Lesson 4

Doctor-patient and the role of the health psychologist and Adherence

To Treatment

WHAT IS COMPLIANCE?

Compliance refers to how well patients follow medical advice regarding taking medications,
following diets, and making lifestyle changes.

Proper compliance is important for patient recovery, but studies show that almost half of
patients with chronic illnesses, like diabetes and hypertension, do not comply with their
medication regimens. Even simple tasks, like using an inhaler for asthma, are often not done
correctly. This lack of compliance can also waste money as drugs are prescribed and purchased
but not taken. It is crucial for patients to follow medical advice for the best possible outcomes.

PREDICTING WHETHER PATIENTS ARE COMPLIANT: THE WORK OF LEY

Ley (1981, 1989) developed the cognitive hypothesis model of compliance. This claimed that
compliance can be predicted by a combination of patient satisfaction with the process of the
consultation, understanding of the information given and recall of this information. Several
studies have examined each element of the cognitive hypothesis model.

Patient Satisfaction

Ley (1988) examined how satisfied patients were after their consultations. He looked at 21
studies of hospital patients and found that 41% of them were unhappy with their treatment.
For general practice patients, the number was 28%. Haynes et al. (1979) and Ley (1988) found
that satisfaction levels depended on various parts of the consultation. These included the
emotional support and understanding given, how the health professional acted, and how
competent they were. Ley (1989) also discovered that satisfaction depended on the
information given during the consultation. Patients wanted to know as much as possible, even
if it was bad news. For example, when patients were diagnosed with cancer, they were happier
when they were told about it rather than being kept in the dark.

In 2003, Berry et al. conducted a study to examine the effect of personalizing health
information on patient satisfaction. Participants were provided with medication-related
information and were asked to rate their satisfaction. Some participants received personalized

Page 1 of 11
information, such as "If you take this medicine, there is a substantial chance of you
experiencing one or more of its side effects." Others received non-personalized information,
such as "A substantial proportion of people who take this medication experience one or more
of its side effects." The results revealed that a personalized style had a positive correlation with
greater satisfaction, lower ratings of side effects risks, and lower ratings of health risks.

A study was conducted by Sala et al. in 2002 to investigate the impact of humor in medical
consultations on patient satisfaction. The researchers examined recorded consultations and
categorized the type of humor used, as well as the level of satisfaction reported by patients.

In healthcare assessments, patient satisfaction is often used as an indirect measure of health

outcome, assuming that a satisfied patient will be healthier. This has resulted in the
development of numerous patient satisfaction measures, but there still needs to be an
agreement on what patient satisfaction means. Despite these issues, several studies suggest
that aspects of patient satisfaction may be related to patient compliance with the advice given
during consultations.

Patient understanding

If the doctor gives advice to the patient or suggests that they follow a particular treatment
programme and the patient does not understand the causes of their illness, the correct location
of the relevant organ or the processes involved in the treatment, then this lack of
understanding is likely to affect their compliance with this advice.

HOW CAN COMPLIANCE BE IMPROVED?

Compliance is considered to be essential to patient well-being. Therefore, studies have been

carried out to examine which factors can be used in order to improve compliance.

The role of information

Researchers have examined the role of information and the type of information on improving
patient compliance with recommendations made during the consultation by health
professionals. Using meta-analysis, Mullen et al. (1985) looked at the effects of instructional
and educational information on compliance and found that 64 per cent of patients were more
compliant when using such information. Haynes (1982) took a baseline of 52 per cent
compliance with recommendations made during a consultation, and found that information
generally only improved compliance to a level of 66 per cent. However, Haynes reported that
behavioural and individualized instruction improved compliance to 75 per cent. Information
giving may therefore be a means of improving compliance.

Recommendations for improving compliance

Several recommendations have been made in order to improve communication and therefore
improve compliance.

Oral information

Ley (1989) proposed that one way to improve compliance is by enhancing communication in terms
of the content of oral communication. According to him, the following factors are crucial for effective
communication:

- The primacy effect - patients tend to remember the first thing they hear
- Emphasizing the importance of compliance

Page 2 of 11
 - Simplifying the information
- Repeating the information
- Being specific –
- Conducting follow-up consultations to provide additional interviews.

