Structure of syllabus
• 6 modules
• Organised as such:
o Introduction of the module
o development with specific topics to illustrate the issues in the
module: examples, studies
o Conclusion: finding ways to improve the situation & address the
The patient-practitioner relationship
• Practitioner and patient interpersonal skills
o Non-verbal communications (e.g. McKinstry and Wang); verbal
communications (e.g. McKinlay, 1975; Ley, 1988).
• Patient and practitioner diagnosis and style
o Practitioner style: doctor and patient-centred (Byrne and Long, 1976;
Savage and Armstrong, 1990). Practitioner diagnosis: type I and type II
errors. Disclosure of information (e.g. Robinson and West, 1992).
• Misusing health services
o Delay in seeking treatment (e.g. Safer, 1979). Misuse: hypochondriasis
(e.g. Barlow and Durand, 1995), Munchausen syndrome (e.g. Aleem
and Ajarim, 1995).
Adherence to medical advice
• Types of non-adherence and reasons why patients
o Types and extent of non-adherence. Rational non-adherence (e.g.
Bulpitt, 1988); customising treatment (e.g. Johnson and Bytheway,
• Measuring adherence/non-adherence
o Subjective: self reports (e.g. Riekart and Droter, 1999). Objective: pill
counting (e.g. Chung and Naya, 2000); biochemical tests (e.g. Roth,
1987); repeat prescriptions (e.g. Sherman, 2000)
• Improving adherence
o Improve practitioner style (e.g. Ley, 1988), provide information (e.g.
Lewin, 1992), behavioural techniques (e.g. Burke et al., 1997).
Module 3: Pain
• types and theories of pain
o Definitions of pain. Acute and chronic organic pain; psychogenic pain
(e.g. phantom limb pain). Theories of pain: specificity theory, gate
control theory (Melzack, 1965)
• Measuring pain
o Self report measures (e.g. clinical interview); psychometric measures
and visual rating scales (e.g. MPQ, visual analogue scale),
behavioural/observational (e.g. UAB). Pain measures for children (e.g.
paediatric pain questionnaire, Varni and Thompson, 1976)
• managing and controlling pain
o Medical techniques (e.g. surgical; chemical). Psychological techniques:
cognitive strategies (e.g. attention diversion, non-pain imagery and
cognitive redefinition); alternative techniques (e.g. acupuncture,
Module 4: Stress
• causes/sources of stress
• Physiology of stress and effects on health. The GAS Model (Selye).
Causes of stress: lack of control (e.g. Geer and Maisel, 1972), work (e.g.
Johansson, 1978), life events (Holmes and Rahe, 1967), personality (e.g.
Friedman and Rosenman, 1974), daily hassles (e.g. Lazarus, 1981)
• Measures of stress
• Physiological measures: recording devices and sample tests (e.g. Geer
and Maisel, 1972; Johansson, 1978); self report questionnaires (Holmes
and Rahe 1967, Friedman and Rosenman, 1974, Lazarus, 1981)
• Management of stress
o Medical techniques (e.g. chemical). Psychological techniques:
biofeedback (e.g. Budzynski et al., 1973) and imagery (e.g. Bridge,
1988). Preventing stress (e.g. Meichenbaum, 1985)
Module 5: Health promotion
• Methods for promoting health
o Fear arousal (e.g. Janis and Feshbach, 1953; Leventhal et al., 1967).
Yale model of communication. Providing information (e.g. Lewin,
• Health promotion in schools, worksites and
• Schools (e.g. Walter, 1985; Tapper et al., 2003). Worksites (e.g. Gomel,
1983). Communities (e.g. three community study, Farquhar et al., 1977).)
• Promoting health of a specific problem
• Any problem can be chosen (e.g. cycle helmet safety: Dannenberg,
1993; self-examination for breast/testicular cancer; obesity and diet:
Tapper et al., 2003; smoking: McVey and Stapleton, 2000)
Module 6: Health and safety
• Definitions, causes and examples
o Definitions of accidents; causes: theory A and theory B
(Reason, 2000); examples of individual and system errors (e.g.
Three Mile Island, 1979; Chernobyl, 1986)
• Accident proneness and personality
• Accident prone personality; personality factors e.g. age,
personality type Human error (e.g. Riggio, 1990); illusion of
invulnerability (e.g. The Titanic); cognitive overload (e.g. Barber,
• reducing accidents and promoting safety behaviours
o Reducing accidents at work: token economy (e.g. Fox et al.,
1987); reorganising shift work; safety promotion campaigns
(e.g. Cowpe, 1989).
• Is it really important? You are there for treatment not
to make friends & invite the doctor / nurse over for
your birthday BBQ.
