3.1 The patient-practitioner relationship
- Syllabus
- 9990–2028–2029
- Topic
- 3.1
- Level
- A2
Learning objectives
3.1.1Practitioner interpersonal skills• 3.1.1 Practitioner interpersonal skills- non-verbal communications with a focus on practitioner clothing, including a study, e.g. McKinstry and Wang (1991).- verbal communications with a focus on understanding medical terminology, including a study, e.g. McKinlay (1975).- Relevant issues and debates and methodology for this topic include: idiographic versus nomothetic, experiments, questionnaires, quantitative data, generalisations.3.1.2Practitioner diagnosis and style• 3.1.2 Practitioner diagnosis and style- practitioner diagnosis focusing on making a diagnosis (disclosure of information, false positive and false negative diagnosis) and presenting a diagnosis.- practitioner style: doctor-centred (directed) and patient-centred (sharing) consultation (exemplified by the following key study).- Key study for the effect of practitioner style on patient satisfaction: Savage and Armstrong (1990).- Relevant issues and debates and methodology for this topic include: application to everyday life, individual and situational explanations, cultural differences, determinism versus free-will, validity.3.1.3Misusing health services• 3.1.3 Misusing health services- delay in seeking treatment:- - reasons for delay, including a study, e.g. Safer et al. (1979)- - alternative explanations for delay, e.g. the health belief model- Munchausen syndrome versus malingering. Diagnostic features of Munchausen (essential and supporting features), including a study, e.g. Aleem and Ajarim (1995).- Relevant issues and debates and methodology for this topic include: reductionism versus holism, idiographic versus nomothetic, interviews, case study, generalisations.
Practitioner communication works only when patients can interpret it
| Channel | Signal and possible effect | Risk |
|---|---|---|
| Non-verbal | Clothing, posture, eye contact and distance can signal role, attention, authority or warmth before words are processed | Meanings vary by age, class, culture, setting and individual preference |
| Verbal | Questions, diagnosis and treatment explanations can build shared understanding | Medical terminology, closed questioning or assumed knowledge may conceal misunderstanding |
| Repair | Explain terms in plain language, invite questions and check understanding in the patient's own words | Repetition alone does not repair language or power barriers |
| McKinstry & Wang (1991) | Evidence |
|---|---|
| Aim/sample | Test acceptability of doctors' clothing and appearance-based confidence; 475 patients from five Lothian general practices |
| Procedure | Patients judged standardised photographs of one male and one female doctor in different outfits and answered closed attitude questions |
| Results | Formal dress was generally favoured; suit/tie for the male and white coat for the female drew many high ratings. Preference was stronger among older/higher-social-class patients; practices varied. 64% called dress quite/very important and 41% said appearance could increase confidence |
| Evaluation | Standardised images and quantitative ratings aid comparison/reliability, but photos are not real consultations, clothing was confounded with gender/outfit details, and one Scottish area limits cultural generalisation |
| McKinlay (1975): terminology | Teaching implication |
|---|---|
| Problem | Practitioner vocabulary and assumptions can make patients appear ‘ignorant’ even when the information was not made accessible |
| Mechanism | Technical terms, compressed explanations and status differences reduce opportunities to disclose uncertainty |
| Safer practice | Use concrete ordinary language, define unavoidable terms, ask open questions, and verify comprehension rather than asking only ‘Do you understand?’ |
| Boundary | Plain language supports understanding; it does not guarantee adherence, trust or an accurate diagnosis by itself |
Apply evidence conditionally: dress recognisably and professionally for the patient group and setting, but prioritise respectful behaviour and comprehension checks. A communication recommendation should specify the channel, how it changes interpretation, and the patient outcome it is expected to improve.
McKinstry and Wang found an overall preference with subgroup and practice variation—not a universal dress law. Technical vocabulary may signal expertise yet still fail if the patient cannot use the diagnosis or treatment information.
