I TOLD YOU I WAS SICK! THE DOCTOR SAYS I HAVE HYPOCHONDRIASIS!

Total Health Expenditure, Canada 1960 - 1997 80 70 60

($ billions)

50 40 30 20 10 0 60 63 66 69 72 75 78 Year 81 84 87 90

Total Health Expenditure as a Percentage of GDP, Canada 1960 - 1997

10.0% 8.0% 6.0% 4.0% 60 63 66 69 72 75 78 Year 81 84 87 90 93 96

Leading Causes of Death In Canada, 1997

79448 58692

80000

70000

60000

50000

40000
20033 8368 7630 7328 6556 5854

30000

20000
3681 3620

10000 0

eS En ys te do m cr in eS ys Ne te rv m ou sS M ys te en m ta lD iso rd er s Su ici G de en ito -u ri na ry

at or y

Re sp ir

.S

Ca nc e

Ci r

Ac c

Di g

es t iv

id en ts

ys te m

Blood pressure
Blood pressure is a vital sign (heart

rate, respiration, temperature, blood pressure)

Hypertension (high blood pressure)

is strongly linked to mortality and morbidity 4.1 million hypertensive individuals in Canada, many die each year

Out of 100 individuals with hypertension:

98% had had their blood pressure tested at least once, ever 73% had had their BP tested in the last 12 months

Blood pressure

Of those with high BP who were18-34 of age:

64% of males, & 19% of females did not know that they had high blood pressure

Out of 100 individuals with high BP, 16 were:

In treatment for their condition, and had brought their BP to acceptable levels

Most people with high BP who die do not

have their condition under control

Also, only 5% of patients requiring cholesterol-

lowering therapy in Canada are actually receiving it

Major Problems
Medical communication problems: Patients are not being informed adequately Patients are forgetful Patients are noncompliant with lifestyle

interventions Patients are noncompliant with medications Patients are not sufficiently empowered to take care of their own health

Perceiving and interpreting medical symptoms

At what point should a person seek medical advice?

Some people carry on no matter what while others adopt

the sick role readily Some people pay more attention to their internal states than others Some people overestimate the significance of their symptoms

Perceiving and interpreting medical symptoms

Our current mood affects our

ratings of health
Good mood = perceived more

healthy
Bad mood = perceived less

healthy (people tend to notice more discomfort)

Diaries kept by patients have

shown this trend

Perceiving and interpreting medical symptoms

An environment that demands attention distracts from

discomfort and physical symptoms People in boring environments notice physical symptoms more Seen in movie theatres Age is a factor (older people report more symptoms) Older people also have more symptoms

Symptom recognition
Symptom recognition

depends on

individual differences in

attention to ones body

as transitory situational

factors that alter the direction of ones attention

 When attention is directed inward, symptoms are more readily recognized

When attention is directed outward (by

Symptom recognition

various distracters) symptoms are less recognizable

We also tend to learn from our

surroundings
A Lay referral system non-medical people (parents, friends) This varies in usefulness

Seeking medical care

Typically, when a person seeks help it is a function specific nature of the symptoms their personal and social needs Pain, body part, visibility of symptom and social

influence are all considered

Seeking medical care

Why do people delay?

Delaying medical care leads to higher rates of morbidity and mortality

Heart attack victims spend about 65% of their delay time deciding if the symptoms are worth treating
This delay can be broken down

Medical Delay
DELAY BY PATIENT Appraisal delay time to decide if symptoms are due to illness Illness delay time between recognition of illness and decision for treatment Behavioural delay time between decision to seek treatment and actually seeking treatment DELAY BY PROVIDER Medical delay
Scheduling time from getting the appointment and going to

appointment Treatment - the time between seeing the doctor and getting treatment

Medical Delay
Those that seek care earlier are usually in the most

pain
Those that wait usually have other things to worry

about in their lives (sometimes wait to see if symptoms go away)

One study broke down total delay into delay by

patients and delay by providers

In breast cancer patients:

Older women delayed more but were delayed less by

providers
Young women delayed less but were delayed more by

providers
Delay by providers did not relate to decreased survival

Anxiety and Medical-care Seeking

Probability of medical careseeking

Low

high

Symptom anxiety
Sirois, F. M., & Gick, M.L. Psychological factors in medical care seeking: To seek or not to seek has always been the question. Paper presented at the 65th annual convention of the Canadian Psychological Association, St. Johns, Nfld.

