Patient - Practitioner diagnosis and style Flashcards
What is practitioner diagnosis?
-This refers to the process of declaring a patient as ill or otherwise.
-When diagnosis is accurate, treatment will be valid.Also the patient will be satisfied and more confident in the doctor’s ability.
What are the 3 main parts of practitioner diagnosis?
1)Making a diagnosis
2)Presenting a diagnosis
3)Coping with diagnosis
Making a diagnosis involve
-This involves all processes leading up to declaring a patient as ill or healthy.
-In this stage of diagnosis accuracy is important.
-Accurate diagnosis depend on both patient and practitioner variables.
What patient variables affects the accuracy of diagnosis?
One patient variable that affects accuracy of diagnosis is disclosure of information.
When patients fail to disclose important information during clinical consultations the doctor may error in diagnosis.
Give two reasons why patients could fail to disclose information during their diagnosis
1) Lack of vocabulary to describe their symptoms
2)The symptoms are sensitive and potentially embarrassing.
What doctor variables could affect accuracy/validity of diagnosis?
1) Negative stereotypes they have of their patients could impair their objectivity during diagnosis.
2) Doctor training; a doctor who is only trained in the biological framework may only look at the biological basis of your diagnosis
What are the two errors of judgement that could occur due to both patient and doctor variables.
- False positive (Type 1 error) - declaring a healthy person as sick
-False negatives (Type 2) - declaring a sick person as healthy
What are the repercussions of type 2 error
-The symptoms persist or may worsen leading to more severe illness
-More invasive treatment in future
-Death
-Possibility of hospitalization
What are the repercussions of type 1 error
-Irrelevant treatment program leading to misuse of health service.
-Waste of resources
-Side effects of medication
-Loss of confidence in the doctor
Describe the study by Robinson and West (1922) - making a diagnosis
AIM:
• To investigate the amount of information disclosed by patients through a computer based interview and paper based questionnaire, compared to a doctor at a genital urinary clinic.
SAMPLE:
• 69 patients visiting a genital urinary clinic.
PROCEDURE:
• Patients who are waiting to have a face to face interview with the doctor, were asked to disclose their symptoms either through a computer based questionnaire or paper based questionnaire.
• After completing the questionnaire, they proceed to have a face to face interview with the doctor.
RESULTS:
Patients revealed disclosed more information in the computer based questionnaire than the paper based questionnaire.
Both computer based and paper based questionnaire, gathered more symptoms than the doctor gained when speaking to the patient.
CONCLUSION:
- Patients may not give or may not disclose full and accurate information to doctors, particularly if it is of a sensitive or embarrassing nature, such as information about STI.
Presenting a diagnosis
After diagnosis has been done the practitioner has to present the diagnosis/break the news to the patient. This can be done in different methods e.g
-Face-to-face
-Telephone
-Letter
-> There are individual differences to patient preferences for the channels of breaking news of diagnosis
Describe the study by Cooke and Clover (2016) - patients satisfaction with how their test results were presented after diagnosis
Aim;
-To test how satisfied patients were with the channel chosen for communicating the test results after a biopsy.
Sample;
-77 patients with suspected skin cancer
Procedure;
-All the patients were given leaflets detailing the pros and cons of each of the three methods of breaking news of a diagnosis i.e letter , telephone , face-to-face
-1 month after receiving their biopsy results patients were sent a questionnaire asking various closed questions about how they received their diagnosis including
a)Whether they were given the information leaflet or not
b)Whether they were satisfied with the chosen method of breaking the news of the diagnosis.
Results;
-94% of patients were happy with the way they received their diagnosis, and when asked whether they would change the method they chose in hindsight , 80% remained happy with their original choice.
-Only 11% said they wished they had made a different choice.
-Only 5% would have chosen face to face retrospectively
-Of the 77% patients 48% chose to receive their diagnosis via letter , 37% by phone , 11% face to face and 5% a combination of two methods.
Conclusion:
-There are differences in patient preference for the channels of breaking news of diagnosis. Hence doctors should consult the patients for their preferred method of delivering the diagnostic style.