Diagnosis accuracy, presentation and consultation style are distinct outcomes
| Diagnostic pathway | What can go wrong | Consequence |
|---|---|---|
| Patient disclosure | Embarrassment, anger, misunderstanding, closed questions or sensitive face-to-face disclosure may hide/distort information | Clinician reasons from incomplete evidence |
| Evidence interpretation | Symptoms overlap; training/tests may be incomplete or unavailable | Healthy patient classified ill = false positive (Type I); ill patient classified healthy = false negative (Type II) |
| Action | Error is carried into testing/treatment or reassurance | False positive risks anxiety/unneeded procedures; false negative delays needed treatment |
| Presenting a diagnosis | Evidence and implication |
|---|---|
| Choice of channel | Cooke & Colver's 77 skin-cancer patients chose letter 48%, phone 37%, face-to-face 11%, combined 5%; 94% of those receiving their chosen method were happy |
| Quality over channel alone | Schofield et al. found no significant phone–face-to-face difference in satisfaction/anxiety/depression; preparation, explicit/clear/full information mattered |
| Application | Explain pros/cons, offer feasible choice, communicate clearly, check support and next steps—especially for serious/uncertain diagnoses |
| Boundary | Skin-cancer preferences do not automatically generalise to every condition, urgency, literacy level or culture |
| Consultation style | Practitioner behaviour | Possible strength/risk |
|---|---|---|
| Doctor-centred / directing | Doctor defines problem, gives diagnosis/instructions and takes expert control | Efficient/clear and may reassure; can suppress patient priorities or shared agency |
| Patient-centred / sharing | Doctor elicits concerns/preferences and shares options/decisions | Supports voice and tailoring; may feel less decisive and needs time/information |
| Savage & Armstrong (1990) | Evidence map |
|---|---|
| Design/sample | 359 randomly selected patients aged 16–75 from one inner-London GP; randomised directing versus sharing style during treatment/advice/prognosis |
| Outcome/result | Immediate satisfaction and one-week follow-up; directing scored higher on most satisfaction outcomes, especially physical problems/prescriptions. No significant style difference for longer, advice, psychological or chronic consultations |
| Strength | Random allocation and scripted contrast support a causal test within this GP's consultations |
| Limits | One GP, self-reported satisfaction, 89% initial and 58% one-week response; satisfaction is not adherence, diagnostic accuracy or health improvement |
False positive = illness diagnosed when absent; false negative = illness missed when present. Savage and Armstrong support a context-bound satisfaction effect of directing style—not ‘doctor-centred is always medically better’.
Delay has three stages; fabricated illness must be distinguished by motive
| Safer et al. (1979) stage | Interval | Predictors/examples |
|---|---|---|
| Appraisal delay | Notice symptom → decide it signals illness | Well-defined/painful symptoms shortened delay; reading/research and attempts to interpret or self-treat could lengthen it |
| Illness delay | Decide ‘I am ill’ → decide to seek professional care | Perceived severity, imagined consequences, beliefs about treatment benefit/discomfort |
| Utilisation delay | Decide to seek care → attend/use service | Cost, appointment effort, childcare/life barriers, pain and belief that the condition is curable |
| Study architecture | Evidence/evaluation |
|---|---|
| Sample/procedure | 93 first-time patients (38 men, 55 women; mean age 44) with mostly mild complaints in waiting rooms of four clinics at a large inner-city hospital; 45-minute interview/questionnaire |
| Result/conclusion | Different variables predicted each stage; painful symptoms and no competing personal problem predicted shorter total delay. One total-delay score hides distinct decisions |
| Strength | Detailed stage model has practical value: information targets appraisal, belief support targets illness decision, and access reform targets utilisation |
| Limits | Retrospective self-report is vulnerable to recall/reconstruction; severe cases were excluded and one hospital context restricts generalisation |
| Pattern | Symptoms/illness behaviour | Primary motive |
|---|---|---|
| Munchausen syndrome / factitious disorder imposed on self | Deliberately feigns, exaggerates or induces illness and repeatedly seeks the patient role | Internal psychological need to occupy the sick role, without an obvious external reward |
| Malingering | Deliberately feigns/exaggerates illness | Clear external incentive such as money, avoiding work/duty, drugs, shelter or legal advantage |
| Genuine illness/somatic presentation | Symptoms are not intentionally fabricated | Distress or disease; absence of a quick physical explanation does not prove deception |
| Munchausen diagnostic evidence | Examples |
|---|---|
| Essential pattern | Pathological lying, travelling between services, recurrent feigned/simulated illness |
| Supporting—not individually decisive | Multiple admissions/scars, unusual dramatic presentation, medical knowledge, willingness for tests/operations, evidence of self-induced signs, deprivation/personality history |
| Diagnostic caution | Corroborate records, observations and biological tests; assess motive and alternatives. Lists vary across classifications and overlapping features do not establish intent alone |
| Aleem & Ajarim (1995) | Evidence map |
|---|---|
| Case | 22-year-old woman repeatedly treated since age 17, presenting with bodily swelling and complaints without a coherent physical cause |
| Critical observation | Ward staff found a needle containing faecal material; it was believed she had injected breast tissue. When confronted she became angry, left and did not return |
| Value | Rare, detailed clinical evidence reveals a possible method of symptom induction and repeated service use |
| Limits/ethics | One case cannot estimate prevalence or universal cause; retrospective records and clinician interpretation risk bias, and confrontation/confidentiality require care |
Both Munchausen syndrome and malingering can involve intentional symptom production; the key distinction is motive. Never infer either merely because tests are negative, and never treat a supporting feature—such as scars or repeated admissions—as a diagnosis by itself.