Emotions in physician agency | J Rod - nickchinlund.info
Results The perception scores of the doctor–patient relationship were by multiple government agencies, an increasing number and diversity of new media has been lead to resistant emotions which has a negative impact on the public perceptions of .. Lessons learnt from this case would be that mass media should not. CiteSeerX - Document Details (Isaac Councill, Lee Giles, Pradeep Teregowda): This paper identifies an array of complications in doctor-patient communication. The doctor-patient relationship remains the cornerstone of medical practice. In the perfect agency model, a specific case of the principal-agent theory, the doctor . Indeed, a number of emotions that evolve during the consultation have.
Still, it is yet uncertain whether efficiency improves or declines when patient-acquired Internet information is brought into the decision-making process.
This subject warrants further investigation. The "deliberative" or "participatory" decision-making model is recommended as the preferred model of treatment decision-making in the clinical encounter [ 141617 ]. One necessary requirement for this decision-making process is that both parties take steps to participate in the process of treatment decision-making. In this model, the patient takes a newly found responsibility for disclosing preferences, obtaining information, and weighing treatment alternatives.
Someone who is willing to accept such responsibility will be at an advantage through consulting the Internet for information. The patient brings to the table technical knowledge in addition to that offered by the physician. This is more likely the case if the information was obtained through a qualified Web site certified by an evaluating organization for accuracy. Eventually, informed consent may become more a reality than a theoretical concept.
The physician's role in shared decision-making has several requirements. Physicians must ensure that the information a patient wishes to use in making a decision is founded in fact and not misconception or falsehood.
In addition, proposed treatment options must be weighed with assistance from physicians. To accomplish these tasks, physicians must be prepared to address alternative therapies that may not have been suggested if the patient had not learned about them from external sources.
Health providers must avoid frustration about having their role as the sole source of information challenged, or possibly risk losing patients. In one survey of different specialty and general medicine practices, one third of the patients who felt their relationship with their physicians was low in participatory decision-making changed providers within a year [ 16 ]. In addition, because higher volume practices were rated as "less participatory," efficiency becomes an important factor to consider.
Thus, physicians must be open to those highly motivated patients who are active participants in their healthcare. Shared decision-making includes the ideal that both parties need to agree on a treatment option, even if both do not agree that it is the best possible treatment to implement [ 14 ].
Certain types of physicians are probably more likely to subscribe to this model than others. Some doctors may not be willing to relinquish the authoritative role.
Research suggests that physicians vary widely in the extent to which they feel comfortable in facilitating patient participation in decision-making [ 16 ]. In one survey of Norwegian physicians, 3 out of 4 doctors had experiences with patients bringing Internet information to the consultation setting [ 18 ].
Although most found this experience unobtrusive, some believed it had a negative effect on the patient-physician relationship, and others found it to be a positive challenge. Physician and the Knowledge-Acquirer Physicians need to be aware that patients who are interested in obtaining additional knowledge may not be motivated to participate in actual decision-making. This circumstance may reflect less assertive personality traits on the part of some patients. Consequently, the patient-physician relationship may more likely resemble the "physician-as-agent" model [ 13 - 14 ].
In this case, the patient the knowledge-acquirer provides some personal values to the physician. By possessing the medical knowledge and learning about the patient's values and beliefs, the physician may then be the formulator of the final decision. Though the patient may not actively pursue outside sources of information prior to the clinical visit, there still may be interest in learning more about the medical condition or treatment decided on by the physician.
This case was found to be particularly true after relatively long patient-physician encounters [ 19 ]. This type of patient may benefit from obtaining information on the Web after the clinic visit. This supplemental information may allow the individual to feel more comfortable or satisfied with a treatment decision, even though there is no involvement in the actual decision-making process.