• YES – can affect health-seeking behaviour,
compliance & be a matter of life and death
• Bad experiences linked to doctors being in a hurry,
no eye contact, not listening to the patient, irritation
when patients ask questions, seek information,
refusing to involve patient in the treatment
• Different cultural background can be a problem
Patients perception of inadequacies of
communication arise from:
• Content skills – what doctors say, e.g., the
substance of the questions asked, the answers
received, the information given, the
differential diagnosis list, and the doctors
medical knowledge base
• Process skills – how doctors say it, e.g., how
the doctor asks questions, how well he listens,
how he sets up explanation and planning with
the patient, how he structures his interaction
and makes that structure visible to the patient
through signposting or transitions & how he
build relationships with patients
• Birdwhistell (1970) estimated that only 30 to 35% of
the social meaning of a conversation is carried by
• Non-verbal communication includes features of
speech such as:
o tone of voice,
o rates of speaking,
o duration and pauses.
• Other forms of non-verbal communication are
conveyed by gestures, dress, physical proximity,
facial expressions, posture and orientation.
Argyle (1975) four major uses
To assist speech, for example in synchronising
conversation or supplementing speech by putting stress
on certain words, or pausing between words or varying
the tone and speed of speech
As a replacement for speech
To signal attitudes, e.g. trying to look cool
To signal emotional states, i.e. we can tell how a person
is really feeling by looking at their facial expression or
• McKinstry and Wang (1991)
o Non-Verbal Communication
• Specifically: Appearance and first
• Study consisted of showing pictures of
doctors to patients attending surgeries
• Same male and female doctor
• Dressed formally (white coat over suit or
• Dressed informally (jeans, open-necked,
short-sleeved shirt, or pink trousers, jumper
& gold earrings)
• Task: rate how happy they would be to
see the doctor in the picture or how
much confidence they would have in the
• Acceptability higher for:
o Male doctor wearing white coat, suit
o Female doctor wearing white coat and skirt
• Acceptability lower for:
o Male doctor wearing jeans (59%), wearing an earring (55%) & having long hair
o Female doctor wearing jeans (63%) & jewellery (60%)
• Expectations are that doctors should wear:
o White coat – 15%
o Suit – 44%
o Tie – 67%
• Conclusion???: traditionally dressed images received
higher preference ratings than the casually dressed ones,
esp. for older & professional-class patients
• Can you think of any??
o Showed importance of appearance & first impressions in developing
confidence in doctors
o Consistency / reliability – same male, same female used
o Reductionist / simplistic – NVC more complicated / complex than dress
alone – other factors eye contact, facial expressions (Argyle (1975)
o Lacks ecological validity – use of pictures & not real persons
o Sampling issues – done in Western Europe (UK); will it have same results in
Africa? / other countries?
• Jourard (1966) considered where it is acceptable to
be touched and by whom.
• Doctors need to be careful not to alarm the patient
by touching them in a 'no go' area without their
• Jourard (1966) also found cultural differences in the
amount of touching. Observing people in cafes
around the world he counted the number of times
people touched each other during the course of
one hour. His results were:
Place Number of touches
San Juan (Puerto Rico) 180
• McKinlay, 1975 – assessment of lower-class women
understanding of 13 technical terms in a maternity
• Words used
• Antibiotic Mucus Breech
• Protein Enamel Purgative
• Glucose Suture Membrane
• Do you know what these words mean?
• On average, each of the term was understood by
less than 40% of the women
• Health workers themselves expected even lower
levels of understanding by the women (even lower
• But they used these terms with their patients!!
• Medical language makes health workers look more
knowledgeable, more important & keep
conversations brief because the women are afraid
to ask questions without looking stupid (Banyard,
2004, p. 131)
• Ecologically valid – use of real terms in real settings
with patients and health workers
• Unethical – disrupting health service for a survey
• Useful – will help improve communication between
health workers & patients
• Not generalisable – used only women, not their
partners / husbands / boyfriend, only setting of the
maternity ward, not any other setting
o What do people remember of real consultations?
• Talked to people after they had visited the doctor &
asked them what they recalled about medical
information given to them by their doctor. Asked to
repeat what the doctor had told them to do.
• This was compared with what was actually said to
• People remembered 55% of what they were told
• In detail:
• Good recall of first thing told (Primacy Effect)
• Recall did not improve with repetition (no matter how often
doctor told them the info.)
• Remembered information which had been categorised
• Remembered more if they had some medical knowledge
• Patient recall is increased by categorisation, signposting,
summarising, repetition, clarity and use of diagrams
• Useful for practice - led to development of a manual
for doctors to use to communicate with patients / led
to 70% increase in recall
• Ecologically valid - used real patients who have
been to see real doctors for real illness
• Sampling / site of study - study done in a particular
Byrne and Long 1976
• Physicians can be doctor-centred or patient-centred.
