As a long-time researcher and proselytizer among my clinical colleagues for the value of research, I love examples where researchers start out with an hypothesis only to be told by the data that they were wrong. Yesterday’s New York Times provides one of these examples.
Those concerned with improving doctor patient interaction have encouraged doctors to loosen up how they talk to patients, in order to build a relationship that can facilitate communication and compliance with medical advice. Some thought that doctors being willing to reveal personal details about themselves might contribute to improved communication.
Researchers studied doctors in Rochester who agreed to have two unidentified pseudo patients come to their office and surreptitiously record the consultation. the researchers were surprised by the results. When the doctors revealed personal details, rather than aid communication, it seemed to hijack the discussion to the doctor’s concerns and away from the patient’s.
June 26, 2007
Study Says Chatty Doctors Forget Patients
by Gina Kolata
A new patient comes into a doctor’s office weighing 204 pounds. He’s six feet tall. The following conversation ensues:
Doctor: Is that up a little bit for you, weightwise?
Patient: It might be up a few pounds. I used to jog and I just haven’t …
Doctor: See, ’cause I’m weighing more like 172, 173 and I’m six foot. And I’m still running. I’m doing the 5 and 10 and 15 K’s. The half marathons and …
Patient: So, I’m 30 pounds heavier than you?
Doctor: Right now, yeah.
That, a group of researchers say, is part of an actual conversation they recorded in the course of a study that showed that many doctors waste patients’ time and lose their focus in office visits by interjecting irrelevant information about themselves.
Their paper, published yesterday in The Archives of Internal Medicine, involved 100 primary-care doctors in the Rochester area. As part of a study on patient care and outcomes, the doctors agreed to allow two people trained to act as patients come to their offices sometime over the course of a year. The test patients would surreptitiously make an audio recording of the encounter. The investigators analyzed recordings of 113 of those office visits, excluding situations when the doctors figured out that the patient was fake.
To their surprise, the researchers discovered that doctors talked about themselves in a third of the audio recordings and that there was no evidence that any of the doctors’ disclosures about themselves helped patients or established rapport.
Nor, in the vast majority of cases, did the doctors circle back to the personal conversation or try to build upon it.
“I think all of us on the team thought self-disclosure is a potentially positive aspect to building a doctor-patient relationship and that we ourselves were quite good at it,” said Susan H. McDaniel, a psychologist who is associate chairwoman of the department of family medicine at the University of Rochester and lead author of the study.
“We were quite shocked,” Dr. McDaniel added. “We realized that maybe not 100 percent of the time, but most of the time self-disclosure had more to do with us than with the patients.”
Dr. Howard B. Beckman, medical director of the Rochester Individual Practice Association and an internist and geriatrician who was an author of the study, analyzed conversations before and after the doctors started talking about themselves.
“I’d been saying for many years that disclosure was a form of patient support,” Dr. Beckman said. “If someone says, ‘I have a problem,’ and you say, ‘I understand because I have it, too,’ that would be comforting.” But, he added, “in truth that never happens.”
Patients were not comforted, he said, and conversations got off track. Four out of five times when a doctor interjected personal information, the doctor never returned to the topic under discussion before the interruption.
“We found that the longer the disclosures went on, the less functional they were,” Dr. Beckman said. “Then the patient ends up having to take care of the doctor and then the question is who should be paying whom.”
The researchers studied the conversations looking for any hint that patients were helped when the doctors talked about themselves.
“We looked for any statement of comfort, any statement of appreciation, any deepening of the conversation,” Dr. Beckman said.
They found none.
Dr. Jeffrey Borkan, who is a professor and chairman of the department of family medicine at Brown University, said it was easy to see why doctors thought it was helpful to talk about themselves. Doctors are told that they must make a connection with patients. But, Dr. Borkan said, “the instruction is often imprecise — how do you make a connection?” Many think the way to do it is by talking about themselves.
“What’s shocking about this article is how often they moved from the patient’s concerns to their own,” Dr. Borkan said.
But Dr. Richard Frankel, a professor of medicine and geriatrics at Indiana University, hopes that doctors do not conclude that the best course is to clam up completely about themselves.
Patients, for example, may ask a female physician who is pregnant when she is due or whether she is having a boy or a girl. “It would not be appropriate not to say anything,” Dr. Frankel said.
The Rochester researchers, though, say their results opened their eyes to their own transgressions and made them change their ways.
They also made them see that they, too, had been the victims of doctors’ time-wasting disclosures.
Dr. McDaniel said, “I went to my doctor recently, and I realized after I left, when I was in the parking lot, that I had only asked one of my two questions because my doctor was telling me about his trip to Italy.”
But not all doctors informed of the results saw themselves in the data.
Dr. John K. Min, an internist at the Kernodle Clinic in Burlington, N.C., said he had always been circumspect when he talked to patients.
Then, however, he recalled a patient who came to see him five years ago for a physical exam. Dr. Min is avid about building furniture and the patient was skilled at furniture building. The patient spent 40 minutes with Dr. Min. When he left, Dr. Min looked at his notes.