For example, when behavioral interventions are addressed, prior interactions with a physician may have a "priming effect" - improving the behavioral response to reading materials encountered subsequently [ 20 ]. This outcome may be a potentially important benefit not realized by physicians who mistakenly feel that "no interest in making decisions" translates into "no interest in medical knowledge. Physicians Recommending Web Sites to Patients: The Internet Prescription A physician-recommended Web site could be thought of as an Internet prescription.
For example, a young woman presents to her physician's office with an interest in starting an exercise regimen, but she is concerned about developing athletic injuries.
The Internet-savvy physician "prescribes" a specific Web page on stretching exercises [ 21 ]. At home, the patient initially views the recommended information, including images, animation, or video [ 22 ].
Subsequently, she also searches the Internet for alternative information and ends up reading about the dangers of traditional stretching exercises [ 23 ]. The physician may not have intended her to read this information; though it may be of interest to the open-minded patient. Although healthcare providers may suggest to patients that they acquire information from specific sources, patients will likely obtain a "second opinion" on the Internet.
In this case, the potential benefit of the Internet prescription may arise from a patient viewing suggested information first and giving it preference because his or her physician provided it. Furthermore, patients who find additional sources of information on the Internet have the option of obtaining another opinion through their physicians.
In this case, the woman in our example could provide her physician with the Web address or printed information that addresses the dangers of traditional exercises. This step may promote discussion between her and her physician about its interpretation.
Whereas it is difficult to teach "evidence-based medicine" to the layperson, it is more feasible to discuss articles with patients using related concepts that physicians have learned.
There is great concern about the accuracy and validity of medical information found on the Internet [ 3 - 5 ]. For the physician prescribing Web sites, there is the persistent challenge of ensuring quality in online content. Both physician and patient must become aware of what information is available, the source of information, and the intended audience [ 24 ].
Online information that differs significantly from that prescribed by the physician may result in unanticipated consequences. The additional strength and reinforcement of referenced consumer information requires the physician to carefully review what patients will read and to recognize that such information may be periodically updated.
In the instance of a major medical illness, some sites may soothe an individual's anxiety whereas others may raise false hopes [ 25 ]. The physician's traditional reluctance to offer more information than is necessary may be well intended. However, with the Internet, patients may opt to pursue stories and anecdotal literature evoking strong emotions for an example, see ConquerCancer. To combat online misinformation, healthcare providers must positively influence patient selection of online materials.
The presentation of awards on medical Web pages may not have a significant impact on patients' assessment of credibility [ 27 ].
However, approximately 3 out of 4 Internet users seeking health information feel that a doctor recommendation would make them more likely to trust a health Web site [ 28 ]. Physicians need to take an active role in this regard. For example, physicians can link their own Web sites to various known Web sites that provide quality content. This idea appears to be increasing in popularity as physician practice Web sites continue to grow in number.
As an alternative, medical journals and professional health organizations may represent even more valuable sources, for they offer assessment and dissemination of the best evidence for clinical problems. Referenced Web sites may be explicitly recommended to patients during clinical encounters or by electronic mail. It then becomes important for physicians to know where high caliber information is located in cyberspace rather than merely know what the specific information is itself [ 24 ].
Given how difficult it is for health professionals to keep track of the ever-changing Web, it becomes equally important to know about quality repositories of medical links. The "healthfinder" Web site selects links to health information from sources that include government agencies, nonprofit and professional organizations serving the public interest, universities and other educational institutions, libraries, and so on [ 30 ]. This site was developed by the US Department of Health and Human Services to provide up-to-date resources beyond what physicians have time to prepare on their own.
Physicians may feel more comfortable recommending information from MEDLINE plus rather than a "dot-com" source of medical information, which often endorses products or companies. Despite the existence of quality repositories of health information, there is still significant resistance to online physician activity. Many have a "fight or flight" response to these technical communicative innovations, creating a challenge in implementation [ 33 ].
The Research Agenda Though there have been previous studies analyzing the patient-physician relationship, research must be directed toward evaluating the impact of electronically obtained knowledge on this relationship. Further analysis of the current models for the patient-physician relationship may reveal that new, emerging trends are taking place. Efficiency, patient satisfaction, and clinical encounter time may vary when Internet-acquired information is considered in decision-making.
