Consultation Behaviours And Patient Adherence

Question 1

Outline the 5 step process from illness to recovery, in an ideal world.

Answer 1

Experience a problem -> see an expert -> receive a diagnosis -> follow medical advice -> get well

Question 2

Name a few examples of problems that can get in the way of patients’ help seeking.

Answer 2

Symptom appraisal, feelings towards doctors, problems with getting an appointment and expectations about self.

Question 3

Experiencing symptoms: initiating consultation is a _____________

Answer 3

Behavioural decision

Question 4

Health psychology is largely about _________ and __________ behavioural decisions.

Answer 4

Understanding/modifying

Question 5

The complicated nature of behavioural models (e.g. Ref?) show that ___________________.

Answer 5

(The integrated behaviour change model; hagger and chatzisarantis, 2014) lots of factors structure and impede behavioural decisions.

Question 6

We know that intentions ___________ but do not ______________ behaviour.

Answer 6

Influence/guarantee.

Question 7

Experiencing symptoms: what is the ‘clinical iceberg effect’?

Answer 7

While some people consult for minor ailments, others are more stoic and rarely consult - this leads to the clinical iceberg effect whereby there are lots of people who don’t see doctors.

Question 8

Name some structural factors which influence consultation behaviours.

Answer 8

Inability to get an appointment, fastest finger first, postcode lottery.

Question 9

Data from the ____________ showed that there was an _____ percent increase in A&E visits from 08/09 to 12/13 as a result of people not being able to get a gp appointment. (Ref?)

Answer 9

National patient survey
11% (6million)
Cowling et al., 2014

Question 10

Name two diseases for which early consultation and diagnosis is important and give reasons.

Answer 10

1. Dementia:
   Helping patients make sense of the condition and put their affairs in order while they still can.
   Avoidance of risks e.g. Road accidents
2. Cancer:
   Early diagnosis can help to slow the progression and save lives.

Question 11

Which 3 cancers does the NHS routinely screen for?

Answer 11

Bowel, Breast and Cervical

Question 12

What % of new cancer diagnoses are made after and A&E visit?

Answer 12

25%

Question 13

What % of people see their GP more than 5 times before receiving a cancer diagnoses?

Answer 13

10%

Question 14

What are the 4 possible outcomes of cancer screening? and what might each of them lead to?

Answer 14

1. True/positive - this is only useful if treatment is available and is likely to impact quality of life.
2. True/neg - May lead to complacency
3. False/pos - May cause distress or unnecessary risk from invasive procedures.
4. False/neg - May lead false sense security and delayed help seeking

Question 15

Who identified 3 thresholds which underpin perceptions of symptoms (ref)?

Answer 15

Ogden (2012)

Question 16

What were the 3 threshold underpinning perception? identified by Ogden 2012

Answer 16

1. Is it a real symptom (and is it norm/abnorm?)
2. Do I need help?
3. Could a doctor help me?

Question 17

Is it a symptom?: In what way might personality factors affect symptom decisions? (ref)

Answer 17

Decisions may depend on a tendency to be internally or externally focused in terms of attention.
Internal focus inc. likelihood of sensitivity to symptoms but may lead to overestimation and slower perception of recovery.
Pennebaker (1983)

Question 18

Is it a symptom?: In what way might social identity labels affect symptom decisions?

Answer 18

(St. Claire et al) If you consider yourself as someone who gets colds, you are more likely to perceive symptoms as indicative of a cold.

Question 19

Is it a symptom?: Give a list of factors that affect symptom decisions.

Answer 19

Personality factors, social identity labels, demographics, mood/cognitions, social context and self categorisation.

Question 20

Is it a symptom?: Who studied categorisation effects in perceptions of the common cold? (ref)

Answer 20

Levine & Reicher (1996)

Question 21

Is it a symptom?: Describe Levine & Reicher’s (1996) study on categorisation effects in perceptions of the common cold.

Answer 21

Study looked at a P.E teacher/female identity and perceptions of facial scars, they presented pics of females with scars to female P.E teachers and manipulated the salience of gender/job role ‘study of women’s/P.E teachers attitudes’.

Question 22

Is it a symptom?: Describe the results of Levine & Reicher’s (1996) study on categorisation effects in perceptions of the common cold.

Answer 22

Results -> Gender group rated scarring as more impactful on identity. This shows how self categorisation can influence symptom perception.

