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Patient - Provider Interaction
HCOM 510
Libby Bradshaw, DO, MS
Department of Public Health and Family Medicine
Tufts University School of Medicine
Memorial Hospital
Rhode Island
mhriweb.org/.../
doctor_patient_full.jpg
Session I Outline
Introductions
Syllabus – It’s not as bad as it looks…
Goal setting
Purpose – Why Bother?
Exploring an Example
Course Overview
Discussion of readings/topic
Communication models
Patient-Provider Interaction
Introductions
What’s the purpose here?
Why have this course?
Why take this course?
Why teach this course?
Patient-Provider Interaction
Why take the course?
Sounded easy, interesting, enjoyable
Was told to take it
Had a bad experience with a (doctor,
nurse, X-ray tech, etc)
I am/ I want to be a (provider,
researcher, consultant, regulator..)
Why teach the course?
Patient-Provider Interaction
Why have this course?
What’s the purpose here?
Health Communications
Public Health
Pain Research-Education- Policy
www.dtaresources.com
Patient
When is a person a patient?
How does a person become a
patient?
Who is a patient?
How does a healthcare consumer
differ from a patient?
Must a person be a patient OR a
consumer?
Provider
Who is a “provider”?
What personal qualities characterize
healthcare providers?
What are the motivations to become
a provider?
What makes a person a provider?
What are the characteristics in
common across the spectrum of
health care providers?
What are major differences between
provider categories?
What’s In a Word?
Patient-Provider Interaction
Patient
Provider
Interaction
(Healthcare)
Is there a difference?
Interaction
Communication
Relationship
Health care
Medical care
Communication
Communication is a range of purposeful behavior
which is used with intent within the structure of
social exchanges to transmit information,
observations, or internal states, or to bring about
changes in the immediate environment. Verbal as
well as nonverbal behaviors are included, as long
as some intent, evidenced by anticipation of
outcome, can be inferred……not all vocalization
or even speech can qualify as intentional
communicative behavior.
Written by Susan Stokes under a contract with CESA 7 and funded by a
discretionary grant from the Wisconsin Department of Public Instruction.
Communication
Communication: "Any act by which one person
gives to or receives from another person information
about that person's needs, desires, perceptions,
knowledge, or affective states. Communication may
be intentional or unintentional, may involve
conventional or unconventional signals, may take
linguistic or nonlinguistic forms, and may occur
through spoken or other modes.“
(National Joint Committee for the Communicative Needs of
Persons with Severe Disabilities, 1992, p. 2
Julia Scherba de Valenzuela, Ph.D.
Definitions
Communication
a process by which information is exchanged
between individuals through a common system
of symbols, signs, or behavior
Interaction
mutual or reciprocal action or influence
Relationship
the state of being related or interrelated
a state of affairs existing between those having
relations or dealings
» Merriam-Webster Online 2005
» http://www.m-w.com/cgi-bin/dictionary
Definitions
Relationship
the way in which two or more people feel and behave
towards each other
Interaction
when two or more people or things interact
(communicate or react)
Communication
the act of communicating with people
Communicate
to share information with others by speaking, writing,
moving your body or using other signals
to talk about your thoughts and feelings, and help other
people to understand them
» Cambridge Advanced Learner’s Dictionary Online
» http://dictionary.cambridge.org/
Communication
Communication
putting thoughts into words
– expressing thoughts clearly
understanding others’ perceptions
“Communication is the process of
understanding and sharing
meaning.”
» JC Pearson & PE Nelson 1991
Understanding and Sharing
Process
On-going effort to understand
Time frame – before encounter, continues after
Expectations – past, present, future
Personal goals - maintain, restore health
Providers – other possible
– time, burnout, knowledge, finances, personal
Patients – healing, information
– emotions (fear, anger), desires (forgiveness, reassurance)
Interdependence
No one communicates alone
– Process of acting, reacting, negotiating
Sensitivity
Communication success related to sensitivity to other people’s feelings &
expectations
– Public health campaigns most effective when designed w/ audience’s resources &
concepts
– patient satisfaction w/ physicians who seem to understand patient feelings
Shared meaning – how to know?
Pre’ 2000
An Example
Interaction
Communication
Physician socialization
Relationships
–
–
–
–
–
Dr-Pt
Dr-Dr
Dr-Nr
Pt-Pt
Pt-Family
Expectations
Attitudes
Life world views
Course Overview
Road Maps
Course Overview – Rules of the Road
Description - in the eye of the beholder
health communications, pain, public health
students
Learning Objectives
Evaluation, Assignments
Syllabus, Readings
Expectations –
student, faculty, program, institution
Contact information – student, faculty
Calendar – presence / absences ?adjustments
Charting the Dyad Territory
Clinical perspective
Professional practice
Goals, objectives
Educational process
Patient perspective
Health status, Age
Encounter structure,
function
Goals, objectives
www.bridgeporthospital.org/.
