thus increase adherence Acute illness Chronic illness Chronically ill people see physicians more often but are more critical of them than acutely ill people Recommending only one Recommending multiple To increase adherence, instruct the patient to make one change (e.g., stop smoking) this month, and make another change (e.g., start dieting) next month Recommending too behavioral change at a tir behavioral che it : eles javroral changes af once | many chonges at once will reduce the likelihood that the patient will make any changes ‘Adherence is higher with medications that require once Simple management Complex management daily dosing, preferably with a meal Patients are more schedule Schedule likely to forget to take medications requiring frequent or between-meal dosing rene ara Usually young physician age is only an issue for patients in the initial stages of management ‘Membership in a group of people with a similar problem Peer support Little rt oon mecnetian tee (e.g., smoking can increase adherence By/ Mokhtar Behavioral science lecture notes ©Behavioral science lecture notes e Do’s and Do Not’s regar ig the Physician-Patient Relationship About another doctor complains about a relationship with another physician Problem Do Do Not Y Do not take the patient’s anger : personally (the patient is probably we oe Angry patient Do acknowledge the patient's anger feorful cheut beouming dependant as well as of being ill) Y Do encourage the patient to speak to the ¥ Do not intervene in the patient's Complaining patient: other physician directly if the patient relationship with another physician unless there is a medical reason to do so Complaining patient: About you or your staff Y Do speak to your own office staff if the patient has a complaint about one of them Y Do not blame the patient for problems with you or your office staff Y Do acknowledge the patient's sadness and Y Do not rush the patient or use patronizing statements such as “do Crying patient sree i‘ ‘i not worry” to comfort the patient. quietly wait for the patient to speal 7 (Dai net say “| understand." The patient makes that judgment. No. rent patient; |“ 20 examine the patient's willingness to Y Do not attempt to scare the patient ve Te ee health | change his or her health-threatening into adhering (e.g., showing behavior behavior (e.g., smoking); if he or she is not frightening photographs of willing, you must address that issue first untreated illness) By/ MokhtarBehavioral science lecture notes © Problem Do Do Not ape EeE INonadherent pailenk identify aS (e.g., fear) for oo , : Needs a fest or treatment | the Patient's refusal to adhere to or to not refer the patient to another consent to a needed intervention and physician (e.g., mammogram) . address it Y Do call in a chaperone when you are with the patient Y Do not refuse to see the patient v i ion using di v je Secretive patical Do gather information using direct rather Do not refer the patient to another than open-ended questions physician Do not fail to act if the Y Do set limits on the behavior that you will patient crosses a social boundary tolerate Y Do not assume that the threat is not serious Y Do assess the seriousness of the threat Y Do not release a hospitalized Suicidal patient Y Do suggest that the patient remain in the patient who is a threat to himself or hospital voluntarily if the threat is serious herself (patients who are a threat to self or others can be held involuntarily) By/ MokhtarBehavioral science lecture notes © Saas 4 The clinical interview } _ 1- Communication skills © Patient adherence with medical advice and patient satisfaction with the physician are improved by good physician-patient communication. © The aim of interview: To obtain the patient's psychiatric history, including information about prior mental problems, drug and alcohol use, sexual activity, current living situation, and sources of stress. how to interview patients 2 ~> The physical setting or the interview should be: | Y as private as possible. VY Ideally, there should be no desk or other obstacle between the physician and patient Y the participants should interact at eye level (e.g., both seated). > During the interview, the physician must first establish trust in and rapport with the patient and then gather physical, psychological, and social information to identify the patient's problem. +> Finally, the physician should try to educate the patient about the illness and motivate the patient to adhere to management recommendations. > The physician should obtain backup (e.g., hospital security) if it appears that a patient is dangerous or threatening. Minterviewing young children: 0 i ed be ecg oh ed ee ee drawing pictures). +> Use direct rather than open-ended questions (see next page), for example, OE ee ee + Aik gnilione tn the third parse, for example, “Why do you think tha the liffle boy in this picture is sad?” By/ Mokhtar 8 |Behavioral science lecture notes é , 2- Specific interviewing techniques Direct questions = + Direct questions are used to elicit specific information quickly from a patient: Y in on emergency situation (e.g., “Have you been shot”) Y when the patient is seductive or overly talkative. © Open-ended questions : Y open-ended types of questions are more likely to aid in obtaining information about the patient, and not close off potential areas of pertinent information. ¥ Using open-ended questions (e.g., “What brings you in today?”), the interviewer gives little structure to the patient and encourages the patient to speak freely. rer Aims of the Clinical Interview and Specific Interviewing Techniques Aim Technique Specific Use Example Toestablish