Psychological Aspects of

Treatment of the Somatic

Patient

PART 1

Magdalena Lazarewicz,

Dept. of Medical Psychology, Warsaw Medical

University

[e-mail]

Last week…

• Psychological consequences of somatic

disease

– Effects of disease on human functioning

– Illness Cognitions (IC)

– Attitudes Towards Illness (ATI)

• Last week reading:

– Basic textbook, pages 39-52
– Illness Perception Questionnaire at: http://www.uib.no/ipq/

Today

• Case study - summary

• The Doctor – Patient Relationship

• Principles underlying

development of good
doctor-patient relationship

Case study - summary

• Determinants of the myocardial

infarction (bio-psycho-social risk
factors).

• The patient’s responses to illness and

treatment and ATI components.

• Implications for the doctor in charge of

the case and for the family.

Communication exercise

Nonverbal

Communication
Barriers

1. Flashing or rolling eyes
2. Quick or slow movements
3. Arms crossed, legs crossed
4. Gestures made with

exasperation

5. Slouching, hunching over
6. Doodling
7. Staring at people or avoiding

eye contact

8. Excessive fidgeting with

materials

Verbal Communication
Barriers

1. Attacking (interrogating,
criticizing, blaming, shaming)

"If you were folowing my advises we probably
wouldnít be in this situation, would we?"

2. "You Messages" (moralizing,
preaching, advising, diagnosing)

"You don’t seem to understand how important it
is for you to quit smoking. Don’t you see that
you’re well on your way to die from lounght
cancer?"

3. Showing Power (ordering,
threatening, commanding,
directing)

"If you don’t voluntarily agree to this evaluation
we can take you to due process. Go ahead and
file a complaint if you want to."

4. Other Verbal Barriers:
shouting, name calling, refusing
to speak.

Why is a good D-P relationship so
important?

The mutual relationship between the doctor and

the patient…

…is the very essence of medical practice.

…is the fundation for all treatment, no matter what the nature

of the disease or the patient’s situation.

…influances the patients Attitude Towards Ilness.

…has an enormous effect on the patient’s well-being.

…has enormous therapeutic value.

Faith in treatment

⅓

of all effective interventions and

medications can be attributed to the
patient’s faith that something has been
done to help him/her.

The doctor is responsible for establishing
such faith.

example: EPOH & HOPE

What does the doctor bring into the
D–P Relationship

• Knowledge and professional skills

• Personality

• Cognitive schematas

• Stereotypes

The doctors attitude towards the patient:

– Nonverbal responses

• Office

• Outfit

• Facial expression

• Gestures

– Verbal behaviour

• Patients withhold certain problems from the doctor if they get the

impression that he/she is aloof and hostile

– example from research: only ¼ of the patients disclosed the real source of their

apprehension.

First
impression

What does the patient bring into the
D–P Relationship?

• Patient’s conceptualization of

– Illnesses

– Hospitals

– Medical institutions

– Diagnostic procedures

– Treatment interventions

• Patient’s personality and cognitive schemata

– Previous observations and relations with doctors

– Family and environmental influence

• Stereotypes.

Multi-dimensional relationship

Personalit
y

Attitu

de

s

Believes

Stereotype
s

Per

son

alit

y

Pe

rs

on

al

it

y

Personalit
y

Per

son

alit

y

Personalit
y

Ste

reo

typ

e

s

Stereoty

pe

s

Stereotype

s

Stereotype
s

Ster

eoty

pe

s

Attitude
s

Attitude
s

Atti

tud

e

s

Attitu

de

s

Atti

tud

e

s

Believes

Believes

Be

liev

es

Believes

Beli

eve

s

Attitude
s

Models of D-P relationship

• M. Balint

(criterion: the range of doctor’s interest)

– Disease focused
– Patient focused
– Focused on D-P relationship

• E. Emanuel and L. Emanuel

(criterion: patients participation in

making decisions)

– The Paternalistic Model

(authoritative parent)

– The Informative Model

(expert)

– The Interpretive Model

(counsellor)

– The Deliberative Model

(good trustful friend with great

knowledge)

Ideal doctor - patient’s
expectations

Exercice

Injurie in an
accident

Chronic disease

Docto
r

Patient

Performs his
professional functions
correctly

Satisfies the patient’s emotional
needs

(express understanding, kindness

etc)

Satisfies the patient’s
emotional needs

Performs his professional
functions correctly

Polish research

Ideal doctor – other studies

• J. Israel (Sweden)

–

Ability to express his/her feelings to the patient

–

Informing the patient about their illness

–

The doctor’s skills and professional knowladge

„Ideal doctor”

• Proffesional knowladge
• Faith in patient
• Use of comunicative language
• Devoting much time to the patient
• Good manners, understanding for the patient
• Systematically informing the patient on issues related

to his/her illness

• Willing to speak to the patient’s family
• Treating the patient as a partner

Can you think of other important characteristics?

Communicatio

n

Delay at international

airport…

Principles underlying development of
good D - P relationship: getting started

• Eye contact
• Friendly „hello”
• Hand shake
• Offer a seat
• Show interest
• Ask a general question and let the

patient speak freely

• Listen
• Avoid threatening the patient
• Try to understand what the

patient’s expectations really are

• Share information

Dr Rush…

Iatrogenic error

An error committed by the doctor or other member of the medical

staff which leads to deterioration of the patient’s state of health.

wrong direct physical
intervention

improper or
tactless behaviour

deterioration of the patient’s
health

psychological
effects

Iatrogenic errors during the
medical examination

• Examining the patient in the presence of

other patients

(or unnecessary medical stuff)

• Some uncontrolled behaviours

(nodding

seriously, gasping)

• Useless additional tests and „taking the

patient by surprise”

Iatrogenic errors during
treatment

• Unnecessary prescription of an

excessive amount of medication

• Frequent issuing of sick-leave

• Unjustified qualification of patients

for invalid pension

Iatrogenic errors - disturbed
interpersonal
communication

• Lack of any information, more or less

incomplete information

• Unintentionally raising the patient’s fears in

order to encourage the patient to comply more

diligently with the doctor’s orders

• Highly professional „slang”

• Going around one’s own business when

interviewing the patient

Other Barriers of Interpersonal
Communication

1. Giving orders
2. Admonishing
3. Moralizing
4. Labelling
5. Passing judgements
6. Patronizing
7. Commending, Praising
8. Analysing, Interpreting
9. Calming down
10. Ignoring, disrupting
11. Questioning, inquiring
12. Giving advices and ready solutions

T. Gordon

Homework

Literature

• This week reading:

– Basic textbook, pages 53-68.
– Gorney, M., Bristow, J. (2003). Effective physician communication skills.

From: http://www.thedoctors.com/risk/general/communication/J4238.asp

– Lussier, M. T., Richard, S. (2004). Doctor-Patient Communication. Getting

Started. Canadian Family Phisician, 50, 361-363.

– Effective Communication: Barriers and Strategies. Prepared for the TRACE

Workshop, “Developing and Maintaining Professional Relationships”, June
4, 2002. Adapted from Beebe et al. Interpersonal Communication:
Relating to Others 2

nd

Canadian Edition. (Scarborough, Ontario: Allyn and

Bacon, 2000). From:
http://www.adm.uwaterloo.ca/infotrac/tips/effectivecommunication.pdf

• Reading for the next week:

– Basic textbook, pages 81-95.