Written information

Researchers also looked at the use of written information in improving compliance. Ley and
Morris (1984) examined the effect of written information about medication and found that it
increased knowledge in 90 per cent of the studies, increased compliance in 60 per cent of the
studies, and improved outcomes in 57 per cent of the studies.

Ley’s cognitive hypothesis model, and its emphasis on patient satisfaction, understanding and
recall, has been influential in terms of promoting research into the communication between
health professionals and patients. In addition, the model has prompted the examination of
using information to improve the communication process. As a result of this, the role of
information has been explored further in terms of its effect on recovery and outcome.

THE WIDER ROLE OF INFORMATION IN ILLNESS

Using information to improve recovery

If stress is related to recovery from surgery, then obviously information could be an important
way of reducing this stress. There are different types of information that could be used to effect
the outcome of recovery from a medical intervention. These have been described as (1) sensory
information, which can be used to help individuals deal with their feelings or to reflect on these
feelings; (2) procedural information, which enables individuals to learn how the process or the
intervention will actually be done; (3) coping skills information, which can educate the
individual about possible coping strategies; and (4) behavioural instructions, which teach the
individual how to behave in terms of factors such as coughing and relaxing.

Providing patients with sensory and coping skills information before undergoing medical
procedures has been found to reduce distress and the need for painkillers, while also
shortening hospital stays. Moreover, pre-operative information has improved recovery,
reduced anxiety, and decreased pain rating and analgesic intake. Researchers have concluded
that proper communication of information by healthcare professionals can significantly benefit
patients in terms of reducing distress and promoting recovery after hospitalization or medical
interventions. Additionally, pre-operative information may enable patients to mentally prepare
for the anticipated changes and fears following the operation, making any changes more
predictable.

THE ROLE OF KNOWLEDGE IN DOCTOR–PATIENT COMMUNICATION

Ley’s approach to doctor–patient communication can be understood within the framework of

an educational model involving the transfer of medical knowledge from expert to the layperson
(Marteau and Johnston 1990). This traditional approach has motivated research into health
professional’s medical knowledge, which is seen as a product of their training and education.
Accordingly, the communication process is seen as originating from the health professional’s
knowledge base.

Page 3 of 11
In 1970, Boyle highlighted the importance of patients' knowledge. However, he also found that
doctors' understanding of organs’ location and the causes of various illnesses was superior to
that of their patients. Despite this, some doctors incorrectly located organs such as the heart
and misidentified problems like constipation and diarrhea. Studies have also shown that
healthcare professionals lack accurate knowledge about diabetes and asthma.

In recent years, primary care teams have been focusing more on health promotion practices,
such as recommending changes to smoking, drinking, and diet. Research has therefore
examined healthcare professionals' knowledge in these areas. A study by Murray et al. (1993)
looked at the dietary knowledge of primary care professionals in Scotland. The professionals
completed a questionnaire consisting of commonly heard statements about diet and were
asked to agree or disagree with them. The results showed that they had high levels of correct
knowledge for statements such as "most people should eat less sugar" and "most people
should eat more fiber." However, they had relatively poor accuracy for statements such as
"cholesterol in food is the most important dietary factor in controlling blood lipid levels." The
authors concluded that primary health care professionals generally have good dietary
knowledge but that there is a need to improve teaching and training in the dietary aspects of
coronary heart disease.

Problems with the traditional approach to doctor-patient communication

The traditional approach to communication between healthcare providers and patients focuses
on the transfer of knowledge from experts to non-experts. However, Ley's cognitive hypothesis
model of communication includes the role of patients and highlights patient factors in the
communication process, as well as the doctor's provision of relevant information. This approach
encourages research into the broader role of information in health and illness.

Despite its benefits, there are several problems with this educational approach.

