Module: Health Psychology Lecture: Consultation Date: 9 February 2009

1. Module: Health PsychologyLecture: ConsultationDate: 9 February 2009 Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick Tel: +44(24) 761 50222 Email: C.Bridle@warwick.ac.ukwww.warwick.ac.uk/go/hpsych

2. Aims and Objectives • Aim: To provide an overview of the psychological influences within the consultation context • Objectives:By the end of this session you should be able to describe the following: • the psychological factors relevant to the consultation context; • the behaviours that contribute to poor consultation; • the effects / consequences of poor consultation; • unconscious psychological processes that contribute to consultation / communication inequalities.

3. Consultation Quality • People judge adequacy of care by criteria that are irrelevant to its technical quality • Key criteria relate to mannerin which care is delivered • Warmth, listening and empathy = communication skills • Satisfaction declines when Drs express uncertainty about a condition/diagnosis, etc. • Uncertainty expressed in >30% of consultations • Technical quality of care and the manner in which it is delivered are not necessarily related

4. The patient must answer questions, be poked/prodded, whilst in pain and unwell may feel anxious, stressed and/or embarrassed will want a clear diagnosis, answer and/or explanation has expectations about the consultation and the Dr The Doctor: must identify, elicit and evaluate significant information quickly may feel anxious, stressed and/or embarrassed will be acutely aware of the need to find ‘the answer’ has expectations about the consultation and the patient Consultation Context

5. Consultation Factors … just some … Healthcare experience Experience Rapport Language Time Health status Personality Personality Training Consultation Context Health literacy Doctor Patient Targets Beliefs, Fear Evidence Ethnicity SES Gender Social network Litigation Consulting motivation The last patient

6. Bottom Line? • The consultation context is not naturally conducive to effective communication or patient and Dr satisfaction • Realistic expectation is that good consultation should be regarded as the exception and not the rule • Surprising that consultation does not go ‘wrong’ more often • Nevertheless, patients describe Drs as poor communicators • What do patients highlight has indicators of poor communication?

7. Poor Communication • Behaviours that block patient disclosure • Not listening / interrupting (Beckman & Frankel, 1984) • Depersonalisation (Shapiro et al, 1992) • Explaining away distress as normal (Edwards et al, 2002) • Attending to physical aspects only (Maguire & Pitceath, 2002) • Jollying patients along (Erenes et al, 2001) • Use of jargon (Samora et al, 1991)

8. An Example • Not Listening / Interrupting • 74 GPs had 5K+ consultations recorded • In 23% of the consultations patients finished explanations, • i.e. ¾ were interrupted before finishing • Average time to interruption = 18seconds (Beckman & Frankel, 1984; Dale et al. 2008)

9. But does it matter? Beyond ‘satisfaction’ are there any ‘real’ consequences for a patient’s health that derive from poor communication?

10. Effects of Poor Communication • Diagnosis • Treatment • Dose frequency • Duration (Bain et al, 1977)

11. Poor Communication Effects: Summary • Less likely to adhere to medical regimens … and not just because they are dissatisfied • Less likely to use health care services / seek medical help in the future • Less likely to attend check-ups, screening or other forms of preventive health care • More likely to experience negative, but largely preventable, health outcomes (Rutter et al., 1996; Erenes et al, 2001)

12. Does it matter? YES! Quality of communication in consultation can, and should, be considered a risk factor for patient health Hey, … I told you the first thing is to do no harm! Iatrogenic harm

13. What can be done to improve communication, and will this improvement lead to better health outcomes? Understand the problem Intervene in the process Evaluate the effects

14. Understanding the Dr’s Perspective • Why do Drs block? • Pandora’s box effect • Fear of increasing patient distress • Limited time available • Threat to one’s own emotional well-being • Unaware patients fail to disclose important information

15. Understanding the Patient’s Perspective • Why do patients fail to disclose? • Drs’ blocking behaviour • Belief that nothing can be done • Worry that fears will be confirmed • Reluctance to burden healthcare provider • Desire not to seem ungrateful or critical • Concern that it is not appropriate / legitimate to disclose some problems

16. Intervening to Improve Communication • Providers: • Med Ed – communication as a core clinical skill • Modelling – shadowing effective communicators • Ongoing assessment and feedback • Peer support • Self-reflection • Patients: • Preparation – planning questions in advance • Change attitudes –personal responsibility • Realistic expectations - medicine and the certainty of uncertainty

17. Effects of Good Communication • Increased patient satisfaction, greater recall of advice, and higher adherence (Hall et al, 2005) • Improvements in disease control markers such as HbA1c, blood pressure and circulating stress hormones (Stewart, 2005) • Increased Dr satisfaction and amelioration of burnout (Roter et al, 2003)