Variability in patient types and in physician personalities compounds the dynamics of decision-making analysis. Additional focus must be placed on studies that include the impact of electronically obtained knowledge on the patient-physician relationship. Another issue that should be addressed is the extent of responsibility that a patient is willing to accept.
In one pilot study, individuals have been given access to their medical records and have been provided with online communication with their physicians derived from Web-based methods of sharing clinical content [ 34 ].
The Doctor-Patient Relationship: A Review
Patient interest, as well as physician acceptance, has been evaluated. In another pilot project, patients are being provided with consumer health information in waiting and exam rooms [ 35 ].
The resulting patient-physician communication and level of satisfaction will be measured. When patients assume a greater role in acquiring medical knowledge, there must be a corresponding change in the physician's role as treatment decision-maker.
Additional dynamics are likely to result from different physician behaviors, including embracing, avoiding, or disregarding Internet-derived information. To better define this variable, surveys and observational studies are needed that will elicit physician attitudes toward Internet health information and their corresponding patient-physician relationships.
In addition, research is needed to evaluate the barriers to physician implementation of information technology.
In Canada, researchers have administered a new survey instrument to stratify primary care physicians into different levels of information technology usage [ 36 ]. This approach may allow for specifically tailored strategies to be used in implementation. Although many individuals have the potential to gain medical knowledge easily through on-line information, others do not. Few studies have examined the benefit of computers in patient education within economically depressed urban areas [ 37 ].
- Interacting with Patients' Family Members During the Office Visit
There is also little evidence that describes how individuals lacking the latest technology including high-speed Internet Service Providers cannot access resource-intensive Web sites, including those requiring audio or video streaming. The long-term effects and potential benefits of computer technology for vulnerable populations have yet to be determined. Although there is a considerable amount of data that demonstrate limited access, there still is overwhelming interest in computer education by all segments of the public.
Additional research is necessary to define how patients of different cultural or socio-economic backgrounds utilize computers and the Internet for information, and how this has an impact on their relationship with healthcare providers.
Most patients using a home computer have access to medical information on the Internet. This circumstance will likely reflect a select, educated patient population with income levels that support the equipment.
Yet there was significant interest expressed in on-line health information. If minority patient populations are to become active participants in the Internet age, it is necessary to continue to devote greater resources to improving easy access of electronic information. There is a definite need for interventions that empower ethnic minority patients and help them become informed and active healthcare consumers [ 39 ].
Patients with poor literacy skills are less likely to take advantage of the Internet in order to acquire additional medical knowledge, whether they have access or not. Unfortunately, because these individuals are more likely to have worse health, their needs for health education are greater, especially for those with chronic illnesses [ 40 ].
This issue affects their relationship with physicians; studies have shown that patients' acceptance of diagnoses and treatment plans depends on education [ 41 ]. Hence, additional efforts are required to assist persons with lower literacy skills. In these models, physicians are ready in a way that we will discuss in this paper.
Impor- to lie if this makes patients feel better. In particular, we focus on the patient behavior and the agency relationship with the role of information in physician agency.
Then, in standard information accurately. In the tage makes him able to influence the medical services emerging view, on the other hand, where physicians are benevolent and information is detrimental to anx- 1 Arrow  first stressed how information asymmetry between ious patients, information does not necessarily lead to physicians and patients is the primary cause of market failure in an efficient use of medical resources. In this respect health care markets.
The timing structure of these tests and Similarly, when the physician is a perfect agent for the disclosure of their results can be strategically man- his patient, no strategic interaction exists. In this case, aged by physicians to help patients cope with their the physician takes exactly the decisions the patient disease.
