Patient is our word for a person who is ill. It is derived from the Latin word pati which means to suffer. Client is our word for the person who is in need and is derived from the Latin word clinare which means to lean. Illness frequently involves suffering and a need stemming from some kind of loss (loss of normal functioning) which necessitates the support of another person.

The earliest primitive cultures left their sick to fend for themselves or die in isolation. There was no obligation to assist the sick since the objective of the group was to rid themselves of the detriment.  No attempt was made to ascertain causes or cures of illness.

In somewhat advanced primitive cultures, illness was believed to have been caused by evil spirits or curses from a maligned person. Groups began to feel a sense of responsibility toward the sick individuals and considered them "victims." Incantations were used to appease the evil spirits and countercurses employed to negate the power of the person inflicting the curse.

From a religious perspective, the Old Testament contains many references to illness as punishment for sin, either of the person or the family. The New Testament references illness differently. Suffering and disease are seen as a grace. The healthy person could participate in such grace by associating with the sick where caring for the sick became an obligation. Buddhism also taught compassion for the ill.

The ancient Greeks regarded health as one of the highest values.  Disease was an evil in that it rendered a person unworthy.

Through the ages, the concept of caring for the sick grew. However, despite wishes to help the sick, remnants of earlier primitive concepts are still with us. There is usually a subconscious desire to avoid sickness and disease and we still believe illness is a punishment for some type of sin (i.e. AIDS and choice of lifestyle).

Parsons characterized the sick role as having two rights and two duties.

     Two rights
          Freedom from blame
          Exemption from normal roles, tasks, and obligations

    Two duties
          Do everything possible to recover
          Seek technically competent help

Abuses of these rights and duties do occur. Some people feign illness (hypochondriacs) or fear the health care system, thus refusing to seek competent help.  

"The concept of a hospital as a refuge too often means that patients are robbed of their status as human beings.  Too often they are called "good" or "bad" only according to the degree of their passivity in the face of the hospital demand for their obedience, dependence, and gratitude.  The fine traditional mixture of charity and discipline they receive is a practiced technique for removing their initiative as adult beings and making the 'patients'. They are then less trouble for the staff." (from T.F. Main's "The Hospital as a Therapeutic Institution")

Health care providers view “bad” patients as:
     Chronic complainers
     Hypochondriacs
     Non-compliant
     Neurotic
     Wimpy
     Whiny
     Demanding

Health care providers view “good” patients as:
     Always on time for appointments
     Compliant with recommended medical regimen
     Responsible for personal health
     Not a complainer or hypochondriac
     Shows respect and thoughtfulness
     Doesn’t leave the most important reason for seeking health care
          as last item discussed with the provider

Self-concept is very important in determining a person's response to illness. Reactions cannot be predicted due to differences in culture, experiences, and personal characteristics which all influence an individual's response to treatment. Being aware of the patient's self-concept is important for the health care provider in planning the patient's care, making it possible to take advantage of positive aspects, and reducing the stress of negative aspects.

Four stages of the patient's reaction to illness:

1. Denial or trivialization of illness.
2. Illness seen as reality when it becomes obvious or does not respond to ordinary remedies. The patient experiences a sense of loss and feels threatened due to reduced functional ability.
3. Dependency occurs in acute stage of illness. Psychological needs may prove to be an obstacle to recovery. This is actually a form of regression which can cause a lowering of emotional control causing exaggerated reactions to ordinary stimuli, accompanied by a need for help, attention, and affection. A shift from adult to child-like behavior occurs. Egocentricity may occur resulting in a dominant, intoleranct, demanding sickroom patient.
4. Convalescence. A shift back to personal responsibilities and autonomy occurs.  The (ex)patient is prepared to return to the normal routines of life.

Family’s response to illness:

1. Try to balance the support and discipline required in caring for an ill family member.
2. Illness may deprive the family of the usual role of the ill family member (i.e.breadwinner).
3. Emotional and physical draining may occur.
4. Fatigue may lead to withdrawal of support and patient will consider themselves a nuisance.
5. Other family members may feel neglected or ignored.

Response of health care providers to illness:

1. Must possess generous measures of understanding and self-discipline.
2. Must understand oneself and why certain things and people evoke certain types of reactions.
3. Avoid extremes of sympathy, both too much or too little.
4. Be sensitive.
5. Avoid falling into the trap of superiority or power.

Infants

1. Pre-Natal period is very important. It is either the starting point for good health or the beginning of a lifetime of illness & shortened life expectancy.
2. About 1% of infants die before age 1.
3. Four causes account for more than 1/2 of all infant deaths: disorders related to low birth weight; congenital anomalies: Sudden Infant Death Syndrome (SIDS); and respiratory distress syndrome.

Children

1. Immunizations eliminate most childhood diseases.
2. Unintentional injuries are the major cause of death: motor vehicle accidents; drowning; falls; poisoning; and fires.
3. Preventable problems include: homicide and suicide; child abuse and neglect; developmental problems; and lead poisoning.
4. Early preventive measures are recommended through health education: anti-smoking, alcohol, and drug education; nutrition education; daily physical education; and health education.

Adolescents & Young Adults (15-24 years)

1. Dominant preventable health problems include injuries and violence that kill and disable and emerging lifestyles that affect health in later years.
2. Need to lay the foundation for chronic disease prevention through the promotion and maintenance of a healthy lifestyle.

