Interpersonal SkillsHealth Psychology student doctors Although student doctors found chemistry and biology relatively easy dealing with their patients is not so easy. Battenburg and Gerritsma (1983) ± student doctors ± found it hard to: 1. hard to initiate conversation 2. decide on diagnosis 3. cope with patient¶s emotions Patients Perhaps patients also find it difficult to talk to doctors and therefore avoid going to see them. Patients make 11 Lay consultations for every one consultation with a doctor (Scambler and Scambler 1984). Pitts (1991) Pitts (1991) suggests there are three reasons for going to the doctor: ± Persistence of symptoms ± Critical incident - e.g. pain gets worse ± Expectation of treatment ± Kent and Dalgleish (1996) Kent and Dalgleish (1996) two types of patient satisfaction that should be considered: ± Cognitive satisfaction ± how happy the patient is with the treatment etc. ± Emotional satisfaction ± how happy the patient is with the doctors level of interest and concern. What patients like People often judge the adequacy of their care by criteria that are irrelevant to the technical quality of the care. What people do know is whether or not they liked the practitioner: whether he or she was warm and friendly or cool and uncommunicative. (Feletti, Firman, & SansonFisher, 1986; Scarpaci, 1988; Ware et al., 1978). Patients are poor judges Even more significant, since people are poor judges of technical quality of care, they often judge technical quality on the basis of the manner in which care is delivered (BenSira, 1976, 1980). For example, if a physician expresses uncertainty about the nature of the patient's condition, patient satisfaction declines Mooney, K. M., 2001 Mooney, K. M., 2001, 'Predictors of patient satisfaction in an outpatient surgery clinic¶. Plastic Surgical Nursing, 21, 3, 162-4 Aim To investigate which elements of the patient-practitioner relationship lead to satisfied patients. Participants An opportunity sample of 345 patients (96 per cent of those asked to participate) attending an out-patient plastic surgery clinic. Informed consent was obtained. Procedure The participants were required to evaluate items such as how long they waited to get an appointment, time spent waiting at the surgery before the doctor was seen, the explanation given about any procedures undergone, the technical skills (thoroughness, competence and carefulness) of the practitioner and the interpersonal skills (courtesy, sensitivity, friendliness etc.) of the practitioner on a 5-point scale ranging from poor to excellent. Results 60 per cent rated their overall level of satisfaction as excellent and 30 per cent as very good. The quality of interaction with the practitioner received the highest individual rating, while those concerned with the facilities and access to services were rated lower. The interpersonal skills of the doctor were found to contribute more to patient satisfaction than the technical skills of the doctor and were considered to be a better predictor of patient satisfaction. Smucker, D. R., Konrad, T. R., Curtis, P., Carey, T. S., 1998 , 'Practitioner self-confidence and patient outcomes in acute back pain', Archives of Family Medicine, 7, 223-8 Participants 189 doctors and chiropractors, randomly selected from licensing databases in North Carolina, USA, who regularly treated patients for lower back pain. Informed consent was obtained. Procedure The medical practitioners were sent a postal questionnaire to complete. The questionnaire contained ten items such as, 'I lack the diagnostic knowledge and tools to treat someone with lower back pain', 'I know exactly what to do to treat someone with lower back pain' and 'I feel very comfortable treating people with lower back pain', which assessed their self-confidence (the first four items on the scale) and attitudes (the next four items on the scale) in dealing with patients with lower back pain. Procedure The last two items dealt with knowledge of the progression from acute to chronic low back pain and patient satisfaction with treatment. The practitioners had to use a 5-point Likert scale (1 = strongly agree, 5 = strongly disagree) to record their level of agreement with each statement. The scores for the first four items were added together to generate a self-confidence score for each practitioner and those for the next four yielded an attitude score. The last two items were treated individually. Procedure The medical practitioners were also asked to provide contact details of any patients who came to them for treatment for lower back pain and had not yet received any treatment. Additionally, all the patients had to own a telephone and be able to speak English. A total of 1633 patients were recruited and informed consent was obtained from them. The patients were telephoned immediately after their initial visit to their practitioner, and again after two, four, eight, 12 and 24 weeks or until they had fully recovered from this episode of lower back pain. Procedure The length of time until they had returned to a level of functioning equal to that before the onset of the lower back pain was recorded. The practitioners' self-confidence scores were then compared with the length of time taken by the patients to return to the same level of functioning as prior to the lower back pain. Results 179 (95 per cent) of the 189 practitioners sent the questionnaire returned it, and of these 162 (86 per cent - 107 doctors, 55 chiropractors) completed all ten items. A strong correlation was found between scores on the first four items (measuring selfconfidence) and the next four items (measuring attitudes) for both doctors and chiropractors. The relationship between the item dealing with patient satisfaction and the self-confidence score was higher for the chiropractors than the doctors. Results Despite differences in levels of self-confidence and attitudes among the health practitioners, there was no significant relationship for either of these factors with the length of time it took patients to recover functionality. Thus it is not possible to use a practitioner's level of self-confidence or attitude as an indicator of the speed of recovery from lower back pain. Ogden