This is the Chapter 10 of the book Introduction to Health Psychology (Val Morrison_ Paul Bennett) 4th Edition. Which is content for the exam of the component Health Psychology of Module 5 (Health Psychology & Applied Technology) of the University of Twente, in the Netherlands. 

Ch.10: the consultation and beyond

Medical consultation:

Nature of encounter:

• Phases of consultation:

1. relationship with the patient.
2. reason for the patient’s attendance.
3. verbal or physical examination
4. considers the condition.’
5. considers further treatment or further investigation.

• “Good” medical consultation:

1. Good medical knowledge
2. Good relationship with the patient
3. Establishing patient’s medical problem
4. Understanding of the patient’s understanding of their problem and its ramifications
5. Engaging the patient in any decision-making process
6. Not rushed

Who has the power?

• Professional-centred Approach:
  • health professional control interview --> direct/close questions
• Patient-centred approach:
  
  • Professional listens --> encouraging engagement
  • shared decision making --> only occur when there is equipoise: when there is no dominant choice of treatment
    
    • Example: woman with breast cancer deciding whether or not to conserve a breast with a lumpectomy: only the tumour and a small area of surrounding tissue are removed
• Shared Decision-making consultation approach (Elwyn et al.’s 2012):
  
  • • Choice: conveys awareness’ that a choice exists
    • Option: detailed information about options
    • Decision: based on ‘what matters most to patients’
  • Decision aids: provide patients with information both for and against a number of treatment options, encouraging them to score each item of information in terms of its desirability or lack of it
  • Partnership talk: designed to engage patients in decision-making was actually used to minimise resistance to medically suggested treatment approaches
  • Lee et al. (2002): patients with either breast cancer or who were receiving stem cell transplants (stem cells are replaced following radiotherapy or chemotherapy or diseases such as leukaemia) where they may be damaged.to identify their preferred consultation style. Minority opted for the shared decision-making approach

Influence process of consultation:

Working together:

• doctor behaviour that actively benefits the consultation:
  • Reflection: paraphrasing and restating words of the speaker to show empathy and understanding
  • Mirroring: strategy in the process of reflection health professional repeats key words or the last words by a patient --> show understanding and prompts further information provision

Culture and language:

• Communication errors: health professionals’ overestimation of the level of language understanding --> well educated end to gain more information and to have longer consultations
• Highly rated consultations when patient and health-care professional are ethnically similar

Bad news:

• Six stage SPIKES model of Baile et al. (2000):
  • Step 1: S – SETTING UP the interview: mentally rehearsing interview physical setting in an appropriate way.
    • Arrange for privacy: no one can overhear or intrude
    • Involve significant others: someone with them at this time
    • Sit down: Avoid barriers between you and the patient
    • Make connection with the patient: eye contact/touching hand
    • Manage time constraints and interruptions: inform constraints you may have
  • Step 2: P – Assessing the patient's PERCEPTION: open-ended questions. gain an understanding of how the patient perceives their medical situation
  • Step 3: I – Obtaining the patient's INVITATION: goal of this stage is to determine how much the patient wants to know about their diagnosis
  • Step 4: K – Giving KNOWLEDGE and information to the patient: bad news’ is given, verbal warning of the message may lessen any shock
  • Step 5: E – Addressing the patient's EMOTIONS with empathic responses: responding to the patient's emotions
    
    • Observe emotions
    • Identify them
    • Identify reason for emotion --> may not be clear which issue is of concern
    • empathic feedback
    • medical dialogue needs to be suspended until the patient is able to reengage with it
  • Step 6: S – STRATEGY and SUMMARY: Having, and knowing, a clear treatment plan --> reduce anxiety

Beyond consultation:

• Decision making process:
  • Hypothesis testing: logical sequencing of establishing and testing hypotheses, when they fail are replaced by further hypotheses until a final ‘correct’ hypothesis is established.
  • Pattern recognition: compares patterns of symptoms with disease prototypes.
  • Opinion revision or ‘heuristics and biases’: decisions based on partial evidence, using rules of thumb or heuristics.
    
