If health professional–patient communication is seen as an interaction between two individuals then it is important to understand the extent to which these two individuals speak the same lan-guage, share the same beliefs and agree as to the desired content and outcome of any consulta-tion. This is of particular relevance to general practice consultations where patient and health professional perspectives are most likely to coincide. For example, Pendleton et al. (1984) argued that the central tasks of a general practice consultation involved agreement with the patient about the nature of the problem, the action to be taken and subsequent management.
Tuckett et al. (1985) likewise argued that the consultation should be conceptualized as a
‘meeting between experts’ and emphasized the importance of the patient’s and doctor’s poten-tially different views of the problem.
Recent research has examined levels of agreement between GPs’ and patients’ beliefs about different health problems. Ogden et al. (1999) explored GPs’ and patients’ models of depression in terms of symptoms (mood and somatic), causes (psychological, medical, external) and treatments (medical and non-medical). The results showed that GPs and patients agreed about
THE PROBLEM OF DOCTOR VARIABILITY 89
the importance of mood-related symptoms, psychological causes and non-medical treatments.
However, the GPs reported greater support for somatic symptoms, medical causes and medical treatments. Therefore the results indicated that GPs hold a more medical model of depression than patients. From similar perspective, Ogden, Bandara et al. (2001) explored GPs’ and patients’ beliefs about obesity. The results showed that the GPs and patients reported similar beliefs for most psychological, behavioural and social causes of obesity. However, they differed consistently in their beliefs about medical causes. In particular, the patients rated a gland/hormone problem, slow metabolism and overall medical causes more highly than did the GPs. For the treatment of obesity, a similar pattern emerged with the two groups reporting similar beliefs for a range of methods, but showing different beliefs about who was most helpful. Whereas the patients rated the GP as more helpful, the GPs rated the obese patients themselves more highly. Therefore, although GPs seem to have a more medical model of depression, they have a less medical model of obesity. Research has also shown that doctors and patients differ in their beliefs about the role of the doctor (Ogden et al. 1997), about the value of patient-centred consultations (Ogden et al. 2002), about the very nature of health (Ogden, Baig et al. 2001), about chronic disease and the role of stress (Heijmans et al. 2001) and in terms of what is important to know about medicines (Berry et al. 1997). If the health professional–
patient communication is seen as an interaction, then these studies suggest that it may well be an interaction between two individuals with very different perspectives. Do these different perspectives influence patient outcomes?
The role of agreement in patient outcomes
If doctors and patients have different beliefs about illness, different beliefs about the role of the doctor and about medicines, does this lack of agreement relate to patient outcomes? It is pos-sible that such disagreement may result in poor compliance to medication (‘why should I take antidepressants if I am not depressed?’), poor compliance to any recommended changes in behaviour (‘why should I eat less if obesity is caused by hormones?’) or low satisfaction with the consultation (‘I wanted emotional support and the GP gave me a prescription’). To date little research has explored these possibilities. One study did, however, examine the extent to which a patient’s expectations of a GP consultation were met by the GP and whether this predicted patient satisfaction. Williams et al. (1995) asked 504 general practice patients to complete a measure of their expectations of the consultation with their GP prior to it taking place and a measure of whether their expectations were actually met afterwards. The results showed that having more expectations met was related to a higher level of satisfaction with the consultation.
However, this study did not explore compliance, nor did it examine whether the GP and patient had a shared belief about the nature of the consultation. Therefore, further research is needed to develop methodological and theoretical approaches to the consultation as an interaction. In addition, research is needed to explore whether the nature of the interaction and the level of the agreement between health professional and patient predicts patient outcomes.
Informed choice
Gaining informed consent has become a central requirement for any research study or clinical intervention and aims to ensure that the participants have understood what they are about to take part in and any side effects that it might have. Informed consent can be either written or verbal depending on the nature of the study and is an essential requirement for gaining ethical approval, and medical councils across the world stipulate that patients must be given sufficient information to enable them to consent to any procedure in an informed way. Informed consent
therefore relates to a formal process prior to research or clinical work. Within health psychol-ogy, researchers have also focused on informed choice and informed decision making, although defining the differences between these is often difficult. It is generally agreed that an informed decision is one that is made effectively but whether effectiveness relates to evaluations of the final choice (i.e. the outcome) or the way in which the decision is made (i.e. the process) is unclear. Bekker (2003) provides a clear analysis of these two different perspectives and high-lights the theoretical positions that inform the emphasis on either outcome or process.