et al (2002) Ogden et al (2002) explored the impact of the way in which uncertainty was expressed (behaviourally versus verbally) on doctor's and patient's beliefs about patient confidence. Second the study examined the role of the patient's personal characteristics and knowledge of their doctor as a means to address the broader context. Ogden et al (2002) Matched questionnaires were completed by GPs (n=66, response rate=92%) and patients (n=550, response rate=88%) from practices in the south-east of England. Ogden et al (2002) The results showed that the majority of GPs and patients viewed verbal expressions of uncertainty such as `Let's see what happens' as the most potentially damaging to patient confidence and both GPs and patients believed that asking a nurse for advice would have a detrimental effect. Ogden et al (2002) In contrast, behaviours such as using a book or computer were seen as benign or even beneficial activities. When compared directly, GPs and patients agreed about behavioural expressions of uncertainty, but the patients rated the verbal expressions as more detrimental to their confidence than anticipated by the doctors. Ogden et al (2002) In terms of the context, patients who indicated that both verbal and behavioural expressions of uncertainty would have the most detrimental impact upon their confidence were younger, lower class and had known their GP for less time. Barnett (2002) Barnett (2002) has found that a quarter of surgeons are brusque, unsympathetic or impatient when they break bad news to patients. Family doctors are better at breaking bad news, but most patients are told by surgeons (86%). 106 cancer patients were interviewed. 94 of these had been told by doctors and the rest by family members. Barnett (2002) The patients were asked to rate the way the news was delivered in four categories: positive, neutral, negative and very negative. In 26 per cent of the cases, memories of the moment were negative or very negative. There were also complaints about the lack of clear, simple information. (The Times 01-07-02) Doctors are sometimes accused of not listening Beckman and Frankel (1984) studied 74 visits to the doctor. In only 23% of the cases did the patient have the opportunity to finish his or her explanation of concerns. In 69% of the visits, the doctor interrupted, directing the patient towards a particular disorder. Doctors are sometimes accused of not listening Moreover, on average doctors interrupted after their patients had spoken for only 18 seconds. Doctors can be trained in NonVerbal Communication Birdwhistell (1970) estimated that only 30 to 35% of the social meaning of a conversation is carried by words alone. Non-verbal communication includes features of speech such as: y tone of voice, y inflection, y rates of speaking, y duration and pauses. non-verbal communication Other forms of non-verbal communication are conveyed by gestures, dress, physical proximity, facial expressions, posture and orientation. Argyle (1975) four major uses: ± To assist speech, for example in synchronising conversation or supplementing speech by putting stress on certain words, or pausing between words or varying the tone and speed of speech ± As a replacement for speech ± To signal attitudes, e.g. trying to look cool ± To signal emotional states, i.e. we can tell how a person is really feeling by looking at their facial expression or posture. On the card in front of you is written an emotion. You have to stand up in front of the group and communicate this emotion non-verbally, that is you must not use any words. You can communicate vocally by altering such things as the pitch, tone and volume of your voice by counting from 1 to 5 whilst using any other nonverbal channel. Other members of the group write down the emotion they think is being demonstrated as each member takes his turn. Emotional words Fear, Disbelief, Sadness, Dominance, Boredom, Disgust, Interest, Shame, Anger, Surprise, Love, Embarrassment, Admiration, Happiness Smiling a lot can make people happy. Zuckerman et al (1981) divided males and females into three groups. 1.The first group saw a film of a pleasant scene. 2.The second group were shown a film of a neutral scene. 3.The third group were shown a nasty film. Within each group 1.a third were asked to suppress their facial expressions, 2.a third were asked to exaggerate their facial expressions 3.and the other third were not asked to do anything apart from watching the film. Results The people who exaggerated their facial expressions showed higher levels of arousal and reported stronger positive or negative emotional reactions, compared with the other two groups. So making patients smile will make them feel happier about themselves. Learning to suppress facial expressions at times of stress could reduce stress. Doctor¶s dress. McKinstry and Wang (1991) Pictures of same doctor dressed formally or informally. Pictures of formally dressed doctors rated higher for the amount of confidence the patients had in them, and on how happy they would be to see them. Older and professional-class patients particularly preferred the formally dressed doctors. Touch Jourard (1966) considered where it is acceptable to be touched and by whom. Doctors need to be careful not to alarm the patient by touching them in a 'no go' area without their permission. Cultural differences Jourard (1966) also found cultural differences in the amount of touching. Observing people in cafes around the world he counted the number of times people touched each other during the course of one hour. His results were: Touch Place San Juan (Puerto Rico) Paris London Number of touches 180 110 0 British Nurses Davitz & Davitz (1985) report that American patients' perceptions of British nurses might be influenced by different cultural norms: y The expression of a range of emotions on the part of American patients, in many situations, often made the British nurses uncomfortable and even more reserved. It is interesting to note that a number of patients whom we interviewed judged this discomfort as dislike, insensitive, and hardboiled. 