Health Psychology: The Patient–Practitioner Relationship (3.1)

Hello, Future Health Psychologists! This chapter is all about one of the most important interactions in healthcare: the relationship between the person seeking help (the patient) and the medical professional (the practitioner, like a doctor or nurse).

Why is this crucial? Because great communication and mutual trust don't just feel nice—they directly impact whether a patient gets a correct diagnosis and adheres to their treatment, ultimately saving lives and improving health outcomes!

3.1.1 Practitioner and Patient Interpersonal Skills

The relationship starts the moment the patient and practitioner meet. Psychologists study how both non-verbal and verbal behaviours affect trust, satisfaction, and outcomes.

A. Non-Verbal Communication: What We See

Non-verbal cues include body language, facial expressions, and even clothing. A key focus here is how a practitioner's appearance influences the patient's perception of their competence and trustworthiness.

Key Study: McKinstry and Wang (1991) - Doctor Clothing

  • Aim: To investigate patient preferences for the clothing worn by doctors.
  • Procedure: Patients in British general practice surgeries were shown photographs of male and female doctors dressed in different ways (e.g., formal suit, white coat, casual attire). They were asked to rate which doctor they would prefer for different situations (e.g., surgery, routine examination).
  • Findings: Most patients (especially older patients) preferred the doctor in traditional, formal attire (like a suit or a white coat). Traditional clothing was associated with competence and reassurance. The least popular choice was the casual look.
  • Key Takeaway: Non-verbal cues, such as clothing, significantly impact patient perception and satisfaction, suggesting that a formal appearance can enhance perceived professionalism.

B. Verbal Communication: What We Hear

Verbal skills are essential, particularly ensuring the patient understands complex medical information.

Key Study: McKinlay (1975) - Understanding Medical Terminology

  • Aim: To investigate how well women understood medical jargon (technical language) used by their doctor during consultation.
  • Procedure: A large sample of Scottish women attended a clinic. After their consultation, they were asked about the meaning of nine common medical terms (e.g., 'ovulation,' 'lesion') that their doctor had used.
  • Findings: The women misunderstood a significant proportion of the terms (up to 39% confusion rate). Misunderstanding was often worse among working-class women compared to middle-class women.
  • Key Takeaway: Practitioners often overestimate how much their patients understand. Using complex medical jargon can lead to confusion, potentially impacting how well patients follow medical advice.

💡 Quick Review: Interpersonal Skills

Non-verbal (McKinstry & Wang): Dress professionally to appear competent.
Verbal (McKinlay): Use simple, clear language; avoid medical jargon.

3.1.2 Patient and Practitioner Diagnosis and Style

How a practitioner makes and presents a diagnosis, and the style of the consultation, are critical factors in the relationship.

A. Practitioner Diagnosis: Accuracy Matters

Diagnosis is the process of identifying a disease or condition. Errors can occur:

  • Disclosure of Information: Practitioners must decide how much information (especially negative news) to share and how to phrase it. Too much information can cause anxiety; too little can feel patronising.
  • False Positive Diagnosis: When a person is wrongly diagnosed as having a disease when they are actually healthy. (Example: A screening test wrongly suggests you have a rare cancer). This causes immense unnecessary stress and potentially harmful treatment.
  • False Negative Diagnosis: When a person is wrongly told they are healthy when they actually have the disease. (Example: A heart monitor fails to detect a serious problem). This is very dangerous as vital treatment is delayed or missed entirely.

B. Practitioner Style: Who's in Control?

Consultation styles fall mainly into two types:

1. Doctor-Centred (Directed) Consultation
  • Description: The practitioner leads the interaction. They ask direct, closed questions (yes/no answers), focusing primarily on the physical symptoms and a diagnosis.
  • Focus: Biological and medical facts. The practitioner retains control (directive role).
  • Strengths: Often quicker and more efficient. Good for emergency situations.
  • Weaknesses: Patients often feel rushed, ignored, or dissatisfied, leading to poor information recall and potentially lower adherence.
2. Patient-Centred (Sharing) Consultation
  • Description: The patient is encouraged to share their experiences, feelings, and social context. The practitioner uses open questions and aims for a collaborative discussion and shared decision-making.
  • Focus: The patient's whole experience (holistic view) and building a relationship.
  • Strengths: Leads to greater patient satisfaction, better understanding, and often higher adherence to advice.
  • Weaknesses: Time-consuming; less efficient in busy clinics.