• 2,500 tape recorded medical consultations in several
countries including England, Ireland, Australia and
• Most styles were doctor-centred. Physicians asked
questions that required only brief replies (e.g. yes no,
etc.). Focus on first symptom or problem that was
reported by the patient. Often ignored attempts by
patient to mention other symptoms.
• Patient-centred approach - doctors ask open-ended
questions, requiring the patient to give lengthy replies.
Medical jargon was avoided. They allowed patients to
participate in the decision making process.
(Byrne & Long, 1976)
• Doctor-centred style – impersonal, intent on
establishing link between symptoms and organic
o Ask closed yes-no questions, focus mainly on first problem,
tend to ignore attempts to discuss other problems
• Patient-centered – personal style, less controlling
o Open questions to allow patient to share more information and
introduce new facts, tended to avoid jargon, share decision
• All western countries, so does not generalise to non-
• Ethical considerations – confidentiality.
Savage and Armstrong
• Savage and Armstrong (1990) found that patients
were more satisfied with a ‘directed consultation’
rather than a ‘sharing consultation’.
Savage and Armstrong (1990)
• Directed consultation – statements made such
as “you are suffering from…”, “it is essential
that you take this medication”, “you should be
better in …. days”, “come and see me in ….
• Sharing consultation – “what do you think that
is wrong?”, “Would you like a prescription?”,
“Are there any other problems?”, “When
would you like to come and see me again?”
Savage and Armstrong (1990)
• 359 randomly selected patients – free to
choose their doctor. 200 results used.
• 2 questionnaires – one immediately and one
a week later.
• Results – overall a high level of satisfaction,
but higher for directed group. Higher for
‘satisfaction with explanation of doctor’ and
with ‘own understanding of the problem’.
More likely to report that they had been
• Random selection – ensures objectivity, less bias
• Ecological validity – real patients, real situations
Errors in diagnosis
• Type I error (false positive) – declaring an illness when one
does not exist
• Type II error (false negative) – declaring that a person is well
when he is ill
• Screening involves relatively cheap tests that are given to
large populations, none of whom manifest any clinical
indication of disease (e.g., Pap smears).
• Testing involves far more expensive, often invasive,
procedures that are given only to those who manifest some
clinical indication of disease, and are most often applied to
confirm a suspected diagnosis.
Robinson and West (1992)
• Computer Doctors
• To get over the problem of embarrassment a computer
could be used.
• Patients at a genito-urinary clinic (specialises in
venereal disease) gave more information to a
computer than they subsequently gave to the doctor.
• Patients are less worried about social judgements and
embarrassing details with a computer. They admitted
having more sexual partners, having attended before,
and revealed more symptoms.
• VALIDITY – study is valid as it measures exactly what it
sets out to measure: how much information patients
are prepared to give to doctors
• USEFULNESS – study is useful for medical practitioners.
• Can you guess what measures a hospital or clinic
should put in place based on the results of the study?
• Use computers or electronic means for patients to
give details of their conditions
• Who uses health services?
• Age: children and the elderly have more contacts per
year than adolescents and young adults
• Gender: women have more contacts than men.
Difference starts in adolescence & remains even when
contacts for pregnancy & childbirths not counted
• Sexual orientation: many homosexual men & women
avoid contacts with health services through fears of
discrimination & lack of confidentiality
Why the gender differences???
• Women sicker / physically weaker than men?
• Women use more prescription drugs than men
• Women have higher rates of acute illnesses
(respiratory infections) & nonfatal chronic illnesses
(arthritis & migraine headaches)
• Women more likely to report health problems than
• Women in some cultures such as North America
and even Seychelles taught to be tough, macho
and to ignore pain.
Delay in seeking treatment
• Three phases
• 1. appraisal delay - the time it takes for a person to interpret their
symptoms as a sign of illness
o Am I sick No Delay (YES Enters Treatment)
• 2. illness delay - the time it takes between realising that you are ill
and deciding to seek medical advice
o Do I need professional care? No - Delay
(YES Enters Treatment)
• 3. utilisation delay - the time it takes between deciding to go, and
turning up at the surgery. Different people will delay at different
points in this process, and different symptoms and conditions will
also bring about different patterns of response.
o Is the care worth the financial, human, emotional & social
costs? No - Delay (YES Enters Treatment)
• Delay in seeking treatment
• To discover which psychological factors affect delay at each
of the 3 delay stages
• Waiting rooms of 4 clinics in a large inner city USA hospital. 93
patients of mixed age, gender and ethnicity.
• Interviewers approached patients who were there to report a
new symptom or complaint and 45mins worth of questions.
• P’s were asked about when they first noticed the symptom,
when they decided they were ill and when they decided to
seek medical help. They were also asked a series of other
questions looking at factors that may have contributed to
• Mean total delay was 14 days.
• Key factors were:
• Presence of severe pain + whether patients had
read about the symptoms and bleeding correlated
with appraisal delay.