18. If interventions are effective in promoting better communication between Drs and patients, does that mean the ‘communication’ problem has been solved? No

19. Communication Inequalities • Providers give less information, are less supportive and less clinically proficient with certain patients: • Ethnic minorities (Cooper, 2002) • Low SES groups (Schmelkin et al, 1998) • The elderly (Haug, 1987) • Females (Hall et al, 1993) • Chronic illness (Wilcox, 1992) • Psychological symptoms (Hall, 1993)

20. Why? Widely regarded as being a consequence of Drs beliefs about members of various social groups? i.e. Stereotypic knowledge Recall from Lecture 1: Stroop, and person perception

21. Race of Person Caucasian (White) African-american (Black) Match  Mismatch  W Colour Of Ink Mismatch  Match  B New methodologies:Stroop & Person-perception (Karylowski, et al., 2002)

22. Race of Person Caucasian (White) African-american (Black) Jerry Seinfeld Oprah Winfrey W Colour Of Ink Rosie O’Donnell Bill Cosby B Stroop and Person-Perception Name/read the colour of the ink Mis-match Match (Karylowski, et al., 2002)

23. Stroop and Person-Perception • Slower to name ink colour in the mismatch condition • Mismatched info requires additional processing time • What is the mismatched info? • Ink and skin colours are mismatched - not the name • Mismatch can only occur if reading name generates racial category information • Info generated in milliseconds Reaction Time (ms) Racial categories come to mind automatically Ink Color (Karylowski, et al., 2002)

24. Just because some stereotypes are automatically activated doesn’t mean they necessarily influence our behaviour, ability, judgment, etc. Three experiments to convince you otherwise

25. Automatic Effects on Behaviour • University students - mean age 24 years • Prime: Words presented without awareness (<20ms) • Elderly stereotype words, e.g. wrinkle, old, knitting • Neutral words, e.g. thirsty, clean, telephone You were just primed – ‘wrinkle’ – were you aware? • Told experiment is over • Outcome measure: Time taken by the participant to walk to the lift – 9.75m • Design: Randomised cross-over (7 days) (Bargh et al 1996)

26. Results Participants exposed to the elderly prime took significantly longer to walk to the lift … … compared to unexposed participants and themselves, i.e. cross-over in Study 2 Mdif = 9.3 seconds Almost twice as long! Explanation: Behaviour unconsciously adjusted to be consistent with primed stereotype

27. Automatic Effects of Performance • UK gen pop: N=1000; M age = 35; 53% female • Prime: Write about the behaviour, lifestyle and attributes of the typical X • University professor or football support • No prime/writing, or 2 or 9 mins prime • Outcome: Score on a 60 question general knowledge test

28. Results Prime: ProfessorImproved performance – stereotype consistent Prime: HooliganImpaired performance – stereotype consistent

29. Automatic Effect on Interaction • White students unknowingly screened for relevant stereotype belief – black males more aggressive • Participate in ‘response task’ study – very boring • Prime: Black male or white male faces presented without awareness (<20 ms) • Near end of ‘task’, message appears - ‘Warning: Fatal Error Restart Computer’ • Told they must re-do the entire (boring) task • Outcome: Hostility towards the experimenter - videotaped

30. Results • Level of hostility rated by experimenter and blinded assessor • Greater hostility among stereotype-activated participants • black face prime • Behaviour became consistent with stereotype belief Hostility Rating Experimenter Rating Blinded Assessor

31. Once activated, stereotypic knowledge influences behaviour, performance and judgements about, and interaction with, other people Helps us understand evidence showing that, for certain social groups, clinicians offer less information, less support and are less clinically proficient … of course, patients do it too!

32. Conclusions • Patients judge quality of care by how satisfied they are with the consultation interaction – especially communication • Quality of communication is linked strongly to clinical outcome across wide range of illnesses • Quality compromised by both Dr and patient factors, as well as contextual demands • Interventions for Drs and patients can improve consultation quality, satisfaction and clinical outcomes • Behaviour, communication and decision making can be (are often) influenced by stereotypic beliefs • Awareness of stereotype influence is a necessary but not sufficient precondition to prevent their negative effects

33. Summary • This session would have helped you to understand … • the psychological factors that are relevant to the consultation context • the behaviours that contribute to poor consultation / communication between Dr and patient • the effects / consequences on patient behaviour and health of poor consultation / communication • unconscious psychological processes that help to explain consultation / communication inequalities

34. Any questions? • What now? • Obtain / download one of the recommended readings • In your small groups consider today’s lecture in relation to tutorial tasks: a) integrated template b) ESA question