Key Study: Savage and Armstrong (1990) - Style and Satisfaction

This study practically compared the effect of the two styles described above on patient satisfaction.

  • Aim: To investigate whether a doctor using a "sharing" style would lead to greater patient satisfaction compared to a "directed" style.
  • Design: A field experiment (controlled study) using a sample of 359 patients in London general practices. Doctors were instructed to use either a highly directed (doctor-centred) style or a sharing (patient-centred) style.
  • Procedure: After the consultation, patients completed questionnaires measuring their satisfaction (satisfaction was the Dependent Variable).
  • Findings: Patients who received the sharing (patient-centred) consultation style reported significantly higher levels of satisfaction than those who received the directed style.
  • Conclusion: A patient-centred approach, which involves actively seeking patient input, improves the doctor-patient relationship and increases patient satisfaction.

Key Takeaway: While the doctor-centred style is fast, the patient-centred style is better for patient satisfaction and long-term compliance, emphasizing the importance of shared decision-making.

3.1.3 Misusing Health Services

Sometimes the practitioner–patient relationship is complicated by patients who delay seeking necessary help or, conversely, those who fake illness.

A. Delay in Seeking Treatment

This occurs when someone has symptoms but puts off going to the doctor.

Reasons for Delay (Safer et al., 1979)

Safer et al. suggested delay occurs in five distinct stages:

  1. Appraisal Delay: The time taken to notice a symptom and realise it is serious. (E.g., "It's just a cough, I'm fine.")
  2. Illness Delay: The time taken between deciding the symptom is serious and deciding that one is actually sick and needs professional care. (E.g., "Okay, I'm sick, but maybe I can just treat it at home.")
  3. Behavioural Delay: The time taken to decide to make an appointment.
  4. Scheduling Delay: The time spent waiting for the appointment (this is often influenced by the system, not the patient).
  5. Treatment Delay: The time spent between attending the appointment and starting the recommended treatment.
Alternative Explanation: The Health Belief Model (HBM)

The HBM, covered in more detail elsewhere, helps explain appraisal and illness delay. A person delays treatment if they perceive low severity or low susceptibility to the illness, or if they perceive high barriers (like cost, fear, or inconvenience) to seeking help.

Analogy: If you think a tiny lump is just a muscle knot (low perceived severity/susceptibility) and you hate needles (high barrier), you will delay seeking help.

B. Munchausen Syndrome versus Malingering

These terms describe conditions where individuals fake illness, but the motivation behind the deception is different.

1. Malingering
  • Definition: Falsifying or exaggerating physical or psychological symptoms to achieve an obvious, concrete, external gain.
  • Motivation: Usually related to avoiding work, obtaining drugs, seeking compensation (money), or avoiding military service.
  • Mnemonic: Malingering is for Money or Material gain.
2. Munchausen Syndrome (Factitious Disorder)
  • Definition: Falsifying or inducing injury or illness, typically for a psychological or emotional reward (internal gain).
  • Diagnostic Features (Essential and Supporting):
    • Essential Feature: Intentional production or feigning of physical or psychological signs or symptoms.
    • Supporting Feature: The motivation for the behaviour is to assume the sick role (e.g., gain sympathy, attention, or care). The patient often goes to extreme lengths to convince medical staff.

Study Example: Aleem and Ajarim (1995) - Munchausen Case Study

This is a case study of a specific type of Munchausen Syndrome (Factitious Disorder) where the individual caused their own illness, making diagnosis extremely difficult. They documented the case of a 22-year-old woman who repeatedly presented with severe, unexplainable skin lesions, which she created by injecting herself with faecal matter. Her motivation was not external gain, but the desire to be treated as a sick patient.

Key Takeaway: When health services are misused, it poses ethical and practical challenges. Malingering is for tangible benefits, whereas Munchausen syndrome is driven by the internal need for attention and to adopt the sick role.