Question 23

Is it a symptom?: Who studied self categorisation and performance in cognitive tests on old people? (ref).

Answer 23

Haslam et al (2012)

Question 24

Is it a symptom?: Describe the design of Haslam et al’s 2012 study on self categorisation and performance in cognitive tests on old people.

Answer 24

N = 68, 60-70yr olds
All completed baseline cognitive tests
Half asked to draw comparisons between themselves and older people (self cat:younger)
Other half asked to draw comparisons between themselves and younger people (self cat:older)
Second manipulation: half given info that ageing is associated with specific memory decline.
Other half given info that ageing is associated with general cognitive decline.
Outcome measures = Memory test/general cognitive ability tests.

Question 25

Is it a symptom?: What were the findings of Haslam et al's 2012 study on self categorisation and performance in cognitive tests on old people?

Answer 25

People who self categorised as older performed worse overall = stereotype threat effect. This effect interacted with expectations = those expecting general decline performed worse on cognitive tests (and met criteria for dementia). Those expecting memory decline performed worse on memory tests.

Question 26

Is it a symptom?: What is the significance of Haslam et al's 2012 study on self categorisation and performance in cognitive tests on old people?

Answer 26

This study highlights the importance of social identity in symptom perception and role performance. Has implications for diagnoses of dementia (doctors may influenced by own categorisation or patients OR patients behaviour may be influenced by GP behaviour based on these categorisations).

Question 27

Is it a symptom?: Who performed qualitative interviews with old people r.e age related labelling by healthcare professionals?

Answer 27

Warmoth et al (2015)

Question 28

Is it a symptom?: What are the findings and implications of Warmth et al's (2015) qualitative interviews with old people?

Answer 28

Older people feel routinely treated as 'old/frail' and this underpins their performance in consultation settings in that they conform to this label. The implication of this is that they may not consult if they feel that their symptoms are 'just because I'm old'.

Question 29

Do I need help?: In any given 2 week period, between ___ and ____ percent of people report some ill health symptoms, but only _____ take consultation action. (ref?)

Answer 29

50 - 75%, 1/3 (Porter et al., 2004)

Question 30

Do I need help?: Of those individuals who don't consult, some self medicate or just live with it. ___________ are important to this decision.

Answer 30

Illness cognitions.

Question 31

Do I need help?: What are illness cognitions?

Answer 31

Illness cognitions are what people think about the consequence of illness.

Question 32

Do I need help?: Who identified 5 steps in illness cognitions?

Answer 32

Leventhal et al., 1997

Question 33

Do I need help?: What are the 5 steps in illness cognitions, and what conclusions must be drawn for a person to decide they need help? (Leventhal et al., 1997)

Answer 33

1. Identification/classification - Is it a symptom? (yes) 2. How long will it last? (a significant period of time) 3. What caused this? (a serious cause) 4. How will this affect my life? (Large impact) 5. Is this something I can control? (No - I need help to do this)

Question 34

Do I need help?: What is the problem with the number of steps in illness cognitions?

Answer 34

They take time and many symptoms may pass before consultation takes place.

Question 35

Can a doctor help me?: Past experience of ___________ and _________ can reinforce inaction. This is because symptom experiencing is _________.

Answer 35

not seeking help/things getting better/normalised

Question 36

Can a doctor help me?: Patients must also analyse the _____ and ______ of seeking help (e.g.?)

Answer 36

Costs/benefits/e.g. money, procedures, medication side effects etc.

Question 37

Can a doctor help me?: Social pressures not to seek help can come from _________.

Answer 37

Public health campaigns

Question 38

Can a doctor help me?: Who wrote a summary of social stigma around mental health?

Answer 38

Vogel and Wade (2009)

Question 39

Can a doctor help me?: What did Vogel and Wade (2009) find re: stigma around help seeking?

Answer 39

They found that there is social stigma attached to help seeking, particularly in mental health - with consulting being seen as a 'mark of disgrace, particularly in certain cultures.

Question 40

Can a doctor help me?: What proportion of people with depression never seek help? (ref?)

Answer 40

1/3 (Vogel and Wade, 2009)

Question 41

Can a doctor help me?: What is one proposed reason why a high proportion of people with depression never seek help? (ref?)

Answer 41

People with depression often spend a long time denying that their symptoms are indicative of depression before they consult (Vogel and Wade, 2009).

