Table Of Content1 -
J SS CA L AVI RE L AV T
We couldn't have written this book without the love and support of
Diane (wife of Fred, mom of Jessica), the willingness to listen, and
kid-watch, of Melanie and Jodi (daughterlsister and friend, respec-
tively), the inspirational model of curiosity and exploration of Ma'Tia
and Elijah (grandkids/kids), and the endless patience and generosity of
Ian (son-in-Iaw/husband).
This book is dedicated to all of you, with love.
IMPROVING
MEDICAL
OUTCOMES
I M P R O V I N G
M E D I C A L
O U T C O M E S
The Psychology of
Doctor-Patient Visits
Jessica Leavitt
and
Fred Leavitt
ROWMAN & LITTLEFIELD PUBLISHERS, INC.
Lanham • Boulder • New York • Toronto • Plymouth, UK
Published by Rowman & Littlefield Publishers, Inc.
A wholly owned subsidiary of The Rowman & Littlefield Publishing Group, Inc.
4501 Forbes Boulevard, Suite 200, Lanham, Maryland 20706
http://www.rowmanlittlefield.com
Estover Road, Plymouth PL6 7PY, United Kingdom
Copyright © 2011 by Rowman & Littlefield Publishers, Inc.
All rights reserved. No part of this book may be reproduced in any form or by any
electronic or mechanical means, including information storage and retrieval systems,
without written permission from the publisher, except by a reviewer who may quote
. .
passages m a reVIew.
British Library Cataloguing in Publication Information Available
Library of Congress Cataloging-in-Publication Data
Leavitt, Jessica, 1970-
Improving medical outcomes: the psychology of doctor-patient visits I Jessica Leavitt and
Fred Leavitt.
p.; cm.
Includes bibliographical references and index.
Summary: "The ability of doctors to properly diagnose and treat patients is often
colored by nonspecific factors that can affect outcomes in profound ways. Communication
between doctors and patients is key, but often what is left unsaid is just as important,
and messages from outside sources such as medical journals, drug companies, and other
patients can affect how a doctor treats anyone patient at anyone time. This book outlines
the nonspecific factors that come into play when doctors and patients interact, how both
doctors and patients can overcome these messages to focus in on the health of the person
sitting on the table, and how psychological factors in both the doctor and the patient can
affect medical outcomes. Anyone hoping to improve the medical care they give or the
medical care they get will find in these pages strategies for improving those results" -
Provided by publisher.
ISBN 978-1-4422-0303-7 (cloth: alk. paper) - ISBN 978-1-4422-0305-1 (electronic)
1. Physician and patient. 2. Patient participation. 3. Medical offices. 4. Patients
Psychology. 5. Physicians-Psychology. I. Leavitt, Fred. II. Title.
[DNLM: 1. Physician-Patient Relations. 2. Office Visits. 3. Patient Participation. 4.
Patients-psychology. 5. Physicians-psychology. 6. Treatment Outcome. W 62]
R727.3.L342011
610.696-dc23
2011013594
e
MTM
The paper used in this publication meets the minimum requirements of
American National Standard for Information Sciences-Permanence of Paper
for Printed Library Materials, ANSIINISO Z39.48-1992.
Printed in the United States of America
CONTENTS
Introduction
IX
1 Doctor-Patient Communication
2 Interpreting Medical Information 23
3 Decisions: Overview 43
4 Decisions: Biases 57
5 Medical Diagnosis: The Problems 79
6 Reducing Diagnostic Errors 99
7 Prescriptions for Prescribing 121
8 Expectation Effects: Power to the Placebo 139
9 Complementary and Alternative Medicine 175
10 Patient Outlook and Social Connectedness 189
1 1 Healing Environments 201
Appendix I: Psychiatric Diagnosis 215
Appendix 2: Darwinian Medicine 219
vii
vii i CONTENTS
Appendix 3: Wellness Strategies 229
Notes 253
Index 303
INTRODUCTION
The problems faced by medical doctors and automobile mechanics
are in some ways quite similar-something isn't working correctly and
must be fixed. They must both figure out the cause of malfunctions and
determine the appropriate treatments. For the mechanic, the differ
ence between what a car engine should be doing and is doing is a factor
that, if appropriately addressed, can turn a non functioning car into a
functional one. The specific mechanical factors are the only ones that
come into play. Mechanics have no need to worry about an automobile's
psyche, but in health care, the factors influencing outcomes are broader.
