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Date Created: 09/04/14
Using Health Services 9414 228 PM Recognition and Interpretation of Symptoms Awareness of what is going on in our bodies is limited 0 Social and psychological factors 9 recognitioninterpretation ofiHness Recognition of Symptoms Individual Differences Some are more likely to notice a symptom than others Women are not more likely to report symptoms than men Older people report more symptoms than young people Neuroticism affects perception of symptoms Negative way of viewing the world Recognize and report more symptoms fast Believe they have serious diseases Exaggerate symptoms or more attentive to real symptoms 0 OOO Cultural Differences Anglos report symptoms that occur infrequently Mexicans report symptoms that occurred frequently Attentional Differences Influence the experience of symptoms Focus on self 9 quicker to notice symptoms than those who have external focus 0 External focus more distractions Situational Factors Influence whether someone will recognize a symptom o Boring situation 9 more attentive o More physical activity 9 less attentive Medical students disease as they study each illness they imagine that they have it 9 leads to focus on own fatigue and other internal factors 9 illness symptoms seem to emerge Stress Can precipitate or aggravate the experience of symptoms Mood Influences sef appraised health 0 Good mood more healthy 0 Bad mood more symptoms Interpretation of Symptoms Social and psychological factors are important Prior Experience Interpretation of symptoms heavily influenced by experience Experience with medical condition 9 estimate prevalence to be greater and regard condition as less serious than those with no history Meaning of symptom is influenced by how common it is within a person39s social circle or culture 0 High prevalence 9 seen as less serious Expectations Women experience PMS more severely because of the expectation that the symptoms will occur People may ignore symptoms they don39t expect and amplify symptoms that are expected Seriousness of the Symptoms Symptoms affecting valued parts of the body are usually interpreted as being more serious Anxiety when faceeyes are affected Pain 9 more prompt care seeking Cognitive Representations of Illness Commonsense model of illness people hold implicit commonsense beliefs about symptoms and illnesses that result in organized illness representationsschemas 0 Acquired through media experience family friends o Lend coherence to a person39s comprehension of the illness expenence 0 Can influence preventative health behaviors adherence expectations for future health Commonsense models include 0 Basic info about illness Identitylabel 9 name of illness Causes 9 factors person believes gave rise to an illness Consequences 9 symptoms treatments implications Time line 9 duration expected Controlcure 9 person39s belief as to whether the illness can be controlled or cured o Coherence 9 how well the beliefs hang together in representation of the disorder Most people have at least 3 models 0 Acute illness caused by specific viralbacterial agents short in duration with no long term consequences flu 0 Chronic illness caused by multiple factors long in duration severe consequences heart disease 0 Cyclic illness alternating periods during which there are no symptoms or many symptoms herpes OOOOO Lay Referral Network Informal network of familyfriends who offer their own interpretations of symptoms well before any medical treatment is sought May offer advice about seeking treatment and recommendations for home remedies Ethnic communities 9 network sometimes incorporates beliefs about causes and cures that would be regarded as supernatural or superstitious Complementary and Alternative Medicine WHO is cataloguing remedies to identify those that are successful and to reduceeliminate use of those that are riskyunsuccessful 13 americans may use CAM during course of a year 0 Relaxation chiropracty massage etc Some work but restrelaxation also works The Internet Lay referral network Most physicians think that the internet will positively affect health A lot of what is on the internet is not accurate Who Uses Health Services Age Very young and very elderly use services most frequently Illness frequency and use of services declines through adulthood and increases again in late adulthood Genden Women use services more than men 0 Pregnancy and childbirth help explain this 0 Women may have better homeostatic mechanisms than men do 9 report pain earlier experience temperature changes more rapidly detect new smells faster 0 Maybe more sensitive to bodily disruptions Social norms 0 Men expected to project tough image 9 ignoring pain 0 Women not subject to these pressures Economic factors 0 More women are part time workers so may not lose income when ill also part time work leads to increased illness Women may use services more because medical care is more fragmented 9 multiple doctors Social Class and Culture Low class use services less than more affluent persons 0 Less money to spend on services 0 Not as many high quality services available to poor Biggest gap is in preventative care lays groundwork or better health across lifespan Social Psychological Factors Individua s attitude toward and beliefs about symptoms and health services influence who uses health services Health belief model seeking treatment results from two factors 0 Whether person perceives threat to health 0 Whether person believes that health measure will be effective in reducing threat 0 Explains treatment seeking behavior of those with money and access Influenced by socialization actions of one s parents Relationships influence care seeking Social interference influences care seeking Social sanctioning also influences care seeking Health services are used by those who have the need time money experience beliefs that favor the use of services Misusing Health Services People seeking help for problems that are not medically significant overloading the medical system Delay Using Health Services for Emotional Disturbances As much as 23 of time taken up by patients whose complaints are psychological rather than medical 0 Anxiety and depression 0 Can cause physicians to intervene with medical treatments that are inappropriate Why does this occur 0 Stress