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 compare how well lower working-class women actually understood medical terms with how well their doctors expected them to understand.
  • Procedure: Lower working-class women using maternity services in Scotland were tested on 13 medical terms commonly used by staff (e.g., 'ovulation', 'lesion'). Each word was read aloud and used in a sentence, and the women explained what it meant; their answers were scored independently by two doctors. Separately, a group of doctors was given the same list and asked to estimate how many of the women would understand each term.
  • Findings: The women understood considerably more of the terms than the doctors predicted — the doctors consistently underestimated their patients' comprehension. Understanding was still incomplete, and it was higher among women who made more use of the services.
  • Key Takeaway: Note the direction of this finding — it is the whole point of the study's title, "Who is really ignorant — physician or patient?". Doctors underestimated their patients. That matters because a practitioner who assumes a patient cannot understand may explain less, fall back on jargon as a shortcut, and leave the patient less informed than they needed to be.

💡 Quick Review: Interpersonal Skills

Non-verbal (McKinstry & Wang): Dress professionally to appear competent.
Verbal (McKinlay): Doctors underestimate what patients understand — don't talk down to them, but still avoid unnecessary 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 can feel rushed or ignored, which may lead to poor information recall and lower adherence. Note, however, that this does not always translate into lower satisfaction — see Savage and Armstrong (1990) below.
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: Encourages a fuller understanding of the patient's situation and is often linked to higher adherence to advice. It is not automatically the more satisfying style for patients, however — see Savage and Armstrong (1990) below.
  • 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 compare the effect of a directing style and a sharing style of consultation on patients' satisfaction.
  • Design: A randomised controlled study at a single inner London general practice. 359 randomly selected patients consulting one GP were randomly allocated to receive either a directing (doctor-centred) or a sharing (patient-centred) style during the treatment, advice and prognosis part of the consultation.
  • Procedure: Patients completed a satisfaction questionnaire immediately after the consultation and again one week later (satisfaction was the Dependent Variable). Response rates were 89% immediately and 58% at one week.
  • Findings: Contrary to what most students expect, patients who received the directing style were more satisfied. They rated the doctor's understanding of the problem and the quality of the doctor's explanation more highly, and reported greater subjective improvement one week later. For example, among patients with physical problems, 34% rated the explanation "excellent" after a directing consultation versus 15% after a sharing one. The effect was strongest for patients with physical problems and those who received a prescription; there was little difference for patients with psychological or chronic problems.
  • Conclusion: Consultation style does affect patient satisfaction, but a sharing style is not automatically the more satisfying one. Patients often want a practitioner to take charge and give clear, authoritative answers, particularly when the problem is physical.

Key Takeaway: Do not assume the patient-centred style is always "best". It has real advantages for understanding and involvement, but Savage and Armstrong (1990) found the directing style produced higher satisfaction — especially for physical problems and when a prescription was given. An exam answer that simply asserts "patient-centred is better" will lose marks.

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. studied patients attending clinics at a major inner-city hospital and identified three stages of delay:

  1. Appraisal Delay: The time taken to notice a symptom and appraise it as a sign of illness. (E.g., "It's just a cough, I'm fine.")
  2. Illness Delay: The time between deciding one is ill and deciding to seek professional medical care. (E.g., "Okay, I'm sick, but maybe I can just treat it at home.")
  3. Utilization Delay: The time between deciding to seek care and actually attending the clinic and using its services. (E.g., "I'll ring for an appointment tomorrow... or maybe next week.")

Exam warning: A five-stage model of delay (appraisal, illness, behavioural, scheduling and treatment delay) does exist — but it belongs to Andersen, Cacioppo and Roberts (1995), not to Safer et al. Attributing five stages to Safer et al. is a common and costly mistake.

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.