 The model assumes that the information provided by healthcare professionals is based
solely on factual knowledge and is not influenced by their personal beliefs.
 Additionally, patient compliance is viewed as a positive and straightforward outcome.
 The model also overlooks the role of patient health beliefs in the communication
process.

The adherence model of communication

 In an attempt to further our understanding of the communication process, Stanton

(1987) developed the model of adherence. The shift in terminology from ‘compliance’ to
‘adherence’ illustrates the attempt of the model to depart from the traditional view of
doctor as an expert who gives advice to a compliant patient.
 The adherence model proposes that effective communication from healthcare
professionals leads to improved patient knowledge and satisfaction and adherence to
the recommended medical treatment. This aspect of the model is similar to Ley's model.
However, the adherence model also takes into account the importance of patients'
beliefs, and emphasizes their locus of control, perceived social support, and the impact
that adherence can have on their lifestyles. As a result, the adherence model builds
upon Ley's model by including the patient's perspective and highlighting the interaction
between healthcare professionals and patients.

Page 4 of 11
  It is worth noting that the current communication model assumes that the health
professionals' information is solely based on objective knowledge and is not influenced
by their own health beliefs. However, this model fails to consider that patients are
individuals who have their own unique beliefs and perspectives that should be taken
into account by doctors. These beliefs should be addressed in terms of the language and
content of the communication. Conversely, doctors are often regarded as objective and
neutral, holding only professional views.

THE PROBLEM OF DOCTOR VARIABILITY

Traditionally, doctors are regarded as having an objective knowledge set that comes from their
extensive medical education. If this were the case, it could be predicted that doctors with
similar knowledge and training would behave similarly.

According to a traditional educational model of doctor–patient communication, this variability

could be understood in terms of differing levels of knowledge and expertise. However, this
variability can also be understood by examining the other factors involved in the clinical
decision-making process.

Explaining variability – clinical decision-making as problem-solving

A model of problem-solving

Clinical decision-making is a specialized form of problem-solving that has been studied within
the context of information processing theories. It is often assumed that clinical decisions are
made using inductive reasoning, which involves collecting evidence and data to develop a
conclusion and hypothesis. For instance, during a consultation, a general practitioner would ask
appropriate questions about the patient's history and symptoms to develop a hypothesis about
the problem.

However, doctors' decision-making processes are generally considered within the hypothetico-
deductive model of decision making, which emphasizes developing hypotheses early on in the
consultation. This model involves several stages that result in a solution to the problem. Newell
and Simon's (1972) model of problem-solving is a useful framework for examining clinical
decisions. The stages involved are as follows:

1. Understand the nature of the problem and develop an internal representation. At this
stage, the individual needs to formulate an internal representation of the problem. This
process involves understanding the goal of the problem, evaluating any given conditions
and assessing the nature of the available data.
2. Develop a plan of action for solving the problem. Newell and Simon differentiated
between two types of plans: heuristics and algorithms. An algorithm is a set of rules that
will provide a correct solution if applied correctly (e.g. addition, multiplication, etc.
involve algorithms). However, most human problem solving involves heuristics, which
are rules of thumb. Heuristics are less definite and specific but provide guidance and
direction for the problem his solver. Heuristics may involve developing parallels
between the present problem and previous similar ones.

3. Apply heuristics. Once developed, the plans are then applied to the given situation.
4. Determine whether heuristics have been fruitful. The individual then decides whether
the heuristics have been successful in the attempt to solve the given problem. If they

Page 5 of 11
 are considered unsuccessful, the individual may need to develop a new approach to the
problem.
5. Determine whether an acceptable solution has been obtained.
6. Finish and verify the solution. The end-point of the problem-solving process involves the
individual deciding that an acceptable solution to the problem has been reached and
that this solution provides a suitable outcome.

According to Newell and Simon’s model of problem solving, hypotheses about the causes and
solutions to the problem are developed very early on in the process. They regarded this process
as dynamic and ever-changing and suggested that at each stage of the process the individual
applies a ‘means end analysis’, whereby they assess the value of the hypothesis, which is either
accepted or rejected according to the evidence. This type of model involves information
processing whereby the individual develops hypotheses to convert an open problem, which
may be unmanageable with no obvious end-point, to one which can be closed and tested by a
series of hypotheses.

