doctor patient communication

RECENT TRENDS: the role fo culture

1. Cultural differences may be reflected in the ways health care professionals and patients communicate with each other. 2. Discrepant, culturally specific explanatory models of health and illness may lead to misunderstandings 3. Cultural differences play a role in how patients perceive and evaluate their doctors' conduct. 4. When working with patients from ethnic minorities, doctors have poorer interpersonal skills, provide less information and use a less participatory decision-making style. 5. As Western societies are becoming increasingly multicultural, more research is needed about the role communication may play in perpetuating health inequalities.

10 principles of cultural competence

1. Have an understanding of race, ethnicity, and power 2. Understand historical factors about the group 3. Understand psycho-social stressors 4. Understand cultural differences within minority groups—very heterogeneous 5. Understand culture within the family life cycle and in an intergenerational conceptual framework 6. Understand the differences between culturally acceptable behaviors vs. psychopathological characteristics 7. Understand indigenous healing practices 8. Understand cultural beliefs around health 9. Understand health service resources for minority patients 10. Understand public health policies

how do you become culturally competent?

1. Learn about your own culture 2. Learn about other's cultures 3. Identify and retain cultural informants 1.Ask questions about their culture and verify your perceptions 4. Attend cultural events in the community 1. Learn about rituals and values 2. Demonstrates your sincere interest 3. Be flexible in your intercultural interactions 5. Reserve judgment about behaviors and intentions until you understand the cultural context in which they occur

culturally competent system

1. Recruitment efforts 2. Interpreter services 3. Training services 4. Appropriate materials 5. Appropriate health care settings

recent trends: the role of gender

1. studies have identified differences in doctor communication 2. female doctor use more patient-centered communication styles 3. males tend to be more directive and controlling 4. both male and females patents seem to feel more empowered by communicating with female doctors 5. future research requires exploration of the relationship between physicians...

most doctors interrupt a patient describing most appropriate form of touch? most often lawsuits tend to be based on... some good reasons for good doctor/ patient communication...

18 seconds handshake appearances • malpractice suits are used more on perceived treatment than actual incompleteness if patients don't like you they wont follow your instructions, if they don't like you they change doctors, if they don't like you they don't pay their bills as much

cultural competent physician

A culturally competent physician...."those who can provide patient-centered care by adjusting their attitudes and behaviors to the needs and desires of different patients and account for the impact of emotional, cultural, social, and psychological issues on the main biomedical ailment." (AMA)

culture, competence, cultural and linguistic competence

culture • "Integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups" competence • "Implies having the capacity to function effectively as an individual or organization within the context of cultural beliefs, behaviors, and needs presented by consumers and their communities." cultural and linguistic and competence • "a set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals that enables effective work in crosscultural situations."

barriers to doctor-patient communication • patient characteristics • physician or system characteristics

patient characteristics • anxiety/ fear • unrealistic patient expectations • language • health literacy • altered mental state • medication effects • gender differences • racial or cultural differences physician or system characteristics • training • language • time constraints • system constraints • gender differences • fear of litigation (lawsuits) • racial or cultural differences

patient characteristics associated with non-adherence

social/ macro characteristics • lack of social support • insecure housing • competing or conflicting demands • lack of resources • characteristics of individual's situation personal characteristics • lack of understanding • forgetfulness health beliefs • inappropriate of conflicting health beliefs • competing sociocultural and ethnic folk concepts of disease and treatment • implicit model of illness PHYSICIAN FACTORS • patient prefer physicians who adopt the more affiliative style • have a positive view of the patient leads to adopting a much more affiliative style of communication • physician interaction styles have been associated with adherence -keeping good eye contact -smiling -leaning towards the patient can be interpreted as demonstrating interest and consideration -perceived interpersonal competence -social conversation -being understanding of the patient's belief system

recent trends: the role of culture/ ethnicity/ race

studies have identifies physicians bias towards hetero-cultual groups 1. perceived higher substance abuse problems 2. perceived less likely to be receptive to healthy lifestyle changes 3. perceived lower educated 4. lower rates of pain treatment 5. higher rates of comments ignored

sources of miscommunication

the patient the health care provider factors -information -concerns -opinions -reactions -data -experience -intuition