Physician-patient interaction
Three basic physician-patient

relationships have been described

The active passive model
Patients do not participate in own

care
Dont make decisions for themselves

Example: patients in a coma or

unconscious

Physician-patient interaction
The guidance-

cooperation model
Patients answer questions

but the physician makes decisions

Flaws - patient is not

always told details (about physiology or medicine)

Physician-patient interaction
The mutual-participation model
Patient takes on more responsibility than

in the other models

Physician and patient make joint

decisions

diagnostic tests implementation of treatment

Physician-patient interaction
There are other models but they

all boil down to a continuum from low to high patient involvement

Patients seem to prefer the

mutual participation model

Physicians seem to prefer the

consumerist model (patients ask questions physicians answer)

Information Giving
Physicians tend to overestimate the amount of time they

spend giving patients information

One study showed that physicians estimated that they

spent 9 minutes of a twenty minute interaction giving the patient information

They actually only spent 1 minute giving information

Information Giving

Physicians feel that too much information can be bad Example: They feel that reporting side effects of drugs

will reduce compliance and may frighten patients

Patients actually will comply more if they know what

to expect

Faulty Communication Physicians

On average, physicians interrupt patients after 18-

23 seconds of explaining why they are there

Patients usually only take on average 60 seconds to

give all of their information

Patients usually discuss on average 3 issues

Faulty Communication Physicians

Medical jargon and technical

language also contribute to poor communication

More than half of mothers reported

being confused about medical terms when talking to a paediatrician

Why do doctors do this?

Faulty Communication Physicians

They tend to overestimate the amount patients

understand
Sometimes doctors do this to buy credibility and

seem more competent

Sometimes they just forget that (most) patients did

not go to medical school

Faulty Communication Physicians

Suggested remedies for this:
Non-discrepant responses the doctor using
the same level of terminology used by the patient

Multilevel explanations that is to educate

the patient as they explain things

Faulty Communication Patients

Lack of information seeking

behaviour most patients do not seek additional information

this may end soon with the availability of

medical information

Most patients dont want to be seen as

stupid, or have negative reactions from the doctor

Faulty Communication Patients

Remembering it can be tough to

remember something that you do not understand well

Can be difficult to remember things if

you are anxious

Patients can be busy thinking about

the consequences of the newly learned information

Adhering to medical advice

Creative non-adherence involves supplementing the treatment regimen These supplementations are usually

based on private theories about the treatment and health problem

Sometimes this can work, but

sometimes it can actually be harmful (contraindications)

E.g. control of blood glucose level (diabetics know better than doctors) or

asthma (seasonal variability)

Adhering to medical advice

50% of the time patients do not take the prescribed

medical advice 38% do not adhere to short-term 43% do not adhere to long-term 75% do not take lifestyle advice This costs billions of dollars each year (extra medical costs, missed work etc.)

Typical Published Noncompliance Rates

Medication Type
Ley (1976) Food &Drug Barofsky (1980) (1979)

Antibiotics 49% Psychiatric 39% Hypertensive --Tuberculosis 38% Other Medication 48%
Source:Ley (1982)

48% 42% 43% 42% 54%

52% 42% 61% 43% 46%

Factors that predict non-adherence

Characteristics of the treatment

regimen
Some medical advice require patients to change habits Stopping smoking, change diet, exercise These changes are usually unlikely since they are part of

ones lifestyle The greater the complexity of the treatment, the less likely it is to be followed

Factors that predict non-adherence

Characteristics of the treatment

regimen
Unpleasant side-effects do not seem to decrease adherence Longer duration treatments are less adhered to especially if

symptoms are not obvious A patients age can also predict adherence (greatest between 50 and 70 years) Some gender and cultural differences as well

Factors that predict non-adherence

Characteristics of the physician Adherence improves the more we respect the

physicians competence Warm caring friendly and interested physicians also have better adherence from patients Communicating importance to patient (patient must understand to adhere)

Improving Patient Adherence

Social influence in the physician-patient

relationship
Patients and physicians influence each other

during interactions
This ability for influence is termed social power

Improving Patient Adherence

Physicians can attempt to influence

patients so they adhere to medical advice:

Informational power is based

exclusively on the facts presented by the physician about the medical treatment of the patient
Reward power these rewards can be

anywhere from free drug samples to simple praise from the physician

Improving Patient Adherence

Coercive power this is essentially

threat the practitioner can threaten to not treat the patient anymore
Expert power this is the

expression of the physician to the patient of their expertise and a reminder that the physician knows best

Improving Patient Adherence

Legitimate power this stems from the

belief that the patient knows that the practitioner can make medical demands on the patient (backed up by coercive power)
Referent power this is the practitioner

referring to another successful case that followed the treatment and got better (a reference)