Explaining variability

Variations in the behavior of healthcare professionals can be attributed to the diverse

processes involved in clinical decision-making. For instance, healthcare professionals may:

- Access different information about the patient's symptoms.

- Develop different hypotheses.

- Access different attributes to either confirm or refute their hypotheses.

Page 6 of 11
 - Have varying degrees of bias towards confirmation.

- As a result, come up with different management decisions.

Explaining variability – the role of health professionals’ health beliefs

The clinical decision-making process, based on hypothesis testing, sheds light on the factors
that contribute to the variability in health professionals' behavior. The formulation of the initial
hypothesis is a crucial stage that may lead to this variability. Patients' beliefs are unique and not
constant, while health professionals' beliefs are usually assumed to be consistent and
predictable. However, the development of the initial hypothesis depends on the health
professional's own health beliefs, which can be as diverse as those of the patient. The health
belief model, the protection motivation theory, and attribution theory are some of the models
used to study health professionals' beliefs. The beliefs involved in creating the initial hypothesis
can be classified as follows:

1 The health professional’s own beliefs about the nature of clinical problems. Health
professionals have their own beliefs about health and illness. This pre-existing factor will
influence their choice of hypothesis. For example, if a health professional believes that
health and illness are determined by biomedical factors (e.g. lesions, bacteria, viruses) then
they will develop a hypothesis about the patient’s problem that reflects this perspective
(e.g. a patient who reports feeling tired all the time may be anaemic). However, a health
professional who views health and illness as relating to psychosocial factors may develop
hypotheses reflecting this perspective (e.g. a patient who reports feeling tired all the time
may be under stress).

2. The health professional’s estimate of the probability of the hypothesis and disease. Health
professionals will have pre-existing beliefs about the prevalence and incidence of any given
health problem that will influence the process of developing a hypothesis. For example,
some doctors may regard childhood asthma as a common complaint and hypothesize that a
child presenting with a cough has asthma, whereas others may believe that childhood
asthma is rare and so will not consider this hypothesis.

3. The seriousness and treatability of the disease. Weinman (1987) argued that health
professionals are motivated to consider the ‘pay-off’ involved in reaching a correct
diagnosis and that this will influence their choice of hypothesis. He suggested that this pay-
off is related to their beliefs about the seriousness and treatability of an illness. For
example, a child presenting with abdominal pain may result in an original hypothesis of
appendicitis as this is both a serious and treatable condition, and the benefits of arriving at
the correct diagnosis for this condition far outweigh the costs involved (such as time-
wasting) if this hypothesis is refuted. Marteau and Baum (1984) have argued that health
professionals vary in their perceptions of the seriousness of diabetes and that these beliefs
will influence their recommendations for treatment. Brewin (1984) carried out a study

Page 7 of 11
 looking at the relationship between medical students’ perceptions of the controllability of a
patient’s life events and the hypothetical prescription of antidepressants. The results
showed that the students reported variability in their beliefs about the controllability of life
events; if the patient was seen not to be in control (i.e. the patient was seen as a victim),
the students were more likely to prescribe antidepressants than if the patient was seen to
be in control. This suggests that not only do health professionals report inconsistency and
variability in their beliefs, this variability may be translated into variability in their
behaviour.
4. Personal knowledge of the patient. The original hypothesis will also be related to the health
professional’s existing knowledge of the patient. Such factors may include the patient’s
medical history, knowledge about their psychological state, an understanding of their
psychosocial environment and a belief about why the patient uses the medical services.
5. The health professional’s stereotypes. Stereotypes are sometimes seen as problematic and
as confounding the decision-making process. However, most meetings between health
professionals and patients are time-limited; consequently, stereotypes play a central role in
developing and testing a hypothesis and reaching a management decision. Stereotypes
reflect the process of ‘cognitive economy’ and may be developed according to a multitude
of factors such as how the patient looks/talks/ walks or whether they remind the health
professional of previous patients. Without stereotypes, consultations between health
professionals and patients would be extremely time-consuming.