Question 42

Can a doctor help me?: If symptoms could pose a threat to one's 'healthy' identity, this can lead to __________ (ref?)

Answer 42

Denial of symptoms (Farmer et al., 2012)

Question 43

Can a doctor help me?: Concerns about confidentiality are an important factor in the role of anticipated stigma in inhibiting mental health help seeking (ref?).

Answer 43

Clement et al. (2015) (systematic review)

Question 44

Can a doctor help me?: We tend to consult when symptoms are at their _______ and may be in _______.

Answer 44

peak, decline

Question 45

Can a doctor help me?: Spontaneous recovery is ______ in ________________.

Answer 45

Common/commonly experienced conditions

Question 46

Can a doctor help me?: There are two possible consequences of late consultation, when symptoms are in decline, what are they?

Answer 46

1. Doctors may be over confident about their abilities | 2. It can reinforce the medical model (discredits the BPS model)

Question 47

Adherence: What is adherence?

Answer 47

Following medical advice. Once a diagnosis is given (assuming it is correct) adherence/compliance is important for successful treatment.

Question 48

Adherence: How obedient to authority are we? Describe Milgram's (1963) obedience study.

Answer 48

- Teacher and learner | - No participant said they would administer a fatal shock, 65% did

Question 49

Adherence: Do doctors have an authoritative influence? Whose study suggests not?

Answer 49

Krakow and Blass (1995) found that nurses said they would not obey doctors orders to administer unsafe medicine.

Question 50

Adherence: Do doctors have authoritative influence? Whose study suggests they do?

Answer 50

Hofling et al. (1996) 21/22 nurses complied with a telephone order to administer an excessive dose of medication.

Question 51

Adherence: _________ prescriptions are given per day but one meta analysis found that adherence rates were _______- percent, and a more recent one found that they were only ______ percent for chronic illnesses. (refs?)

Answer 51

2.5 million/45-50%/25%/ Ley (1997)/ Van Dulmen (2007)

Question 52

Adherence: Who looked at adherence in patients with poorly controlled diabetes/CHD and depression?

Answer 52

Lin et al. (2012)

Question 53

Adherence: What did Lin et al (2012) do/find?

Answer 53

They conducted an RCT of 214 primary care patients with poorly controlled diabetes/CHD and depression. They looked at patient and physician behaviours and found that frequent and timely adjustments, as well as increased patient self monitoring led to increased adherence.

Question 54

Adherence: There are around _______ identified reasons for non adherence, including _______, _______, ___________, _________ and _________.

Answer 54

200, demographics, number of symptoms, treatment duration, dose frequency and patient factors (Memory; Ley, 1997)

Question 55

Adherence: Adherence is also influenced by _______ of and _________ with consultation: this is linked to perceived empathy (ref?)

Answer 55

Understanding of and Satisfaction with (Griffith, 2003).

Question 56

Adherence: None of the identified factors influencing adherence are consistent predictors, this suggests that obedience is far more complicated than __________'s work might suggest.

Answer 56

Milgram (1963)

Question 57

Adherence and social identity: How does the context dependent nature of social identity potentially impact on adherence?

Answer 57

Advice given whilst under the 'patient' identity may be harder to follow outside of the consultation room, when this identity is less salient.

Question 58

Adherence and social identity: Some groups value health less (ref?)

Answer 58

Oysterman et al. (2007)

Question 59

Adherence and social identity: Groups who value health less/see it as an outgrip thing are less likely to follow prescriptions (ref?).

Answer 59

(Tarrant and Butler, 2010)

Question 60

Adherence and social identity: SI may affect ______, ______ and _______ of consultation.

Answer 60

Understanding, satisfaction with and recall of.

Question 61

Adherence and social identity: Clinical consultation is an __________ context.

Answer 61

Intergroup

Question 62

Adherence and social identity: The intergroup context of clinical consultations influences....

Answer 62

1. How doctors interpret patient behaviours 2. How doctors treat patients 3. How patients respond.

Question 63

Adherence: Who did a 2 year longitudinal study of 186 physicians?

Answer 63

Dimatteo et al. (1993)

Question 64

Adherence: What did Dimatteo et al. (1986) find?

Answer 64

In a 2 year longitudinal study of 186 physicians, they found that adherence was linked to physician work-satisfaction.