Evaluate the study by Cooke and Clover
What are the two topics under misusing health services
-Delay in seeking treatment Safer et al
-Munchausen syndrome (factitious disorder)
Explain delay in seeking treatment under misusing health services
-When people delay in seeking mediacl services, the symptoms worsen
-They may be in need of hospitalization
-
Describe the study by Safer et al
Aim;
To investigate predicators of delay in seeking treatment
-To investigate stages of delay in seeking treatment
Sample;
- 93 patients attending one of the 4 clinics at an inner city hospital
Procedure;
-They completed a 45 min questionnaire and interview measuring the factors affecting total delay (the time between when you notice symptoms and actually access medical services) and stages of delay.
-Patients who were at the clinic for the first time for a particular illness qualified to take part.
Results;
-Mean total delay was 57 days
-Sux variables correlated significantly with total delay
Those variables are;
1) A recent competing problem or a change in life that was unrelated to the medical condition e.g marriage or divorce.
2) Patients not reporting other problems delayed on average 7.2 days .Patients reporting one or more problems delayed on average 23.3 days
3) Painful symptoms delayed by 8.6 days on average. Non-painful symptoms delayed by 23.3 days on average
4) Researching more about symptoms, if they researched a bit 26.4 days on average . Not researching about symptoms 11.5 days. Read a lot about symptoms 50.2 days.
5) Age ; patients under 45 years delay 9.1 days average , patients over 45 years delay 23.5 days on average.
6) waiting to see if their symptoms went away or changed delayed 8.9 days on average , those who did not wait delayed 23 days on average
Those who felt that their symptoms could be cured delayed 9.4 days on average. Those who felt otherwise delayed 15.2 days on average
Results in terms of stages of delay;
1) Appraisal delay - this is the duration of time between when you first notice symptoms and conclude you’re sick.
Results are - Appraisal delay averaged 4.2 days presence of painful symptoms or bleeding (sensory factors) decreased appraisal delay
Reading about symptoms increased appraisal delay
2) Illness delay ~ this is the time between when you conclude you are sick and when you decide to seek medical advice
Results are -
- New symptoms decreased illness delay
- imaging negative consequences increased illness delay e.g going through a surgical procedure
3) Utilization delay
Duration between when you decide you will seek medical care and when you actually see a doctor
Results ;
-Concern about cost (situational factor) increased utilization delay
- painful symptoms decreased utilization delay
-Belief that the symptoms could be cured decreased utilization delay
Conclusion;
-> Various factors such as situational , sensory, imagery , appraisal and conceptual affect total delay in seeking treatment.
Evaluation Safer et Al
1) Nomothetic
This is the idea that data can be gathered using quantitative techniques such as experiments using a sample of subjects. The results can then be generalized to the external population. The study by safer et al on delay in seeking treatment support the nomothetic side of the debate as about factors affecting delay from a sample of 93 patients seeing presenting with new symptoms at the doctor’s surgeries. From this study varies factors such as Appraisal, sensory, conceptual and imagery affect total delay.
2) However, idiographic side of the debate is the idea that data can be gathered from a single individual in their unique context using qualitative techniques such as case studies.
Idiographic side of the debate acknowledges uniqueness of the individuals experiences and context.
The case study by Aleem and Ajarim on the 22 year old university student supports the idiographic side of the debate as alot of qualitative data was gathered about the case history of the patient, using observations and interviews. Also tests were done using cultures.
3) Useful application to everyday life
the data by the study of safer et al has useful application to everyday life as it as the factors of delay can be used to develop health promotion campaign messages to educate patients about the need to shorten delay in seek treatment. To avoid missuse of health services.
Alternative explanations for delay
Health belief model
What is the Health belief model
beliefs are mental states they affect or determine how we evaluate our experience.
• Health beliefs refer to how we evaluate the health system. I.e whether we believe we will obtain help for our condition.
• The HBM was developed in the 1950’s to explain the probability of adopting a prevention health behavior, (Becken and Rosenstock) eg. Exercising or cutting down on sugar.
1. Precieved severity
2. Perceived susceptibility -
3. Perceived benefits -
4. Perceived barriers -
5. Cues to action -
6. Self-efficacy-
What is Perceived severity
when a health condition is perceived as severe, total delay is shortened.
