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Using and Misusing Health Services

Using health services

Kasi and Cobb (1966a, 1966b) made a distinction between illness behavior and sick role behavior. Illness behavior consists of the activities undertaken by people who feel ill— before they are diagnosed. These activities are oriented toward determining one's state of health and discovering suitable remedies. Sick role behavior is exhibited by people who consider themselves ill, either because they have bee diagnosed as ill or they diagnosed themselves as ill.

Obviously illness behaviours will influence whether you use a health service or not. These can include:

Personal Reluctance: Feldman (1966) found that most people were willing to advise other people to see a doctor but, with the same symptoms, were less likely to go to the doctor themselves.

Social and Demographic Factors: Women are more likely to use health care than men. This difference exists for both frequency of doctor visits and in the number of hospitalizations (Rosenstock & Kirscht 1979). Nor is the difference due to pregnancy and childbirth; it persists even when these two reasons are excluded. One possibility for this discrepancy is that our society allows women to seek many sorts of assistance, whereas men may be taught to act strong and to deny pain and discomfort.

Cultural and social factors also affect how people respond to symptoms. David Mechanic (1978) reviewed several studies that found varying attitudes toward illness in different ethnic groups. Jewish Americans, for example, were more likely to seek professional help, accept the sick role, and engage in preventive medical behavior; Mexican-Americans tended to ignore some symptoms that doctors felt were serious and to inflate others that doctors regarded as minor; Irish-Americans tended to stoically deny pain. These differences demonstrate the powerful effects of socialization on illness and sick role behavior.

Symptom Characteristics: Mechanic (1978) listed four characteristics of the symptoms that determine one's response to illness -

1) Visibility of the symptom

2) Perceived severity of the symptom

3) Extent to which the symptom(s) interefere with the person's life.

4) Frequency and persistence of symptom(s)

The sick role will also affect how health services are used. The Sick role was first conceptualised by Talcott Parsons. He identified three assumptions upon which it is based -

1) Lack of Blame: Parsons's main point was that society relieves sick people from responsibility for their illness, a situation that helps people assume sick role behaviour.

2) Relief from Normal Responsibilities: The second feature of the sick role in our society, according to Parsons, is the exemption of the sick person from normal social, occupational, and family duties.

3) Desire to Get Well: Our society tends to assume that sickness is a temporary state and that sick people should be actively involved in their own cure.

People who adopt the sick role will be more likely to use health services because of the above 3 factors.

Misuse of health services

When we talk about people misusing health services we are often referring to people who are wasting health workers time and resources. Such people may experience the psychological state known as hypochondriasis (magnifying bodily experiences so that extreme illness is thought to be occurring) and also be emotionally maladjusted in some way. Paul Costa and Robert McCrae (1980, 1985) have demonstrated an important link between hypochondriasis and emotional maladjustment/neuroticism. These researchers tested about 1,000 normal adults, using two self-report scales: (1) the Comell Medical Index to assess the Ps' "somatic complaints," that is, medical conditions or symptoms, and (2) the Emotional Stability Scale to measure neuroticism. The Ps were in generally good health and ranged in age from under 20 to over 90. Analysis of the questionnaire responses showed that somatic complaints increased with neuroticism; individuals who scored high on neuroticism reported two to three times as many somatic complaints as those who scored low on neuroticism.

Patient and Practitioner Diagnosis and Style

Practitioner Style. McKinlay (1975) found that HCP used terminology and yet did not expect their clients to understand what they were saying. Reasons for this could be that the HCP wants to exert authority on their client by making them feel that the HCP was knowledgeable and they inferior. It may also be to stop the client asking questions out of fear of appearing stupid therefore reducing the length of conversation.

DiMatteo and DiNicola (1982) point out that many of the failures in the medical communications system come from a lack of basic courtesy. Simple things like addressing people by their name and saying hello and goodbye. These things will only add seconds to the consultation but will appear as warm and supportive to the patient.

In a large study conducted over 11 sites in the USA, Bertakis et al. (1991) content analysed 550 physician-patient interviews. The interviews were tape recorded and patients completed a post-visit questionnaire. They found that physician questions about biomedical topics were negatively related to patient satisfaction while physician questions about psychosocial topics were positively associated with patient satisfaction. In addition, those patients whose physician dominated the interview reported less satisfaction. Bertakis et al. concluded that 'patients are most satisfied by interviews that encourage them to talk about psychosocial issues in an atmosphere that is characterized by the absence of physician domination'.

Cited in Marks et al (2000).