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Beyond the Dyad
Who checks up?
Professional oversight
Rationale
Professional “discipline”
“Disciplinary” standards
Hospital & health facility
oversight
accreditation
Third Party
Payors
Public – M’caid,
M’care
Health plans – MC
Insurers – BC/BS
Malpractice insurers
Employers
Consumer Oversight
Public Oversight
State licensing boards
Stae & Federal Payor
Medicare
Medicaid
Beyond the Dyad
Setting the rules
Ethical precepts
Professional, discipline
Legislative
Regulatory
Scientific
Technological
Cultural precepts, expectations
Exploring the Dyad
Literature
Poetic –
– mystery, pain, magic, devotion
Storytelling –
– insights, humanness, frailty
Journalism –
– print, photo, media
Themes
Celebrating the dyad
Exposing dyad weaknesses
– Cynicism of / towards Dr
– Fallibility of pt
Researching the Dyad
Examining structure, function &
outcomes
Social sciences
Sociology
Psychology
Anthropology
Historical
Health services
Health status
Health outcomes
Course Topics
Big Picture & Tools
I.
II.
III.
Communication Models
Interaction in a Changing Health Care System
Analytic Methods & Tools - Satisfaction, Quality
Encounters
IV.
V.
VI.
VII.
VIII.
IX.
Types of Encounters – Health Promotion to Bad News
Participatory and Shared Decision-Making
Ethical Issues – Lifespan, Mental Illness, Disability
Race, Ethnicity, Health Disparities
Mental Health and Social Illness – Stigma/State of Mind
Difficult Patients, Difficult Providers
What’s the Problem? How to Improve?
X.
XI.
XII.
Miscommunication – Quality, Outcomes, Malpractice
Improving Communication – System Level
Improving Interaction & Communication - Individual
Course Learning Objectives
For patient-provider interactions
Understand structural dynamics
Recognize adverse effects & their causes
Describe current, proposed interventions to
improve
Become familiar with measuring and
analyzing methods
Identify major effects of race & ethnicity
Appreciate responsibilities and
accountabilities
Enjoy some self-directed learning
Course Requirements
Analyze, deconstruct provider-patient interactions
Role-play in-class interaction scenarios
Observe standardized patient interactions
Explore further resources; contribute to annotated
bibliography
Critically analyze an example from literature, film or
personal experience in a written format from both patient
and provider perspectives
Examine policy options in topical arena of patient-provider
interactions
Independently develop a 7–10 page paper and final
presentation
Evaluate, provide course feedback at mid-point and final
sessions
Organization, Confidentiality, Respect
Graduate level seminar with class discussions
and minimal lecture presentations
Individual opinions and experiences important
Broad arena of topics and issues
Respect and confidentiality expected
Bring up communication and interaction issues
individually or in class.
Questions or suggestions welcome
Readings
Syllabus has wide breadth of readings
Additional suggestions are welcome
Session readings may be divided and chosen by
individual students in the preceding class
Optional Texts
Doctors Talking with Patients/ Patients Talking with
Doctors: Improving Communication in Medical Visits.
Debra L. Roter and Judith A. Hall. 1992. Auburn House,
Westport, CT, pp 175.
Talking with Patients, Volume 1: The Theory of DoctorPatient Communication. Eric J. Cassell. 1985. MIT
Press, Cambridge, MA, pp 223.
Evaluation
Activities
15% Classroom participation/preparation
5% Discussion forums
10% Communication exercises & role-plays
10% Critical analysis interaction - Experiential
» Due June 1
5% IRB Training CITI online module – June 7
10 % Analysis of provider-patient interaction – June 10
15% Communication prescription write-up
» Due June 24
30% Final project
– Written (20%) – Due July 1
– Class presentation (10%)
» Due July 3/5
Course Assignments
Due June 1
Provider-patient interaction from literature, film or
personal experience.
Apply perspectives from readings, classroom
discussions and personal insights, critically
analyze the interaction in a 2 – 3 page paper.
Particularly focus on the patient’s perspective, but
examine the interactional frame or model used by
both the patient and the provider.
Questions to consider:
What happened in the interaction? Why did it go the way
it did? How was it successful? Unsuccessful? What did
the patient want? Did they achieve their goals? Why, or
why not? Who had a stake in the interaction besides the
patient and provider? What communication model was
used? Was the provider satisfied? Why or why not?
How would the interaction be improved?
Course Assignments
Communication Prescription
Due June 24 - 3 page written paper
Define patient health care problem or type of encounter.
Examine challenges facing patients and providers.
Describe how you would define quality in this interaction.
Describe your prescription for optimizing quality in this interaction.
Final Project
Due July 1 / July 3/5
Paper 7 – 8 pages, plus references.