and emotional responses create physical symptoms During stress times use services more 0 Worried well concerned about physical and mental health inclined to perceive minor symptoms as serious believe that they should take care of own health Selfcare leads to use more health services Somaticizers express distress and conflict through bodily symptoms Multisomatoform disorders multiple physical symptoms that are chornic and unresponsive to treatment 0 Clue for identifying psychopathology Perception that medical disorders are more legitimate than psychological ones Illness brings secondary gains benefits rest freedom from unpleasant tasks 9 can interfere with process of returning to good heath True malingering person who doesn39t want to go to schoolwork 9414 228 PM What is a Health Care Provider Nurses Advanced practice nursing registered nurses who have gone beyond basic training and have multiple responsibilities for patients Nurse practitioners affiliated with physicians in private practice see own patients provide routine medical care prescribe treatment monitor progress of chronically ill see wak ins Frequently give treatment instructions to patients Physicians Assistants Perform many routine health care tasks The Nature of Patient Provider Communication Criticisms of providers jargon lack of feedback depersonalized care Poor patient provider communication tied to outcomes as problematic as nonadherence Judging Quality of Care People often judge care by criteria that are irrelevant to its technical quality 9 the basis of the manner in which care is delivered in reality these things are unrelated Patient Consumerism Patients have adopted consumerist attitudes toward health care To induce a patient to follow treatment one must have the patient s full cooperation and participation in the treatment plan A patient does better if the their expertise about their illness is tapped and integrated into the treatment program Setting Average visit lasts only 1215 minutes and the physician will interrupt you before you get 23 seconds into your comments Must communicate illness to another person often a stranger Respond to direct and specific questions and be poked and prodded through the diagnostic process Difficult to express effectively when you39re in pain and ability to articulate may be further reduced by anxietyembarrassment Patients over the counter remedy use can mask and distort symptoms Patient s idea of which symptoms are important may not correspond with what the provider knows is important important signs may be overlooked Structure of the Health Care Delivery System Private fee for service care each visit followed by bill which patient paid out of pocket past structure Health maintenance organization prepaid financing and health delivery system agreed monthly rate paid and entitled to use services at no additional or greatly reduced cost 9 managed care Preferred provider organizations network of affiliated practitioners agreed to charge preestablished rates and enrollees in PPO must choose from these practitioners when seeking treatment Patient Dissatisfaction in Managed Care Changing structure in health delivery system can undermine communication Prepaid plans operate on referral basis so that the provider the patient first sees determines what is wrong and then sends patient to specialist to follow up with treatment 0 Colleague orientation rather than a patient orientation can develop 0 Provider may not be overly concerned with patient satisfaction Could produce high technical quality of care but less incentive to offer emotionally satisfying care HMOs and Patient Care Efficiency and cost cutting pressures have assumed increasing importance 9 quality of care has eroded Long waits and short visits 0 Referrals compound this problem Choice limited to what the HMO says you can get 9 patients value choice this contributes to dissatisfaction DRGs and Patient Care Diagnostic reated groups patient classification scheme that determines typical nature and length of treatment for particular disorders Patients in a DRG category assumed to be homogeneous that is clinically similar and should require same types and amounts of treatments and cost Define trim points boundaries that define unusually long or short lengths of stay Puts pressure on medical facilities to limit patient stays and treatment costs Provides impetus for diagnostic vigilance Often ignores psychosocial issues 9 poor predictors of patients need for services and length of hospitalization Contribute to tendency to discharge patients before the DRG boundaries for length of stay are exceeded 9 can compromise care Changes in the Philosophy of Health Care Delivery Change in the role of the physician 0 Roles once given to physician are now shared with other authorities Patients now expected to assume more responsibility for their care 0 Health literacy is not good enough yet The Holistic Health Movement and Health Care Holistic health idea that health is a positive state to be actively achieved not the mere absence of disease Emphasis on health education self help and sef heaing These changes alter the relationship between provider and patient 0 More open equal reciprocal and emotional Provider Behaviors that Contribute to Faulty Communication Inattentiveness Not listening Typically patients don39t have opportunity to finish their explanation of concerns before provider begins process of diagnosis Interruption pattern prevents patients from discussing concerns and may lead to loss of important information Someone interrupting the provider is also an annoyance for the patient Use of Jargon Patients understand few of the complex terms that providers use 0 Can keep the patient from asking too many questions or from discovering that the provider is not certain about the problem Use ofjargon may be a carryover from technical training 0 Forget that patients don39t share this expertise o Inability to gauge what the patient will understand Baby Talk Baby talk and simplistic explanations Can make the patient feel like a helpless child Forestalls questions Nonperson Treatment Depersonalization of the patient is another problem that impairs the quality of the relationship 0 Intentional to keep patient quiet during examination 0 Unintentional because patient has become focus of the provider39s