Impact of computers on communication in the doctor’s surgery. Whilst computers have helped in the process of diagnosis and prescription, they have not aided the interaction between patient and doctor. Greatbatch et al (1995) found that –

a) Doctor’s only spoke after they had finished using the keyboard.

b) Doctor’s visual field was confined to the screen.

c) Everyday chat was restricted. (There is evidence that this aids patients in feeling relaxed and enjoy the process more).

d) Patients limited their responses to when it fitted in with how the computer was being used.

It would seem that whilst computers are beneficial for clinical reasons and speed up other processes, nevertheless they do not benefit patient – doctor interaction. This negative effect is still noticed even when doctors are made aware of the problems.

Practitioner Diagnosis

Given that a main part of doctors role is to diagnose illness we need to be aware of how they do this and the impact it has on the patient-practitioner relationship. It has been found that doctors use a number of heuristics (psychological guidelines) to aid in their diagnosis -

Availability Heuristic: This is when you judge the probability of something occurring by the amount of information you hear about it. For example, most people believe their chances of getting a serious disease is far greater than it really is, due to the fact that there is a lot of information about serious diseases available to the general public. A serious disease jumps to mind a lot faster than something as simple as a cold because they are more frightening and are often large features of media such as soap operas. This bias can affect how dangerous we think certain things are and can affect the diagnosis’ medical professionals make.

Representative Heuristic: This is when you make judgements about people based on the group to which they belong. For example if you become ill and you are a smoker others, and even doctors, can often directly associate your illness with your smoking, even if it turns out to be nothing to do with it. This shows how medical judgement can be affected by the Representative Heuristic.

Base Rate Errors: This is making a judgement but neglecting to realise how common events are in the general population. If we are told a disease affects 5% of the population and the test for it is positive if you have the disease 95% of the time, but we are told that it is also positive 10% of the time if you do not have the disease, then it is hard to work out how likely it is you have the disease if the result is positive. People tend to assume that there is a very high chance of having the disease if you are tested positive but this is wrong because they have ignored the base rate. Really if we receive a positive result there is only a one in three chance of us developing the disease.

All of these affect the client-HCP relationship a great deal. People may not believe that all they have is a simple cold as they have begun believing that what they have is something more serious (due to the availability heuristic). Or alternatively doctors can worry patients by assuming its something more serious before properly investigating because they believe that there is a greater chance of their patient having it than there really is. In the same way if a doctor is told that their patient smokes they may automatically jump the conclusion that it is their patients own fault that they are sick and therefore not have the same manner with them as they would usually have. Also if a doctor fails to indicate the base rate to their patient it could result in them believing they have a great chance of being seriously ill when they in fact do not.

Patients ability to recall infromation

Ley (1988) investigated the ability of patients to recall what their doctors had told them in consultations. He found that in general patients only remembered about 55% of what they were told. Ley found a pattern to these errors -

a) They had good recall of the first thing they were told.

b) They did not improve their recall as a result of repetition.

c) They remembered information that had been categorized.

d) They remembered more than other patients if they already had some medical knowledge.

This shows that the way a consultation is given is very important in helping the patient recall the interaction that has taken place. In a follow up study Ley produced a booklet to help doctors improve their methods of consultation. The patients of these doctors recalled 70% more than they had previously recalled.

Patient Attitudes.

Lupton (1997) investigated the impact of the supposed cultural shift on he attitudes of patients in Australia. She argued that contemporary >pular advice is that the patient should adopt an active consumerist attitude to health care. Thus the patient is conceived as a rational automous being who can carefully weigh up the value of different services. The alternative, more traditional perspective is that of the unquestioning patient who passively complies with medical advice.

In her interviews with a sample of patients, Lupton found a more mixed picture. Many of the patients, especially the older ones, still preferred the issive patient role. Admittedly, they accepted that the traditional authoritarian image of the doctor had been challenged over the past generation . a result of publicity about medical negligence and sexual harassment. Hhis resulted in a certain ambivalence about the doctor and a tension 'tween adopting the consumerist or passive patient role. Thus while some patients would demand a more active role in their treatment and would be frustrated if they were denied it, many patients still preferred to adopt the traditional passive patient role.

As could be expected, the more consumerist stance of certain patients not always welcomed by many physicians. Although several studies have shown that patients generally express a desire for information about their condition, many physicians are reluctant to disclose much information. In his study. West (1984) found that physicians often ignored patients' requests for information. Indeed it was found that patients' requests for more information were often met by challenges to their intelligence. Taylor (1979) suggested that so-called 'bad' patients - those who display anger and rebelliousness in hospital settings - may be reacting to the removal of freedoms and to restrictions on access to information. Conversely, the so-called 'good' patients - those who are more passive - may be too anxious to play a more active role in their encounters with medical staff.