Presentations can be discussions to power point presentations; 10 -15
minutes
Include analysis of a problem and related issues; articulate clear
objectives around this issue (stake out a stand!),
Specify your recommendations and support your suggested
strategies with appropriate references (5-10 references)
Faculty Information –
Please contact me with questions or suggestions
at any time
Ylisabyth (Libby) Bradshaw, DO, MS
Arnold 106
Phone – 617-636-6946
Fax - 617-636-4017
Email – [email protected]
Office Availability – M – T / Th – F
appointment
1 – 5 pm or by
Plus before class about 5 pm; after class
Calendar
Absences? Adjustments?
Initial Conceptual Models
Physician - Patient Relationship
Parsons
Physician dominant, controlling
Patient’s sick role
» Relieved of everyday responsibilities
» Responsibility to get well
Szasz & Hollender
Activity-Passivity Model
» Asymmetrical power; analogous Parsons’
Guidance-Cooperation
» Most common, Dr dominant, Pt’s cooperation
sought
Mutual Participation
Mutual Participation Model
Pt full participant
Pre-conditions
Both participants need equal power
Mutual interdependence
Interactions must be satisfying for both
Physician-Patient Relationships Models
Multiple models
Emmanuel & Emmanuel
Paternalistic – Authoritarian
Priestly
Informative - Consumer
Scientific, engineering
Interpretive
Deliberative
Emanuel & Emanuel 1992
Four Models Physician - Patient
Informative
Interpretive
Deliberative
Paternalistic
Pt Values Fixed, pt
known
Unknown,
requires help
Development,
Objective,
revision thru
shared by Dr
moral discussion & Pt
Dr
Provide
responsib relevant facts
ilities
Implement pt
choices
Elucidate,
interpret pt
values; inform,
implement pt
Articulate,
persuade pt of
best values;
inform,
implement pt
Promote pt
well-being,
independent
of pt current
preferences
Pt
autonmy
Choice,
control over
health care
Selfunderstand’g
re health care
Moral selfdevelopment re
health care
Assent to
objective
values
Dr role
Competent
technical
expert
Counselor,
adviser
Friend, teacher
Guardian
Physician-Patient Relationships
Physician Control
Patient Control
Default
Consumerism
Paternalism
Mutuality
Roter & Hall 1991
Expectations for Interactions
Patient expectations – multiple forces
Societal beliefs
Cultural beliefs
Personal beliefs
Family
Situational
Physician expectations
Personal beliefs
Professional socialization
Organizational
Situational
Interactional
Models – prototypes – not proscriptive
Models of Health
Biomedical model
Physical phenomenon;
Mechanistic; Like fixing a machine
Strengths: Efficient, definitive
Weaknesses:
Marginalizes pt feelings, social experience
Impersonal; patient = parts & symptoms
Communication = Dr control, closed ?’s
Patients dissatisfied, mistrustful
Cartesian dualism (Descartes)
Mind-body dualism; bodies & souls (brain)
Dx = physical condition; Illness = experienced condition
Biopsychosocial model
Models of Health
Biopsychosocial model
Includes physical, psychological, social
person’s biology, feelings, ideas, life events
Engels 1977
Thoughts & emotions influence health
Stress reduces body’s resistance to dx
Stress results in depression, mood changes
Humor improves immune functioning, outlook
Support improves health status
Weakness – difficult to implement
time, effort, skills; limited by setting, pt expectation
Therapeutic Communication
Patient
presentation, concern, issue
Physician response
assessing, defining issue
Rapport / Resolution
information exchange
cognitive, emotional meaning
dyadic (team) interaction
Barriers – setting, time, illness
Mismatched expectations
Physician communication styles
– Control – spatial & social distance,
– Affiliation – empathy, genuineness, nonjudgmental attitude
Silo Philosophy
Macy Initiative on
Health Communication
nyumacy.med.nyu.edu/ curriculum/model/m00a.html
IthacaMed
Patient-Provider Interaction: A Human Scale
We place a premium on humane interactions with our patients. All
providers greet patients themselves from the waiting room. The
initial discussion of a medical problem(s) takes place in a consulting
room before the patient changes for the physical examination. We
feel this allows the patient to feel fully comfortable discussing their
health as a whole person on equal standing, face to face, rather
than trying to present one’s medical concerns while perched on an
examining table, half naked or draped in a flimsy, backless medical
gown!
After changing for the purpose of physical examination (into one of
those flimsy, backless medical gowns!), the patient is then given a
full physical or a problem-focused examination. Following the
examination, the patient dresses and meets again with the doctor or
nurse practitioner to discuss the results of investigations, diagnosis,
and the proposed management plan. Health education and
preventative medicine are an integral part of this part of the
consultation. Patients are encouraged to take an active part in this
process as we recognize that such collaboration leads to the best
outcome.
http://www.ithacamed.com/the_practice/specialities.php4
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