Moreover, in Section 4, we speculate on the would have taken had he had the same level of informa- relevance of health literacy and information diffusion tion. Here, delegation to the physician is indeed optimal by health authorities to the general public and on the and efficient since the latter is completely benevolent, implications of emotional agency concerning the the- perfectly informed about health matters and takes deci- ory and practice of informed consent.
Finally, we argue sions for the patient only in his best interest.
Emotional Agency : The Case of the Doctor-Patient Relationship
The papers What is relevant in the perspective that we adopt analyzed in this review can help to interpret some of the here is that, in both paternalism and perfect agency, dynamics we observe today in patient—physician rela- patient information is useless and the patient has no tionships, such as the emerging evidence that patients reason to acquire information on his health conditions. The article is organized as follows: This section does their objectives are perfectly aligned.
Section 3 is devoted to emotional agency. In particular, the physi- implications from emotional agency models. Sec- cian has important informational advantages making tion 5 concludes and provides suggestions for future opportunistic behaviors possible.
His superior knowl- research. Paternalism and standard physician agency by the patient and the quality of services received is sometimes not verifiable, even ex-post for this rea- 2.
Paternalism and perfect agency son many treatments and medical services correspond to credence goods. Whenever his objectives are not The literature studying the demand for health care perfectly aligned with those of the patient, the physi- had initially assumed that the patient played no role cian may use his informational advantage to exert low in the decision on the type and the amount of health effort  or to increase patient health service utiliza- care to be consumed.
In this view, the patient was not tion [12,18,36,35,6,14,15,17]. Any decision regarding patient health was an increase in the volume of health care and, eventu- ally, a decrease in the appropriateness of health care and patient satisfaction.
The theoretical literature on demand inducement has 4 F. Pauly and Satterthwaite  cian effort. Note that, in both papers from the supply side of health systems.
In particu- and again in line with standard Incentive Theory, the lar, optimal reimbursement schemes that might avoid problem of information asymmetry is mitigated by demand inducement are analyzed in McGuire , repeated interactions between patients and physicians: Scott , Levaggi and Rochaix , Bardey and with repeated interactions the physician is able to ben- Lesur .
In some papers, both the remuneration sys- efit from virtuous behaviors through a good reputation. What is more relevant for the purpose of our dis- Rochaix  provides an interesting example of cussion is the role of patient health information in how patient information on his health may affect the the agency relationship.
This phe- the patient evaluates the cost and benefits of searching nomenon is the result of several factors, probably the for information and plays an active role in improv- most important being that average health literacy has ing the appropriate use of medical resources.
In fact, significantly grown and that nowadays people have when he sees the doctor, the patient does not reveal easy access to several sources of health information.
This often rely on the information they obtain from sources obliges the physician to act more in the interest of the other than their physician. More recently, Smith  proposed an alternative 5 Utility is a measure of the satisfaction from consumption of goods perspective of information asymmetry: In fact, patients buy also informa- their health status, whereas for physicians, health care is generally tion from the physician and the higher the information assumed to be costly to deliver.
Using this evolution in the use of sources of health information alternative to perspective, the author assumes that patient and physi- health professionals: All policies able on the demand for medical care depends on whether to increase patient health information are welfare the two inputs are complements or substitutes. In particu- edge increases because the relatively large increase in lar, the emotional component of the relationship is demand allows the physician to reduce quality, but still extremely relevant and it can modify both the role of earn a higher profit per consultation.
Thus, contrary information and the policy implications. In emotional to the previous literature, this model predicts that, in agency, is information still beneficial to patients? When the complementary case, patient knowledge is not wel- patients fear bad outcomes and physicians are benev- fare improving because it negatively affects health care olent, how can communication between physician and quality.
The previous article stresses the importance of both patient and physician information for patient health recovery without considering communication issues 3. Emotional agency between the two agents. Strategic communica- tions neglected so far.
Calcott  and De Jaegher and Jegers feelings on future health and new issues arise. In these works, supply-induced demand is inves- In standard decision theory, if information has tigated using a different and novel approach.