Outcome
Bekker (2003) describes how the emphasis on outcome reflects classical decision or rational choice theory which suggests that a choice can be deemed effective if it conforms to expected utility theory. This means that a choice is effective if the individual has surveyed all the decision options, evaluated the consequences of each option in terms of likelihood (i.e. the expected probability of the consequences occurring), assessed the attractiveness of the outcome of each option (utility) and then created an ‘expected utility’ value for each option by combining the likelihood of consequence (expected probability) and attractiveness (utility) and then choosing the option that has the greatest expected utility. This approach therefore emphasizes the outcome of a decision. The problem with this approach is that most decisions are not made in this rational way and so would be judged to be ineffective decisions. Further, it is possible that even if the individual were to be so rational, they may be basing it upon inaccurate information.
If this were to occur, the decision would be deemed effective but the final decision would be incomplete.
Process
In contrast to this approach is one that emphasizes process. Bekker (2003) argues that this approach is informed by reasoned choice models which suggest that an effective decision is one that has met three criteria in terms of the process used to make the decision. These criteria are:
the decision is based on information about the alternatives and their consequences; the likeli-hood and desirability of the consequences are evaluated accurately; a trade-off between these factors is evident. Further, central to this approach is a role for the individual’s own beliefs as the evaluation of the consequences and desirability of the options takes place in the context of any existing values or beliefs.
Adding behaviour
O’Connor and O’Brien-Pallas (1989) take a process approach to informed choice but also add in the individual’s behaviour. They describe an effective decision as one that is informed, con-sistent with the decision maker’s values and then behaviourally implemented.
Measuring informed choice
As a means to assess informed choice Marteau et al. (2001) developed a new measure of informed choice which was based upon O’Connor and O’Brien-Pallas’s definition and included measures of knowledge, attitudes and behaviour. They argue that when these three components are consistent with each other, then the person can be deemed to have made an informed choice.
There are therefore different ways of defining informed choice and informed decision making.
To date, however, there remains no consensus as to the nature of informed choice or decision making although these terms are still widely used and regarded as essential to the research and clinical process.
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To conclude
Traditional educational models of doctor–patient communication emphasized patient factors and considered non-compliance to be the result of patient variability. The relationship between health professionals and patients was seen as the communication of expert medical knowledge from an objective professional to a subjective layperson. Within this framework, Ley’s model explained failures in communication in the context of the failure to comply in terms of patient factors, including patient’s satisfaction, lack of understanding, or lack of recall. In addition, methods to improve communication focused on the health professional’s ability to communic-ate this factual knowledge to the patient. However, recent research has highlighted variability in the behaviours of health professionals that cannot simply be explained in terms of differences in knowledge. This variability can be examined in terms of the processes involved in clinical decision making by the health professional and in particular the factors that influence the devel-opment of hypotheses. This variability has also been examined within the context of health beliefs, and it is argued that the division between professional and lay beliefs may be a simplifi-cation, with health professionals holding both professional and lay beliefs; health professionals have beliefs that are individual to them in the way that patients have their own individual beliefs. However, perhaps to further conceptualize the communication process, it is important to understand not only the health professional’s preconceived ideas/prejudices/stereotypes/lay beliefs/professional beliefs or the patient’s beliefs, but to consider the processes involved in any communication between health professional and patient as an interaction that occurs in the context of these beliefs.
Questions
1 To what extent is a medical diagnosis based upon knowledge and expertise?
2 What are the problems with the hypothetico-deductive model of decision making?
3 Discuss the role of health professionals’ beliefs in the communication process.
4 To what extent is non-compliance the responsibility of the patient?
5 Consider the problems inherent in determining whether someone has made an informed choice.
6 Health professionals should attempt to respect and share the beliefs of their patients.
Discuss.