Many nonspecific factors have profound effects, and they constitute the
major topics of this book.
What do we mean by nonspecific factors? Well, instead of a dam
aged car, imagine a damaged appendix. The specific factor is whatever
is physically wrong with the appendix. But whereas mechanics don't
expect cars to describe their symptoms, doctors in most cases must com
municate effectively with patients to properly diagnose the problem.
The information they receive is oftentimes incomplete or inaccurate.
Doctor-patient communication, which includes the doctor's demeanor,
is a nonspecific factor that may greatly affect outcomes.
Another nonspecific factor is the doctor's ability to interpret the ever
expanding medical literature. Doctors should be able to distinguish
ix
x INTRODUCTION
between correlational and experimental studies and to appreciate the
difference between statistical and clinical significance. The research
articles and advertisements they read typically present data in ways that
make a treatment's effectiveness seem greater than it really is. Doctors
who understand various quantitative measures, such as number needed
to treat, odds ratios, absolute versus relative risks, and survival versus
mortality rates (all discussed on pp. 36-40), are better equipped to
evaluate the data and recommend appropriate treatments.
Drug companies are in business to make money, and they use pow
erful and often well-disguised marketing techniques to promote their
products. Promotions are directed at laypersons, students in medical
school, and practicing doctors. Doctors should accept that the findings
presented in published articles, even articles in prestigious medical
journals, are often distorted by the researcher's financial concerns. Be
ing aware of potential conflicts of interest may help doctors prescribe
more appropriately.
People often make decisions that are far from optimal. The conse
quences of a poor decision are often trivial, but in a medical context
they may mean the difference between life and death. We discuss sev
eral unconscious biases that lead to poor decision making; these can be
overcome, but only if doctors are aware of them.
When a mechanic works on a car, the car receives the attention pas
sively. A car will never have its radiator fixed simply by being told that the
work has been done. But nonspecific factors, such as the placebo effect
and other expectation effects, are real and powerful for human patients
and even nonhuman animals. Furthermore, personality characteristics
of patients, such as degree of optimism/pessimism and sense of control,
impact outcomes. So do environmental factors-the light, sound, images,
and sense of privacy in the spaces in which patients are treated. All have
measurable effects on how quickly and well the patients heal.
This book includes three appendices. Appendix 1 deals with psychiat
ric diagnosis, which we believe is sufficiently different from other medi
cal diagnosis to warrant a separate discussion. Appendix 2 introduces
Darwinian medicine, a relatively new and innovative approach that
focuses on diagnosing and treating medical problems from an evolution
ary perspective. Appendix 3 offers general suggestions for maintaining
a healthful lifestyle.
DOCTOR-PATIENT COMMUNICATION
The single biggest problem in communication is the illusion that it
has taken place.
-George Bernard Shaw
Accurate and effective diagnoses and treatment decisions depend on
good communication between doctors and patients. But interpersonal
communication is difficult, and the doctor-patient context can raise
every difficult aspect. In visits that often feel, at least for the patient,
rushed, emotional, and frightening, doctors and patients may also have
to contend with negotiating power and decision-making control and
with accommodating demographic and cultural differences. The out
comes of these conversations have huge impacts on people's lives, so the
stakes are high, and significant stress can result.
It's a wonder that communication in this context is as good as it is. But
it is not very good. Studies have found that1
• In more than 25 percent of all visits, patients and doctors don't
agree on the main presenting problem.
• Almost 50 percent of patient medical problems and more than 50
percent of patient worries about those problems are not commu
nicated.