    • Fast and frugal: quick decision-making on the basis of minimal information
• Problem with the use of heuristics --> limit thinking through the full diagnostic possibilities, and may be biased
  
  • Availability: diseases that receive media attention are frequently thought to be more common --> lead to diagnosed in error
  • Representativeness: comparing patient’s symptoms to symptom prototypes --> clinicians may have inaccurate prototypes of common conditions.
  • Potential ‘pay off’ of differing diagnoses: diagnosis is unclear, diagnosis assigned that carries the least cost and most benefit for the individual.
• Diagnostic reminder system: web-based, provided rapid ­ advice with free text data entry. However, need to be user friendly, otherwise --> rapidly fall into misuse

Compliance, adherence and concordance:

• Compliance: health-professional-led process, patient was expected to comply with whatever instructions they were given
• Adherence: patients were more involved in the decision-making process,
• Concordance: reach a jointly determined agreement concerning the treatment, requires a patient to be fully informed of the benefits and costs of treatment

Take the tablets:

• HAART (Highly Active Antiretroviral Therapy, or ART: HIV antiretroviral medication
• Oral hypoglycaemic agents: reduce circulating blood glucose level --> Between 30 and 50 per cent, not take medication. Higher risk of dying from a stroke than their more adherent counterparts.
• Factors predict use of medication:
  
  • social factors: e.g. low levels of social support
  • psychological factors: e.g. use of emotion focused coping strategies such as denial
  • treatment factors: e.g. misunderstandings regarding treatment, complexity, side effects, …

Maximising medication use:

• Achieving concordance:
  • key factor that may increase adherence, patient and prescriber, agreed to follow a treatment regimen --> shared decision-making
• Maximising understanding:
  
  • achieving concordance, ensuring patients fully understand the nature and implications of any medication they are being prescribed --> professional using language appropriate to the particular patient
• Maximising memory:
  
  • information given in consultations is often surprisingly poor
  • providing written information, audiotapes of consultations
  • direct questioning of patients to ensure they process the information
  • using visual aids during the consultation, minimising the amount of medical jargon, simplifying the language used
  • patient repeating (rehearsing) essential information, and personalised action plans.

Keep taking the tablets:

• Influenced by:
  • timing of drug taking
    • one tablet a day, little demand on memory, increase success
  • relevant information
  • reminders
    
    • contextual cues to help them remember
  • self-monitoring
  • reinforcement of appropriate use of medication
  • family therapy

Changing behaviour:

• Smoking-related diseases: initial quit rates may be higher, but these fall over time and are no higher than among the healthy population.
• Exercise levels: modest levels after health-intervention, reduce over time, patient and non-patient populations
• Eating healthily: fell over a one-year follow-up period and did not differ from the control group by this time

Non-adherence:

Predicted by illness representations and treatment beliefs

• Low-fat diet: lack of motivation, difficulties in adhering to a diet different to that of the rest of the family, and social gatherings
• Exercise: lack of time, coexisting diseases and adverse weather conditions
  
  • Influence psychological factors in adherence to exercise of cardiac patients: --> self-regulation  
    
    • Confidence in the ability to exercise
    • intentions to exercise
    • perceived control over exercise
    • belief in the benefits of previous physical activity
    • perceived barriers to exercise
    • action planning

Adherence to behavioural programmes:

Should be based on self-regulation or health action process models

• Social Cognitive Theory: involves a structured and gradual increase in the degree of behavioural change. Steps should be sufficient to leave the participant feeling they are making acceptable progress, but small enough to ensure that they are achievable.
• ERIC database: number of components that should be central to any programme of behavioural change --> divided into self-regulation and motivational strategies
  
  • Self-control strategies: if they attribute any successful behavioural change to their own efforts rather than those of health professionals.
  • Relapse prevention: identifying high-risk situations that may result in ‘relapse’, and planning how to avoid or cope with them.
  • Motivational strategies: stepwise progression in the degree of behaviour change
    
    • Using social support
    • Structured but flexible approach,
    • Achievable goals and measuring successes in reaching them
    • Rewarding oneself for success – with concrete rewards
  • Make change habitual: establishment of long-term habits