7 Design a research project to assess the role of affect in influencing health professionals’
decision making.
For discussion
Consider the last time you had contact with a health professional (e.g. doctor, dentist, nurse, etc.). Discuss the content of the consultation and think about how the health professional’s health beliefs may have influenced this.
FURTHER READING 93
Assumptions in health psychology
Some of the research cited in this chapter illustrates the kinds of assumptions that under-lie the study of health professionals and also provides insights into the assumptions of health psychology.
1 The mind–body split. Health psychology attempts to challenge the biomedical model of health and illness. This involves challenging biomedical assumptions such as the mind–body split. However, perhaps by emphasizing the mind (attitudes, cognitions, beliefs) as a separate entity, the mind–body split is not challenged but reinforced.
2 Biomedical outcomes. Challenging the biomedical model also involves questioning some of the outcomes used by medicine. For example, compliance with recommen-dations for drug taking, accuracy of recall, changing health behaviours following advice are all established desired outcomes. Health psychology accepts these out-comes by examining ways in which communication can be improved, variability can be understood and reduced, and compliance promoted. However, again, accepting these outcomes as legitimate is also a way of supporting biomedicine. Perhaps vari-ability is acceptable. Perhaps inaccuracy of recall sums up what happens in commu-nication (psychologists who study memory would argue that memory is the only process that is defined by its failures – memory is about reconstruction). Even though psychology adds to a biomedical model, by accepting the same outcomes it does not challenge it.
3 Adding the social context. Individuals exist within a social world and yet health psy-chology often misses out this world. An emphasis on the interaction between health professionals and patients represents an attempt to examine the cognitions of both these groups in the context of each other (the relationship context). However, this interaction is still accessed through an individual’s beliefs. Is asking someone about the interaction actually examining the interaction or is it examining their cognitions about this interaction?
Further reading
Berry, D. (2004) Risk, Communication and Health Psychology. Maidenhead: Open University Press.
The communication of risk is a central part of many consultations. This book provides a compre-hensive overview of research on risk communication.
Boyle, C.M. (1970) Differences between patients’ and doctors’ interpretations of common medical terms, British Medical Journal, 2: 286–9.
This is a classic paper illustrating differences between doctors’ and patients’ knowledge and inter-pretation. At the time it was written it was central to the contemporary emphasis on a need to acknowledge how uninformed patients were. However, it also illustrates some variability in doctors’ knowledge.
Marteau, T.M. and Johnston, M. (1990) Health professionals: a source of variance in health out-comes, Psychology and Health, 5: 47–58.
This paper examines the different models of health professionals’ behaviour and emphasizes the role of health professionals’ health beliefs.
Roter, D.L., Stewart, M., Putnam, S.M., Lipkin, M., Stiles, W. and Inui, T.S. (1997) Communication pattern of primary care physicians, Journal of the American Medical Association, 277: 350–6.
This presents the classic paper describing the Roter index which is frequently used to assess com-munication.
Trostle, J.A. (1988) Medical compliance as an ideology, Social Science and Medicine, 27: 1299–308.
This theoretical paper examines the background to the recent interest in compliance and dis-cusses the relationship between compliance and physician control.
Tuckett, D., Boulton, M., Olson, C. and Williams, A. (1985) Meetings Between Experts. London:
Tavistock.
This is a classic book which describes a study involving consultation analysis. It set the scene for much subsequent research and shifted the emphasis from doctor as expert to seeing the consulta-tion as an interacconsulta-tion.
Chapter overview
This chapter examines the prevalence of smoking and alcohol consumption and evaluates the health consequences of these behaviours. The history of theories of addictive behaviours and the shift from a disease model of addictions to the social learning theory perspective is then described. The chapter also examines the four stages of substance use from initiation and main-tenance to cessation and relapse, and discusses these stages in the context of the different models of addictive behaviours. The chapter concludes with an examination of a cross-behavioural perspective on addictive behaviours and an assessment of the similarities and dif-ferences between smoking and drinking and their relationship to other behaviours.