However, vides information about the need for treatment. Both this usual conjecture that more information is always models use a signaling game where the physician has preferred to less might not be valid for health infor- incentives to provide the wrong diagnosis to induce mation, at least not for all patients.
In particular, a the patient to choose the most expensive treatment. By interpreting induced demand as a problem Handbook edited by Baum et al. For example, of strategic communication, these models represent Lerman et al. Note that, in the case of certified high risk of as in the previous agency models, information gath- breast cancer, early detection of disease for example, mammography can be performed in an appropriate 7 Health care is a search good when patients observe how it con- tributes to their utility ex-ante.
Health care is an experience good 8 Anxiety has been defined as apprehension, tension or uneasiness when patients learn how it contributed to their utility ex-post. In fact, be taken. Kozsegi  shows that, if the The Psychological Expected Utility model pro- patient is sufficiently anxious i.
In other words, since feelings influence decision-makers. According to such information-averse patients dislike bad news more than a framework, the standard model of choice under they like good news, they might choose to get a treat- uncertainty must be enriched by adding beliefs to ment based on their priors about future health rather the description of consequences, in order to capture than one based on the observation of their true health anticipatory feelings such as anxiety or hopefulness.
In Barigozzi and Levaggi , the patient chooses Utility depends not only on physical utility but also the precision of the information he searches for by on the anticipation of such physical utility. Thus, peo- selecting the accuracy of a signal. Thus, all the lev- ple perceive an emotional utility which is directly els of information acquisition are possible: Since peo- can decide to remain uninformed or, by searching for ple derive utility directly from their beliefs, information information from imprecise sources, he can choose dif- choices are influenced by how information affects those ferent accuracies of information.
As for the individual beliefs. As an his family medical history, or he could look for some example, we can take an individual who is aware that information concerning the probability of being high- he is at risk of high cholesterol or high blood pressure.
The patient These health conditions can have serious consequences could also undertake a medical test which is perfectly in the future but they can be asymptomatic in the informative.
The authors show that anticipatory utility present. Since perfect knowledge can lead to anxi- can be non-monotone in information accuracy and the ety, full resolution of uncertainty may not be the best patient can choose full information, no information or choice.
Note that the individual faces a risk that leads to partial information accuracy depending on the param- physical consequences in the future and, in the present, eters of the model. The most interesting result is that, can bring about anticipatory feelings in the form of under certain conditions, partial information acquisi- fear or anxiety.
It has been observed that attitudes towards infor- The works mentioned in this first part of the mation are not uniform: Kozsegi  and Barigozzi and Levaggi . In this respect, 9 According to expected utility theory, the wellbeing of an indi- feelings add an important dimension of complexity vidual facing uncertainty is calculated by considering utility in each possible state of the world and constructing a weighted average.
The weights are represented by the probability of each state. Two recent theoret- expected physical utility using the true probability ical papers, Caplin and Leahy  and Kozsegi , while the patient uses his beliefs.
To game where the patient, who is facing an impend- information-lovers, he would offer the truth about ing operation, has private information on his type he the operation. To those that are information-averse, can be either information-averse or an information- he would say nothing. This ideal solution, however, lover. Thus, ex-post the benevolent physician of uncertainty.
The physician observes what type of always wishes to inform the patient of good news. The operation the patient needs: When the only good news, with the result that, when the doctor operation is low risk the preferred outcome is more does not reveal anything, his behavior is interpreted as likely than the worst one, whereas when the opera- bad news. First the patient effect. To avoid this credibility problem, the physi- decides whether to reveal his type to the physician cian will always inform the patient: Then the physician decides whether to tell the doctor reveals all the information to both patient the patient which operation he needs.
Both patient cation with emotionally relevant certifiable information and physician can certifiably communicate their pri- and no choice of action. In particular, firstly occurring after the play of the show-and-tell game. In the doctor privately and with a positive probability the first period, before the operation takes place, the observes a diagnosis which affects the optimal treat- patient experiences feelings of anxiety which depend ment. Secondly, the physician sends a message to the on the information that he has possibly received from patient, who chooses one of two treatments.