“I realized that I didn’t even examine him,” Dr. Min said. The man, he added, was gracious when Dr. Min called to apologize.
“He said, ‘We’ll just wait for next time,’ ” Dr. Min recalled.
This study has potential relevance for psychotherapy as well. In the therapy world, as in medicine, there has been discussion of whether therapist self-disclosure might facilitate an improved therapist-patient relationship and increased patient sel-disclosure. This study would suggest that examination of this possibility should carefully distinguish between cases where the therapist makes brief personal comments in an attempt to further patient talk and cases where the therapists ends up hijacking the conversation.
June 27th, 2007
The American Psychological Association (APA) Division of Peace Psychology (Division 48) passed a resolution affirming their support for a Moratorium on psychologists’ participation in national secuity interrogations. [I am lat in posting this. When it first came out, we were asked not to pass it around further until the Division membership was notified. It then slipped off my radar. I'm sorry to have missed such an eloquent document for two months.]
Call for an APA Moratorium Resolution
Executive Committee
Society for the Study of Peace, Conflict, and Violence: Peace Psychology Division 48
April 2007
The Executive Committee of the Society for the Study of Peace, Conflict, and Violence: Peace Psychology Division 48 of the APA (American Psychological Association) calls on the APA to adopt a Moratorium Resolution on Psychologist’s Involvement* in Interrogations at US Detention Centers for Foreign Detainees and Individuals Identified as “Enemy Combatants” under the Military Commissions Act of 2006.
The Executive Committee affirms that:
In August 2006, the APA passed the Resolution Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment, which reaffirmed the APA’s long-standing commitment to basic human rights including its position against torture and other cruel, inhuman, or degrading treatment or punishment. The 2006 APA Resolution Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment reaffirmed APA’s support of the McCain Amendment (specifically its reference to United States Reservation I.1 of the Reservations, Declarations and Understandings to the United Nations Convention Against Torture(1)) and defined cruel, inhuman, or degrading treatment or punishment as actions that constitute violations of the Fifth, Eighth, and/or Fourteenth Amendments to the Constitution of the United States(2). The Fifth and Fourteenth Amendments to the Constitution of the United States include guarantees that no person shall be “deprived of life, liberty, or property, without due process of law.” The inclusion of an internationally documented definition of “cruel, inhuman, or degrading treatment” in additional to the internationally accepted definition of “torture” is of critical importance. It underscores the broad and inclusive scope of the 2006 Resolution Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment.
The Executive Committee further affirms that:
The American Psychological Association (APA) is an accredited NGO at the United Nations (UN) and as such is committed to the spirit, purposes, and principles of the UN and other relevant UN instruments (e.g., Universal Declaration of Human Rights(3), Basic Principles for the Treatment of Prisoners(4), the Convention Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment(5), and the International Covenant on Civil and Political Rights (ICCPR)(6)). The United Nations Human Rights Council in 2006 stated, “the United States has the obligation to fully respect the prohibition of torture and ill-treatment. The Special Rapporteur on torture notes the reservations to the Convention and ICCPR made by the United States, indicating that it considers itself bound by the prohibition of cruel, inhuman and degrading treatment only to the extent that it means the cruel, unusual and inhumane treatment or punishment prohibited by the Fifth, Eighth and/or Fourteenth Amendments to the Constitution of the United States” (p. 14-15).
The 2006 United Nations Human Rights Council has determined that indefinite detention constitutes “inhuman” treatment. The report states “uncertainty about the length of detention and prolonged solitary confinement, amount to inhuman treatment and to a violation of the right to health as well as a violation of the right of detainees under article 10, paragraph 1, of ICCPR to be treated with humanity and with respect for the inherent dignity of the human person” (p. 24).
The 2006 United Nations Human Rights Council has called for the immediate closure of the U.S. detention facilities at Guantanamo Bay and called for an immediate cessation of “all special interrogation techniques authorized by the Department of Defense” (p. 25).
The Executive Committee further affirms that:
As stated in the APA Resolution Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment, torture victims and victims of other cruel, inhuman, or degrading treatment or cruel, inhuman, or degrading punishment may suffer from long-term, multiple psychological and physical problems (e.g., Carlsson, Mortensen, & Kastrup, 2005; Gerrity, Keane, & Tuma, 2001; Hermansson, Timpka, & Thyber, 2003; Kanninen, Punamaki, & Qouta, 2003; Somnier, Vesti, Kastrup, & Genefke, 1992). Prisoners held without due process of law, particularly indefinite detention, may suffer long-term psychological harm and related harms (Morishima, 1982; Potts, 1994; Robbins, MacKeith, Davison, Kopelman, Meux, Ratnam, Somekh, & Taylor, 2005)
The Executive Committee further affirms that:
In October 2006, the United States government through the Military Commissions Act(7) declared that certain people held at detention centers are “enemy combatants.” As such, these detainees are not guaranteed human rights protections, particularly in relation to due process, and possibly humane interrogation techniques, as established under the Geneva Conventions and other UN documents, treaties, conventions, and protocols that protect the human rights of people without exception. Current interrogation methods at U.S. detention centers may now legally include techniques defined as torture or other cruel, inhuman, or degrading treatment or punishment under the 2006 APA Resolution Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment due to changes in the Federal Code resulting from the Military Commissions Bill of 2006.