attention May be employed at stressful moments to keep patient quiet and enable practitioner to concentrate Patient depersonalization provides emotional protection for the provider Emotion and empathy communicated by provider can affect patient s attitude toward the provider the visit and his condition When there is mismatch between patient expectations regarding sharing of information involvement in treatment and socioemotional support satisfaction with care is lower Stereotypes of Patients Negative stereotypes 9 poor communication and poor treatment 0 Black and Hispanic patients receive less information less support worse clinical performance from providers Same race 9 satisfaction with treatment is higher 0 Importance of increasing minority physicians Negative perceptions of the elderly Sexism 0 Female physicians conduct longer visits ask more questions make more positive comments during visits and show more nonverbal support 0 Matching gender appears to foster more rapport and disclosure 0 But physicians of both genders prefer male patients Depression anxiety psychological disorders 9 negative reactions from physician Preference of healthier patients preference of the acutely ill Patients Contributions to Faulty Communication Patient Characteristics Neurotic patients present exaggerated picture of symptoms Anxious patients have impaired learning Patient Knowledge Some are unable to understand even simple information about their case many don39t understand statistical information Lack of medical knowledge interferes with patient ability to pay consumer role New illness little prior info greatest distortion in explanations Cognitive deficits in memory and attention 9 nonadherence Disorganized families without regular routines 9 nonadherence Low IQ 9 higher risk of early mortality due to nonadherence Aging 9 number of medical problems increases 9 ability to articulate complaints and follow treatment decreases Patient Attitudes Toward Symptoms Patients respond to different cues about illness than practitioners 0 Patients emphasize pain and symptoms that interfere with activities 0 Providers concerned with underlying illness severity and treatment Patients may misunderstand the provider39s emphasis pay little attention or believe provider is incorrect Patients can give providers misleading information or not report important information Interactive Aspects of the Communication Problem Interaction doesn39t provide opportunity for feedback to the provider 0 Provider doesn39t know impactsuccess rate of advice given Provider may find it hard to know when a satisfactory personal relationship has been established with patients 0 Feedback is more likely to be negative than positive 0 Patients whose treatment has failed are more likely to go back than patients whose treatment was successful Learning is fostered more by positive than by negative feedback 0 Negative feedback doesn39t tell you what to do instead 0 This situation is not conducive to learning Learning occurs only with feedback but providers get lack of feedback Results of Poor Patient Provider Communication Dissatisfied patients less likely to comply with treatment recommendations or use medical services in the future 0 More likely to turn to alternative services that satisfy emotional needs 0 Less likely to obtain medical checkups o More likely to change doctors and file formal complaints Nonadherence to Treatment Regimens Rates of nonadherence 1593 nonadherence Averaging across treatments nonadherence is about 26 Short term antibiotic regimens 0 13 fail to comply adequately 5060 don39t keep appointments for modifying preventative health behaviors 80 fail to follow through with behavior change recommendations 85 fail to adhere completely to prescriptions Measuring Adherence Asking patients about adherence yields fake high estimates Indirect measures of adherence number of follow up or referral appointments kept can be biased Research stats probably underestimate rates of nonadherence Good Communication Fosters adherence 0 Clear jargon free explanation Ask patient to repeat instructions Repeat instructions more than once Write instructions down Clarify unclear instructions Satisfaction with relationship Answering patient questions 0 When providers are warm and caring Patient s decision to adhere OOOOOO Treatment Regimen Qualities of treatment influence degree of adherence 0 Medical advice has high adherence 0 Vocational advice take time off work has low adherence o Socialpsychological advice has lowest adherence Complex sef care regimens show overall lowest level of adherence Nonadherent patient cite lack of time money distractions Those who enjoy activities in lives are more motivated to adhere o Cohesive families is important as well Creative Nonadherence Involves modifying and supplementing a prescribed treatment regimen o Alter dosages o Supplements Can result from personal theories about disorder and treatment Malpractice Litigation Patients cite poor communication as basis of suits Explanation apology and reassurance can help mute effects of malpractice Improving Patient Provider Communication and Reducing Nonadherence Teaching Providers How to Communicate Course of treatment is affected by communication Training Providers Skills that can be learned easily and can be incorporated into medical routines easily Practiced in situations in which the skills will be used Nonverbal communication can affect atmosphere 9 understand other s nonverbal communication Patient centered communication enlists patient directly in decisions about care provider tries to see as patient sees Communication training can improve patient satisfaction with care Training Patients Teach patients skills for eliciting information from physicians Listing questions in advance Probing for Barriers to Adherence Patients are good at predicting how compliant they will be with treatment 9 this allows us to figure out what barriers may be Provider should extract a commitment from the patient Break advice down into manageable subgoals that can be monitored Adherence is a combination of information motivation and behavioral skills Health Care Institution Interventions Postcards or phone calls to remind patients to return Reducing time spent waiting before receiving service
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