Question 65

Improving adherence: What are adherence contracts?

Answer 65

Verbal or written commitments to specified behaviours which contribute to adherence.

Question 66

Improving adherence: Who conducted a review of whether adherence contracts increase adherence across a range of conditions including weightloss and depression?

Answer 66

Bosch-Capblanch et al. (2007)

Question 67

Improving adherence: What were the findings from a review of whether adherence contracts increase adherence across a range of conditions including weightloss and depression? (ref?)

Answer 67

30 RCTs, N = 4,691 - Adherence contracts increase adherence across a range of conditions - AC's lead to significantly better outcomes at mid/end point of treatment and at 3 month follow up - In general, evidence quality in this area is poor so strong inferences are not feasible. Bosch-Capblanch et al. (2007)

Question 68

Improving adherence: Who conducted a systematic review of the effects of text messaging on adherence?

Answer 68

Ershad-Sarabi et al. (2016)

Question 69

Improving adherence: What were the findings of a systematic review of the effects of text messaging on adherence? (ref?)

Answer 69

Across 34 studies, 99.2% reported the effectiveness of SMS in increasing adherence, however the most common outcome measure was self report (41.2%). Ershad-Sarabi et al. (2016)

Question 70

Improving adherence: Who conducted a review of 182 RCTs to try and unpick the best way to ensure adherence?

Answer 70

Nieuwlaat et al. (2014)

Question 71

Improving adherence: What were the findings of Nieuwlaat's (2014) review of 182 RCTs?

Answer 71

Complex interventions with multiple components (support, education, inducing social support) were the best at maximising adherence. Adherence is a complex problem which requires a complex solution.

Question 72

Improving adherence: ________ patients is critical.

Answer 72

Engaging

Question 73

Improving adherence: Engaging patients involves _______ preferences and _______ actions collaboratively.

Answer 73

Exploring, agreeing

Question 74

Getting well: Though there is a ____ - ____ percent misdiagnosis rate among GPs, physicians fail to anticipate this due to ________ (ref?)

Answer 74

10-15%, overconfidence, Berner & Graber (2008)

Question 75

Overconfidence: Doctors underestimate the rate of incorrect diagnoses because of _______ and systematically _______ factors including overconfidence. (ref?)

Answer 75

intrinsic, reinforced, Berner & Graber (2008)

Question 76

Overconfidence: Because of overconfidence, GPs are less likely to refer people for further testing, which has implications for the way patients are treated, listened to and respond (ref?)

Answer 76

Meyer et al. (2013)

Question 77

________ surgeons are the safest, because ______ surgeons have the least _____ and ________ surgeons are _______.

Answer 77

Mid career, early career, experience, later career, overconfidence.

Question 78

Who conducted a study on heuristic errors in clinical reasoning?

Answer 78

Rylander (2016)

Question 79

Describe Rylander's (2016) study on heuristic errors in clinical reasoning.

Answer 79

150 clinical educators were surveyed about common types of heuristic errors in third year medical students and first year residents. Anchoring and premature closure were the most common in both.

Question 80

What is anchoring and what might it be related to in clinical practice?

Answer 80

Anchoring is reliance on initial information and may be a result of overconfidence or lack of attentional resources in clinical practice.

Question 81

What is premature closure and what might it be related to in clinical practice?

Answer 81

Premature closure is prematurely ending the decision making process and may be a result of overconfidence or lack of attentional resources in clinical practice.

Question 82

Cognitive bias can be avoided through procedural change, increase knowledge of diagnoses and metacognition (ref?).

Answer 82

(Vasquez-costa, 2012)

Question 83

Threat to healthy identity can cause patients to deny their symptoms: Describe Farmer et al's (2012) study.

Answer 83

They conducted semi-structured interviews with 20 currently or previously clinically depressed patients, who either had or had not sought professional help. Thematic analysis revealed that the onset of symptoms had caused identity conflict for the individuals, participants used avoidance of help seeking as a strategy to reduce the threat to identity posed by depressive symptoms.

Question 84

Overconfidence means doctors are less likely to refer people for further testing: Describe Meyer et al's (2013) study.

Answer 84

118 physicians correctly diagnosed 55.3% of easier and 5.8% of harder vignettes. But rated their confidence in hard vs easy diagnoses as 6.4/10 and 7.2/10. Higher confidence was related to decreased requests for additional diagnostic tests.