What is Perceived susceptibility
the more susceptible one is to a health condition, the shorter the delay. Eg.( Females are more susceptible to breast cancer )
What is Perceived benefits
if one thinks that they will be helped by the doctor, they are more likely to seek treatment.
What is Perceived barriers
these are individual and situational factors that affect delay, eg. Cost, discomfort, inconvenience, sensory factors.
What is Cues to action
external triggers to action are called cues to action eg. Health promotion campaign or TV by government on vaccination, death of a family members. Where there are cues to action delay is shortened.
Self-efficacy
the belief in one’s ability to successful execute a task. Patients who believe in there ability to make s health related change, eg. Cutting down on sugar are less likely to delay.
What is Munchausen syndrome
• This is a disorder in the spectrum of factitious disorders.
• It is a mental disorder where a person pretends to be unwell, deliberately makes themselves unwell or hurt themselves in a bid to assume the sick role.
• Sick role is when one acts sick in order to attract sympathy and attention. One is relieved from activity.
• Munchausen syndrome is different from malingering.
What are the diagnostic features of Machausen syndrome
Essential features:
• Pathologic lying
• Peregrination (travelling or wandering)
• Recurrent, feigned or simulated illness
Supporting features
• Most likely to be male.
• Equanimity(calm) during procedures.
• Equanimity during treatment.
• Multiple scars.
• Multiple hospitalizations.
• Deprivation in childhood.
Describe the case study by Alem and Ajarim (case study)
AIM:
• To report a case of Munchausen syndrome presenting as immodeficiency.
SAMPLE:
• A single 22 year old university female student reffered as a possible case of neutrophil disorder.
• She is intelligent with modest knowledge of the medical field.
• She is 3rd born in a family of 7. They are all female children.
• Her father is a teacher describe as a supportive and friendly man.
• Her mother has breast cancer.
PROCEDURE (CASE HISTORY)
• At age 17 she had amenorrhea.
• After a few months she developed symptoms suggestive of DVT.
• She was prescribed for anticoagulation (blood thinners) (warfarin)
• Soon after she complained about bilateral painful swelling in the groin area.
• Anticoagulation was stopped and surgical evacuation was carried out.
• In the latest hospital admission that is currently, the patient complaint of a painful swelling above her right breast.
• Also reported having similar swelling in her abdomen over recent months.
• These swelling required hospitalizations and surgeries on approximately 20 occasions.
• A range of test were carried out and eventually surgical evacuation was prescribed, as there was a sign of abscess forming.
• 4 days later a similar lump appeared on the left breast.
• A sample was taken from the swelling and cultured (grow bacteria), the cultured showed that a different strain of bacteria was responsible for the lump/swelling.
• Medication or antibiotics had to be changed but the doctors suspected Munchausen syndrome.
• A psychiatric consultation was arranged where the doctors recommended long term psychotherapy.
• During the consultations, the patient was very defensive and extremely rationalizing.
• She also appeared to be under a great deal of stress.
• One day while she was out, a nurse found a syringe full of fecal matter under bed.
• This led the nurse to suspect that the patient had been causing the abscesses herself.
• When the lady was told this by another patient, she bacme very angry and left the hospital against medical advice.
• She was lost to follow up.
• A diagnosis of Munchausen syndrome was confirmed.
Evaluation Aleem and Ajarim
1) Useful application to everyday life
This is when data from studies can be used to impose human behavior and experience. The data from Aleem and Ajarim can be used to sensitize clinicians about factitious behavior and how difficult it is to diagnose Munchausen syndrome as most patients show equanimity during procedures and treatment. This means the clinicians should watch out for suspicious cases of fake syndromes or self induced symptoms.
2) Idiographic
the debate is the idea that data can be gathered from a single individual in their unique context using qualitative techniques such as case studies.
Idiographic side of the debate acknowledges uniqueness of the individuals experiences and context.
The case study by Aleem and Ajarim on the 22 year old university student supports the idiographic side of the debate as alot of qualitative data was gathered about the case history of the patient, using observations and interviews. Also tests were done using cultures.