Other factors which may influence the development of the original hypothesis include:

 A health professional's mood can impact their decision-making process. Isen et al.
(1991) found that medical students in a positive mood made faster decisions and
showed more interest in patient case histories.
 The characteristics of a health professional, such as age, sex, weight, location,
experience, and behavior, can also influence decision-making. For example, smoking
doctors spend more time counseling about smoking, and thinner practice nurses offer
different advice to obese patients than overweight nurses.

COMMUNICATING BELIEFS TO PATIENTS

Patients' decisions regarding health treatments can be influenced by the language that health
professionals use to describe the treatments. For instance, a study by McNeil et al. (1982)
found that the phrasing of a question could reflect the individual beliefs of the doctor and
influence the patient's choice of hypothetical treatment. The study assessed the effect of
offering surgery either if it would 'increase the probability of survival' or would 'decrease the

Page 8 of 11
probability of death'. Patients were more likely to choose surgery if they believed it increased
the probability of survival rather than if it decreased the probability of death.

Similarly, Senior et al. (2000) showed that how risk was presented to patients influenced their
beliefs about causes and how preventable an illness was. They explored the impact of framing
risk for heart disease or arthritis as either genetic or unspecified using hypothetical scenarios. In
another study, Misselbrook and Armstrong (2000) found that the way medical information is
presented to patients can affect their decision-making process. They presented the
effectiveness of a treatment to prevent stroke in four different ways and found that the ways of
presenting the risk varied, resulting in a variation in patient uptake.

Doctors also have beliefs about illness that could be communicated to patients. Ogden et al.
(2003) found that patients preferred the use of medical diagnostic terms over lay terms as it
made the symptoms seem more legitimate and gave the patient more confidence in the doctor.
In contrast, the use of lay terms made the patients feel more to blame for the problem.
Therefore, doctors need to be aware of the language they use when communicating with
patients and how it could affect patient decision-making.

EXPLAINING VARIABILITY – AN INTERACTION BETWEEN HEALTH PROFESSIONAL AND PATIENT

The current explanations of variability in the behavior of health professionals focus solely on
the health professional in isolation and ignore the factors involved in the clinical decision-
making process and their health beliefs. However, to comprehend the processes involved in
health professional-patient communication and the resulting management decisions, both the
patient and health professional should be considered as a dyad. This shift from an expert model
towards an interaction is reflected in the emphasis on patient-centeredness.

Patient centredness

The idea of putting patients at the center of medical care was first introduced in 1976 by Byrne and
Long. This concept is becoming more popular now. It is suggested that doctors should communicate
with their patients in a patient-centered way to improve patient outcomes. There is also research
exploring how much communication is patient-centered. For example, Tuckett et al. (1985) analyzed
recorded consultations and described the interaction between doctor and patient as a "meeting
between experts". Research has also looked at whether patient-centered communication leads to
better patient satisfaction and health outcomes. This has raised questions about how to define and
measure patient-centered communication. Some studies have used coding frames such as the
Stiles verbal response mode system (Stiles 1978) or the Roter index (Roter et al. 1997) to code
whether a particular doctor is behaving in a patient-centered fashion. In contrast, other studies have
used interviews with patients and doctors (Henbest and Stewart 1990) while some have used
behavioral checklists (Byrne and Long 1976).

the research studies exploring the doctor-patient interaction and the literature proposing a particular
form of interaction have used different related terms such as shared decision-making (Elwyn et al.
1999), patient participation (Guadagnoli and Ward 1998), and patient partnership (Coulter 1999).
However, in general, the patient-centered approach is considered to consist of three central
components: (i) a willingness by the doctor to listen to the patient’s opinions and expectations and to
understand the illness from the patient's perspective, (ii) involving the patient in the decision-making
process and treatment plan, and (iii) paying attention to the emotional content of the consultation for
both the patient and the doctor. This framework is similar to the six interactive components

Page 9 of 11
described by Levenstein and colleagues (Levenstein et al. 1986) and is apparent in the five key
dimensions described by Mead and Bower (2000) in their comprehensive review of the patient-
centered literature.