RAISING SELF AWARENESS

• Culture is not overt and "cultural rules are not discussed until a rule is broken." • We observe, interpret, then act we often misinterpret the actions of others by not understanding their cultural norms • We may not know that we are offending others • Awareness and knowledge increase our choices leads to greater opportunities for successful encounters • Understanding one's own "software" (or culture) is a first step value systems and potential for bias

Adherence

• adherence refers to the extent to which the patient follows the prescribed treatment • the extent of adherence VARIES across the different forms of recommended behaviors • recent review article estimate 50-75% of patients do not adhere to medical advice • non-adherence increase mortality and hospital cost ADHERENCE VS INADHERENCE • physician - patient - no action/ action (adherence: follows treatment) DECISION MAKING - ADHERENCE • physician - patient - action 6 steps of clinical decision-making 1. defining the problem 2. defining the outcome goals 3. generating alternative solutions 4. selecting the best solution 5. implementing the solution 6. evaluating the outcome PARTNERSHIP • assumes a more active patient (not all patients want this active role) • look at diagram

why is doctor-patient communication important?

• communication is an essential route to information • failed communication can have negative health effects • effective communication can have a therapeutic effect • communication can lead to effective behaviors

3 philosophical differences

• deviant patient • authoritarian doctor • the interactive dyad perspective

limitations of doctor-patient communication

• doctor-patient communication is not always effective • patients' understanding and memory is limited • "compliance" with doctors' advice may be lacking • a substantial proportion of patients' problem remain • the proportion of dissatisfied patients remained surprisingly, and disappointingly, constant over 25 years

1. deviant patient perspective

• early studies focused on patient characteristics to understand failed patient communication • in the 60's it was assumed patients routinely masked the 'real' problem • popular research question... 'what is it about the patient that makes hum/ her a defaulter?' • the search for patient characteristics responsible for non-adherence unsuccessful • instead, found link between patent satisfaction and compliance or adherence • traditional concepts of authority were challenged and led to a shift of focus onto the role of the doctor

patient-centered communication technique

• emphasize open-ended inquiry, empathy, and engagement to gather data • I (invite) • L (listen) • S (summarize) • developed to combat high control technique of asking yes/ no questions

2. authoritarian doctor perspective

• focuses on ways doctors use their authority to control the doctor-patient information • in the classic study, Byme and Long (1976) identified different communication styles among doctors -these constitute a continuum from 'patient-centered' to 'doctor-centered' styles patient-centered style: uses the patient's knowledge and experience through techniques such as silence, listening and reflection doctor-centered style: uses the doctor's knowledge and skill, fro example, through asking questions -most opt for middle ground between the two

therapeutic medical encounter: CARE

• help patient Cope with stress and illness or with bad news • Activate patients' participation in self care and well being • Increase patients' sense of accountability • Responsibilty, self-esteem and confidence

advantages of doctor-patient communication

• improvements can lead to... -greater patient satisfaction with health-care services -increased patient adherence to treatment regimens -decrease in anxiety and stress on the part of patients -improved health promotion and disease prevention -better mental health in doctors -quicker recovery from surgery -shorter length of stay in the hospital

3. the interactive dyad perspective

• in the 1990s researchers began looking at the communicative event to which both doctor and patient contribute • both doctor and patient shape the conversation to achieve interpersonal objectives • a focus on the communicative event also allows the role of culture specificity in doctor - patient interactions to be explored

authoritarian doctor perspective criticism

• major criticism of doctors traditional communication style: -used a rigid agenda -little open discussion of treatment options -little open discussion of treatment options • conflicting finding regarding patient-centered styles and patient satisfaction • later studies advocate for patient activation and advocacy