'They're efficient,' noted one patient, 'but they're not sympathetic.' Whitcher & Fisher (1979) A second piece of research highlights the status differences involved in touching. Whitcher & Fisher (1979) arranged for nurses to either touch or not touch patients while providing them with information about impending operations. The nurses in the'touch condition'touched the patients on the hand whilst showing them a booklet describing the operation, whereas those in the 'no touch' condition did not touch the patients at all. All the nurses were female. The patients were asked for their views about the hospital and the prospective operation. Whitcher & Fisher (1979) After the operation, the patients' blood pressure was measured. Female patients touched by nurses reported lower anxiety, more positive feelings to the hospital and had lower blood pressure after the operation than those not touched. On the other hand, male patients who were touched reported greater anxiety, more negative feelings and higher blood pressure after the operation than those who were not touched. Whitcher & Fisher (1979) Whitcher & Fisher (1979) suggest that one explanation for these results stems from status differences. Higher status individuals are at liberty to touch lower status individuals, but not vice versa. Thus females perceived the touching as a sign of caring and warmth; males perceived it as a threatening gesture, which communicated the nurses' superior status in the hospital setting. questioning 1. the most important part of questioning is listening 2. determine the reasons for asking the questions 3. do not ask too many questions questions fall into the following categories 1.closed questions 2.open questions 3.affective questions 4.probing questions 5.leading questions closed questions closed questions are questions which require very short answers and are useful for anxious or nervous people so that tension can be reduced. Asking too many closed questions means that the doctor has to ask lots of questions to get information and they spend less time listening to the patient. As an exercise try asking a friend a series of closed questions for as long as possible. open questions open questions give the respondents the opportunity to respond in anyway they wish. There is no correct answer. A disadvantage is curtailing rambling irrelevances, though the use of well timed closed questions can bring a wandering conversation back to the issue at hand. three main types of sequences: 1.Funnelling. Beginning and interview with an open question and gradually becoming more specific. 2.Inverse funnelling. Going from specific details to general topics. 3.The Tunnel. Asking a series of closed questions. Jesudason (1976) Jesudason (1976) compared open and closed questions in finding out what foods were taboo during lactation (mothers producing milk for their babies) for Indian women. The sample consisted of 1151 women who were asked either to name the foods that were taboo (open) or were read out a list of 12 foods and asked whether they ate each food during lactation (closed). Jesudason (1976) About 53% did not report any food taboos when given the question in open form. When these women were read the list of 12 foods, 32% considered five or more items taboo. affective questions. affective questions. These are questions about the patients feelings and emotions and help to communicate concern and empathy. Probing questions. These questions are used to get a patient talking when they are not forthcoming. Hackney and Cormier (1979) suggests the use of the "accent" and "minimal" prompt. The accent is a short re-statement that echoes and focuses a previous statement. Probing questions. The minimal prompts use a large number of non-verbal responses such as "uh-huh", "mmm", "ah", and "yes, I see." Non-verbal behaviours such as leaning forward would also act as prompts. A problem with using too many probing questions is that the interview can become an interrogation. leading questions 1.Conversational lead. 2.Pressurised agreements. 3.Hidden subtleties. conversational lead. 1. This type of leading question is used to anticipate agreement with the patient and thus convey the impression of friendliness and attentiveness. An example would be "isn't she a marvellous cook?". pressurised agreements. This type of question puts pressure on people to agree with the questioner. For example "you do, of course, brush your teeth every day?". These types of questions should be avoided by doctors because it leads to invalid responses. hidden subtleties. 1. This type of question leads the respondent without their knowledge. Loftus (1975) interviewed 40 people about headaches and headache products, ostensibly for market research. hidden subtleties. They were asked either "do you get headaches frequently, and if so, how often?" Or "do you get headaches occasionally, and if so, how often?" The average number of headaches in the "frequently" group was 2.2; Whereas in the "occasionally" group it was 0.7 headaches a week. hidden subtleties. The subjects were also asked how many products they had tried for the headaches. One group was given a choice of one, two, or three; Another the choice of one, five, or ten. The first groups average was 3.3, the second's 5.2. Similar effects can be used by substituting "short" with "tall" or "the" with "a". Savage and Armstrong (1990) Savage and Armstrong (1990) found that patients were more satisfied with a µdirected consultation¶ rather than a µsharing consultation¶. Savage and Armstrong (1990) Directed consultation ± statements made such as ³you are suffering from«´, ³it is essential that you take this medication´, ³you should be better in «. days´, ³come and see me in «. days´. Sharing consultation ± ³what do you think that is wrong?´, ³Would you like a prescription?´, ³Are there any other problems?´, ³When would you like to come and see me again?´ Savage and Armstrong (1990) 359 randomly selected patients ± free to choose their doctor. 200 results used. 2 questionnaires ± one immediately and one a week later. Results ± overall a high level of satisfaction, but higher for directed group. Higher for µsatisfaction with explanation of doctor¶ and with µown understanding of the problem¶. More likely to report that they had been µgreatly helped¶. The end