• Whether the symptom was new, imagined
consequences and gender affected illness delay.
• Cost of treatment, pain of symptoms and perceived
curing of the problem affected utilisation delay
• ETHICS – asking people personal questions about
their illnesses / confidentiality issues / consent
• METHODOLOGY – consistent method = reliable /
used self reports = unreliable, subjective
• SAMPLING – mixed sample (age, race, gender) but
also small / may not be generalisable to other
• USEFULNESS – helpful to find factors to help people
• Soma – Meaning Body
o Preoccupation with health and/or body appearance and functioning
o No identifiable medical condition causing the physical complaints
• Types of DSM-IV Somatoform Disorders
o Somatization disorder
o Conversion disorder
o Pain disorder
o Body dysmorphic disorder
• Clinical Description
– Physical complaints without a clear cause
– Severe anxiety focused on the possibility of having a serious disease
– Strong disease conviction
– Medical reassurance does not seem to help
– Good prevalence data are lacking
– Onset at any age, and runs a chronic course
– Affect both men & women equally
– Sometimes, misdiagnosis when health worker cannot find any
explanation for the illness behaviour and comes to the conclusion
that it is 'all in the patient's head'.
Barlow and Durand, 1995
• Misuse: hypochondriasis
• Preoccupation with physical symptoms. Key feature =
combines the fear with conviction that one has an organic
disease (Mai, 2004).
• Fear of aging and death. Greater importance on physical
health, but do not have better health habits than someone
who does not have a disorder.
• “Doctor shopping", as well as deterioration with doctor
relationships with frustration and anger towards each other are
common. Deterioration due to medical examination proving
that nothing is wrong & patient continues to believe s/he is sick,
not getting proper care, & resist referral to mental health
professionals. Social relationships become strained.
• One interprets physical symptoms & feelings as signs of a serious
medical illness in spite of medical assurance that they are not.
• May be especially concerned about a particular organ system
(such as the cardiac or digestive system).
• Usually present their medical record in great detail.
• No exact cause
• Serious illnesses, particularly in childhood, & past
experience with disease in a family member
• Psychosocial stressors, in particular the death of someone
close to the individual,
• People highly sensitive to physical pain. They pay
attention more closely to changes in their body, freak out
when something had changed & often make a bigger
deal out of it than it really is
• Misinterpret symptoms. People with Hypochondriasis think
they are ill or something is wrong with them, until they
have proof that there is not.
Nurse Beverley Allitt
• In the UK, between February and April of 1991, there
were 26 unforeseen failures of medical treatment and
unaccountable injuries on Ward 4 of Grantham and
Kesteven General Hospital.
• In total four children died and nine were injured.
• Investigations found that nurse Beverley Allitt had
altered critical settings on life support equipment &
administered lethal doses of potassium & insulin to
children in her care (The Allitt Inquiry, 1991). She was
diagnosed as suffering from Munchausen syndrome by
proxy and was sentenced to thirteen concurrent life
Aleem and Ajarim, 1995
• 22-year-old single female (university student) referred to
hospital as a possible case of immune deficiency
• Problems started at 17yrs with amenorrhea - had only 2
cycles & then failed to menstruate
• Numerous medical problems over the years (thrombosis,
swellings in groin area, multiple scars over abdominal
wall tender, hot area (4 x 5 cm) over right breast).
• Other examinations normal, but bacterial cultures found
in samples taken. When treated, left breast developed
lesions - suspicion raised.
• Offered psychiatric help
• Seemed to have shallow affect, but seemed stressed
• One day when she was absent, syringe with faecal
matter found in her bed
• When confronted, was angry, left hospital & never
Aleem and Ajarim, 1995
• Diagnostic features of Munchausen syndrome.
• Pathologic lying (pseudologia fantastica)
• Peregrination (traveling or wandering)
• Recurrent, feigned or simulated illness
• Supporting features
• Borderline and/or antisocial personality traits
• Deprivation in childhood
• Equanimity (a state of psychological stability & composure which is
undisturbed by experience of or exposure to emotions, pain)for
diagnostic procedures & treatments or operations
• Evidence of self-induced physical signs
• Knowledge of or experience in a medical field
• Most likely to be male
• Multiple hospitalizations
• Multiple scars (usually abdominal)
• Police record
• Unusual or dramatic presentation
• Information is very limited on prevalence of
• Thought to be a rare disorder
• May have been over-reported because patients often
change their names & identities & present to different
physicians at different hospitals
• Most case reports come from North America & Western
Europe - so seems more common in highly educated
• Only 1 case in Saudi Arabia but possibility of more cases
• Case study of 1 person / patient = not generalisable
to other people / population
• Cross-cultural study – shows that condition also
exists in Saudi Arabia & not just Western European
• Ethical issues – nurses searched the bed, was
informed by another patient, lost to follow-up