Adults

1. Must assume their own personal responsibility for health.
2. Leading causes of death are preventable through changes in lifestyle.
3. Screenings are important when tailored to an individual’s age and risk.
4. Patient education, counseling, and increased awareness can help maintain health and prevent disease.

Older Adults

1. Most rapidly increasing population.
2. People who reach the age of 65 can now expect to live into their 80s.
3. Must increase their functional independence. Health care workers need to monitor health status to detect early signs of health problems that can threaten independence.
4. Need regular primary health care services to maintain health and prevent disabling and life-threatening diseases.
5. Social isolation is a risk factor for disease and reduced functional independence.
6. Social & community support services are essential for maintaining independence

Special Populations (includes members from the above groups)

1. People with low incomes
2. Minority groups
3. People with disabilities

The Patient-Provider relationship may be viewed by using four prototypes as described below:

Paternalism

• Increased provider control (dominant) and decreased patient control (passive)
• Traditional form of health care practice
• Illness affords patient brief exemption from social responsibilities
• Patient expected to comply to health care provider
• Provider legitimizes patient's illness and determines course of treatment
• Provider comforts and nurtures the patient
• Idealization of health care provider may have important therapeutic effects.

Consumerism

• Decreased provider control and increased patient control
• Opposite of paternalism
• Shift from curative to preventive services
• Patient redefined as "consumer"
• Physician redefined as "health care provider"
• Seen as challenge to provide authority
• Focuses on patient's rights and provider's obligations

Mutuality

• Increased provider control and increased patient control
• Moderate alternative to extrems of paternalism and consumerism
• Each brings recognized strengths and resources to relationship
• Decisions about health care are made together
• Patient's job is to take responsibility for health care
• Provider's job is to recognize importance of the patient in patient care

Default

• Decreased patient and provider control
• Patient and provider expectations are at odds
• Patient ritualistically continues to see health care provider but fails to commit to therapy or assume responsibility for seeking alternate care
• Health care provider ritualistically sees the patient but ceases to engage, educate, or influence the patient

What is the significance of these relationships to patient outcomes?
The social climate established in a medicl visit appears to be a major determinant of patient satisfaction. Satisfaction increases when health care providers treat patients in a partner-like manner, positive toned words are spoken, less criticism is used, more social conversation occurs, and the information given about the patient's medical condition and treatments is abundant. Compliance to therapy and a medical regimen is positively associated with health care providers offering more information, engaging in more positive talk, and asking few questions.

Good provider-patient communication lead to ...

• higher patient satisfaction
• better compliance
• improved recovery from surgery
• decreased use of pain medication
• shortened hospital stays
• physiological changes in blood sugar and blood pressure

Consumers must become part of quality improvement. Feedback and participation from consumers is needed to improve health care and build better health care systems. Consumers must demand more health information which will allow consumers to do more for themselves and help reduce unnecessary visits to physicians and emergency rooms.

Public is demanding more health information and more control over, choice of, and “connectedness” to the health care process. More patient-centered models of care are being created.

Most consumers lack health information. An individual makes 95% of first-line health decisions through support of family and friends, but without the aid, or access, to health information. About 70% report problems in gaining access to appropriate health information. Sixty percent would be willing to pay for this information. Most consumers agree that once a health event occurs, there becomes a high demand for easy access to information about the condition.

Two kinds of health information are emerging:
     Wellness or prevention information to assist people in staying healthy longer
     Disease management information

Older Adults - better informed about health related matters than younger people. As people grow older, consumption of health information increases along with their use of health care.

Younger people - more likely to use new technology to access info (Internet)

Women - better informed than men. They have a greater use of health care services and usually seek health information on behalf of others, such as their children or aging parents.

Disabled - seek information but are more dissatisfied with its availability.

Everyone desires more and better health information, however access is denied to some due to language barriers and disparities in education and income.

Sources of health information are:
     Newsletters - current circulation between 3-4 million
     Magazines - fastest growing magazine category, ahead of news, fashion, and sports
     Videos - available but not very successful
     Cable/Broadcast TV - consumers prefer to get health information from the local TV news rather than national news, radio news,                                         newspapers, or magazines
     New Technologies - Internet and CD-ROM

1. You ask the right questions.  This means you keep yourself informed about your own health status.
2. You take an active part in health care decisions that affect you.  This follows from being informed. You use this information to ensure that your right to take part in the decisions affecting your health are upheld.
3. You know yourself well enough to understand your own value system. You know what is important to you when it comes to issues such as quality versus quantity of life.
4. You do not rely on the health care system to be everything to everyone. You realize that there are some problems that the health care system cannot fix, and you cannot expect it to fix.
5. You are assertive, determined, open-minded, flexible, and goal-directed.
6. The bottom line is that you are empowered by knowledge and are not afraid to use it.

Return to Syllabus

References:

French, Ruth M. (1979). Dynamics of Health Care. New York, NY: McGraw-Hill, Inc.

Glanz, K., Lewis, F.M., & Rimer, B.K. (Eds.). (1997). Health Behavior and Health Education. San Francisco: Jossey-Bass.

Parsons, Patricia & Arthur (1997). Patient Power. Toronto: University of Toronto Press.

Graham, Judith (1996). The rise of the health care consumer. The State of Health Care in America. 49-53.

PEW Commission. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. (DHHS Publication No. PHS 91-50213). Washington, DC: U.S. Government Printing Office.