Both the early and the late anticipatory feeling. The author analyzes the case resolver patient calculate expected utility using poste- where the doctor can certifiably convey the diagnosis rior beliefs. Note that here the patient has by two terms. The first one describes how pessimistic no private information and communication goes in one beliefs bad news lower the level of anticipatory utility.
The second one reflects the impact of pure uncer- More specifically, in Kozsegi , the framework tainty on anxiety: When news is not allow communication from the physician to the patient sufficiently good the second term in anticipatory utility to occur through a signaling mechanism; subsequently, prevails over the first one, thus information acquisition an action treatment choice is taken by the patient.
As before, anticipatory utility is such that, when the The physician is perfectly empathetic and observes the true probability of the operation type. The opposite holds when the patient is an The intuition is that, when the diagnosis is very bad, information-lover. Physical utility again realizes in the the physician must tell the patient the truth to prevent second period. It is affected both by the state of nature him from choosing treatment that is too inaccurate.
The patient knows that the physician cares When the physician cannot certifiably communi- about both his emotions and his physical health and cate the diagnosis, the signaling mechanism presents anticipates that the doctor is ready to hide or even some similarities with the one used by Calcott  distort information to make him feel better.
Thus, and De Jaegher and Jegers . In fact, in Koszegi credibility problems arise. Here only way to transmit some information is through efficiency is not reached even though the physician is treatment recommendations.
Interestingly the model benevolent. In tion is good news. However, as Caplin and Leahy , fact, wrong treatment choice makes expected physi- p.
As Koszegi , p. Thus, the model shows that mation [must be] kept out of the hands of empathic because of emotions, the doctor and the patient are not caregivers. However, even if some professional norms and Koszegi  extends the full information disclosure guidelines could have a partial commitment role, they result of Caplin and Leahy  to the case where the are unable to control for all the different situations that doctor does not perfectly observe the diagnosis: As Kozsegi news and pretends not to have the diagnosis when news  shows, when information is not verifiable, the is bad.
Koszegi also analyzes the case where the patient communication problem between the physician and his can ask another doctor for a second opinion. Here, the patient is mitigated by poor health literacy. In fact, if second physician discloses more bad news than the first the patient is sufficiently ignorant, he is not able to infer one.
As a result, the patient learns bad diag- proposed by the doctor. Finally and again in the case of 13 If the patient does not know that chemotherapy is used to treat certifiable information, the author shows that a possi- cancer and the physician observes this, the treatment is correctly ble equilibrium is the following: Only communication problems decrease together with dis- after this emotional process has been completed is the tortions in the recommended treatment because the patient ready to be treated.
A final interesting diagnosis is concerned, more time than what is strictly observation is that, since early information alleviates necessary to transmit information might be needed by later communication problems, disclosure of partial the patient. Moreover, in this specific phase, defin- information seems beneficial. In this process, and he actively searches for health information. The the social planner can play an active role in many direc- physician should transmit all available information and, tions: As mentioned in Section 2, the with the patient.
In fact, among health professionals so that patients can choose on the one hand it emerges that they represent sepa- their doctor by taking reputation into account. In turn patient choice is meaningful only if in the previous pages mainly concern the diagnosis patients are sufficiently informed both about physician phase. On the other hand diagnosis and treatment are quality and medical issues.
We saw that the timing of information tions. This implies that, if the physician wishes to disclosure seems particularly important.
In this sense, emotional agency has implications on the way physi- 14 This is also in the spirit of Caplin and Eliaz  who argue that the cians should manage with their patient the timing of spread of AIDS could be reduced by reducing the anxiety associated resolution of uncertainty about the diagnosis. When with testing for the disease. Thus, the authors suggest making the the patient approaches a physician and news is bad, he positive result of the test less informative.