Finally, it is explicitly described by Winefield and colleagues in their work comparing the
effectiveness of different measures (Winefield et al. 1996). Patient-centered care is now the
recommended approach for consultations. It emphasizes a negotiation between doctor and patient
and places the interaction between the two as central. In line with this approach, research has
explored the relationship between health professionals and patients with a focus on the level of
agreement between them and the impact of this agreement on patient outcomes.

Agreement between health professional and patient

Good communication between health professionals and patients is important for successful
treatment outcomes. Recent research has shown that doctors and patients often have different
perspectives on health problems and treatment. While doctors may have a more medical
model of some health issues, patients may have different beliefs. This suggests that health
professional-patient interactions are often between two individuals with different perspectives.
However, the question remains as to how these different perspectives influence patient
outcomes.

The role of agreement in patient outcomes

When patients and doctors have different beliefs about illness and the role of medicine, it may
lead to poor compliance with medication, resistance to behavioral changes, and low
satisfaction with the consultation. However, little research has examined these possibilities. A
study by Williams et al. found that patients who had more expectations met during a GP
consultation reported higher levels of satisfaction, but the study did not explore compliance or
shared beliefs between the GP and patient. Further research is needed to develop theoretical
approaches to the consultation as an interaction and explore whether the level of agreement
between health professionals and patients predicts patient outcomes..

IMPROVING PATIENT-PROVIDER COMMUNICATION AND INCREASING ADHERENCE TO

TREATMENT
How can we improve communication so as to increase adherence to treatment? There are
simple things that both practitioners and patients can do to improve communication.

Teaching Providers How to Communicate

Effective communication is crucial in medical care, and healthcare providers can improve their
communication skills with the right motivation and training. Physicians may want to enhance
communication and participate in decision-making, but may not know how to do so effectively.
Communication training programs should teach skills that are easy to learn and integrate into
medical routines. Simple rules of courtesy, like greeting patients, using their names, and
explaining procedures, can prevent communication failures and create a supportive
environment for patients.

Communication training should be practiced in situations where skills will be used. Direct,
supervised contact with patients and feedback after patient interviews are effective training
methods for medical and nursing students.

Nonverbal communication is also important and can create warmth or coldness. A forward lean
and direct eye contact can reinforce supportiveness, whereas a backward lean, little eye

Page 10 of 11
contact, and a postural orientation away from the patient can suggest distance or discomfort.
Effective nonverbal communication can improve adherence to treatment.

Training Patients
Improving communication between patients and doctors involves teaching patients how to
obtain the necessary information from their doctors. A study by S. C. Thompson and colleagues
showed that women who wrote down three questions they wanted to ask their doctor before
their visit asked more questions and felt less anxious. In another study, some women received a
message from their doctor encouraging them to ask questions, which led to greater satisfaction
with the office visit. Therefore, preparing a list of questions ahead of time can enhance
communication during office visits and increase patient satisfaction.

Probing to barriers for adherence

Patients can predict their adherence to their treatment plan, allowing healthcare providers to
identify potential obstacles and find solutions to increase adherence. By breaking down advice
into achievable sub-goals and emphasizing the importance of lifestyle changes, healthcare
providers can improve adherence.

When doctors prescribe lifestyle change programs to their patients, the patients are more likely
to follow through with the program compared to when they are simply encouraged to use it.
Factors that can influence a patient's adherence to their treatment include being provided with
information about their treatment, having their concerns heard, building a trusting relationship
with their healthcare provider, and receiving assistance in overcoming practical barriers to their
management of diseases. Innovations in technology, such as smartphone apps, email, and
texting, can also help make communication between patients and healthcare providers more
efficient and effective. Patients can even send pictures to their healthcare provider to aid in
treatment and follow-up.

Refernce

Jane odgen book on health psychology

Taylor book on health psychology

Page 11 of 11