Supportand ‘To express the physician's interest, under- “You must have really been frightened rapport ‘empathy standing, and concern for the patient ‘when you realized you were going to fall” Validation To give value and credence tothe patient's “Many people would feel the same way feelings if they had been injured as you were.” Tomaximize Facilitation ‘To encourage the patientto elaborate on an “Please tell me more about what information ‘answer; can be a verbal question or body happened after that.” sathering language, such as a quizzical expression Reflection To encourage elaboration of the answer by “You said that your pain increased after repeating part ofthe patients lifting the package?” previous response Silence Toincrease the patient’ responsiveness Waiting silently for the patient to speak Toclarity Confrontation To call the patient’ attention to inconsisten- “You say that you are not worried about information Cies in his or her responses orbody lan- _—_‘tomorrow’s surgery, but you seem guage really nervous to me.” Recapitulation To sum up al ofthe information obtained “Let's go over what you told me. You fell during the interview to ensure that the lastnight and hurt your side. Your physician understands the information husband called 911. The paramedics provided by the patient came but the pain got worse until they gave you a shot in the emer- gency room. Have I gotten it right?” ee Ask if there Se) er] By/ Mokhtar 9 |Behavioral science lecture notes © Stages of change model ‘The Stages of Change Model Name of Stage sadiness for Change) MSI bis Patient Quote Patient Characteristies Physician Strategies Stage 1 Precontemplation (not ready for change) Stage 2 Contemplation (getting ready for change) Stage 3 Preparation (ready for change) Stage 4 Action (makes change) Stage S Maintenance (continues change) Stage 6 Relapse (goes back on change) “My father was also a big heavy guy—he was a longshoreman and was hardly ever sick “Maybe his weight had something to do with my father’s death, but I don't think so, need to lose weight; I will tty to cut back on my eating.” “Late my last pizza last night.” ts really hard not to eat too much when the family gets together but I am doing it. “Thave been eating all the ‘wrong foods all week. 1 amso angry at myself.” Case scenario Tails to recognize or denies that there is a problem Is ambivalent about making the change Trying small improvements Makes the needed change Continues the changed behavior Feel guilt, anger, and disappointment Bicit the patient’ feelings ‘about the problem and explain the risks of the unwanted behavior. Weigh the pros and cons of making the change and ientify things that may be reducing the likelihood of change. Prepare a plan of action for the patient; identify social support systems. ‘Acknowledge the achievement Develop strategies to manage temptation and reward ‘entify the factors that led to the relapse, and help the patient to “get back on track” OVA physician advises a 50-year-old man who smokes 2 packs of cigarettes a day that he needs to stop smoking. In response, the patient tells the doctor that he had an uncle who smoked all of his life and died at age 95 of natural causes. According to the “Stages of Change” model, in which stage o change is this patient most likely to be? (A) Precontemplation (B) Contemplation (C) Preparation (D) Action (E) Maintenance By/ MokhtarBehavioral science lecture notes © M Ainswer and explanation: The answer is A. This 50-year-old smoker is in the stage of change known as precontemplation. In this stage, the person does not recognize or is in denial about the need to stop smoking. His comment about the uncle who smoked all of his life and died at age 95 of natural causes demonstrates his refusal to acknowledge the problem. ce) 1. 40-year-old male patient tells his physician that he smokes at least two packs of cigarettes a day but would like to stop. Which of the following is the most effective statement or question the physician can use to encourage the patient to give up smoking? a) “You must stop smoking because it causes lung cancer and many other illnesses.” b) “Why does an intelligent person like you continue to smoke?” ¢) “Do you have any relatives who died of lung cancer?” d) “I would like to show you a picture of what lungs look like after a lifetime of smoking.” e) “Please tell me how | can help you to stop smoking.” 2. A 50-year-old, poorly groomed woman has monthly appointments with a cardiologist. The patient, who frequently complains about the office and staff during these visits, tells the cardiologist that on this day, the office receptionist (who is well liked by patients and staff) was unfriendly to her. The physician’s best response is to: ) not comment and proceed with the examination b) apologize to the patient and offer to speak to the receptionist ¢) refer the patient for psychiatric evaluation d) ask a member of the office staff to reschedule the patient’s appointment for another day e) inform the patient that everyone else likes the receptionist By/ MokhtarBehavioral science lecture notes © 3. Patients are most likely to adhere to medical advice or which of the following reasons? @) The illness hos few symptoms. b) The patient likes the physician. ¢) The physician is young. d) The illness is chronic. e) The management schedule is complex. 4. The “sick role” as described by Parsons: a) applies mainly to low socioeconomic groups b) overvalues people’s social support networks ¢) includes lack 0 cooperation with health care workers d) includes exclusion rom usual responsibilities e) applies mainly to chronic illness Manswers: l-e /2-b/3-b/4-d By/ Mokhtar 72 |