Psychologists working in U.S. detention centers may be at risk due to an expectation that they can make judgments outside of their area of expertise. The legality of interrogation techniques and whether a particular technique constitutes a violation of law (e.g., whether a technique is abusive or not) is the role of legal counsel. Currently, psychologists are asked to insure that interrogation techniques are non-abusive, safe, and legal. This represents a position outside of their area of training and expertise and is a by-product of the lack of detainee due process of law.
Psychologists working in U.S. detention centers may be at risk (ethically and psychologically) for involvement in interrogations interpreted as legal under U.S. law but inclusive of torture and other cruel, inhuman, or degrading treatment or punishment as defined under international law and the 2006 APA Resolution Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment.
Therefore, the Executive Committee affirms:
Whereas U.S. detention centers are currently in violation of the UN Universal Declaration of Human Rights, the UN Basic Principles for the Treatment of Prisoners, and the UN International Covenant on Civil and Political Rights by denying due process of law to prisoners. Additionally, U.S. detention centers are currently in violation of the UN Convention Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment specifically, United States Reservation I.1 of the Reservations, Declarations and Understandings to the United Nations Convention Against Torture and the Geneva Conventions. Whereas U.S. detention centers currently deny prisoners due process of law (e.g., legal representation and subjected to indefinite incarceration) as defined by the Fifth, Eighth, and Fourteenth Amendments of the U.S. Constitution.
Whereas, as defined by the 2006 APA Resolution Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment, the existing context of U.S. detention centers currently constitutes cruel, inhuman, or degrading treatment of prisoners.
Whereas, under the Military Commissions Act of 2006, interrogation techniques may now legally be used against detainees that represent violations of the 2006 APA Resolution Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment.
Be it resolved that the Executive Committee of the Society for the Study of Peace, Conflict, and Violence: Peace Psychology Division 48 of the APA (American Psychological Association) calls on the APA to adopt a Moratorium Resolution on Psychologist’s Involvement in Interrogations at US Detention Centers for Foreign Detainees and Individuals Identified as “Enemy Combatants” under the Military Commissions Act of 2006.
Be it resolved that the Executive Committee calls on the APA to more broadly publicize and highlight the full import of the 2006 APA Resolution Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment.
References Carlsson, J. M., Mortensen, E. L., & Kastrup, M. (2005). A follow-up study of mental health and health-related quality of life in tortured refugees in multidisciplinary treatment.
Journal of Nervous and Mental Disease, 193, 651-657.
Gerrity, E., Keane, T. M., & Tuma, F. (Eds.). (2001). The mental health consequences of torture. Bethesda, MD: National Institute of Mental Health.
Hermansson, A., Timpka, T., & Thyber, M. (2003). The long-term impact of torture on the mental health of war-wounded refugees: Findings and implications for nursing programmes. Scandinavian Journal of Caring Sciences, 17, 317-324.
Kanninen, K., Punamaki, R., & Qouta, S. (2003). Personality and trauma: Adult attachment and posttraumatic distress among former political prisoners. Peace and Conflict: Journal of Peace Psychology, 9, 97-126.
Morishima, J. K. (1982). American Psychological Association statement on wartime relocation and internment of civilians. AAPA Journal, 7(1), 6-12.
Potts, M. K. (1994). Long-term effects of trauma: Post-traumatic stress among civilian internees of the Japanese during World War II. Journal of Clinical Psychology, 50, 681-698.
Robbins, I., MacKeith, J., Davison, S., Kopelman, M., Meux, C., Ratnam, S., Somekh, D., & Taylor, R. (2005). Psychiatric problems of detainees under the Anti-Terrorism Crime and Security Act 2001. Psychiatric Bulletin, 29, 407-409.
Somnier. F., Vesti. P., Kastrup. M., & Genefke, I. K. (1992). Psycho-social consequences of torture: Current knowledge and evidence. In M. Basoglu (Ed.), Torture and its consequences: Current treatment approaches (pp. 56-71). New York: Cambridge University Press.
United Nations Human Rights Council (2006). Economic, social and cultural rights, civil and political rights, situation of detainees at Guantanamo Bay. Retrieved April 10, 2007, from http://daccess-ods.un.org/access.nsf/Get?Open&DS=E/CN.4/2006/120&Lang=E.
* The Executive Committee of the Society for the Study of Peace, Conflict, and Violence wants it to be clear that this Call for a Moratorium is not intended as an indictment of psychologists currently working within military settings. Rather, this Call for a Moratorium is an expression of concern for the well-being of prisoners at U.S. Detention Centers for foreign detainees identified as “enemy combatants” under the Military Commissions Act of 2006 and also the well-being of psychologists in such settings. The Call for a Moratorium is furthermore, and most importantly, based on the reality that the setting alone is one defined by the UN Human Rights Council, the United States Reservation I.1 of the Reservations, Declarations and Understandings to the United Nations Convention Against Torture, and the 2006 APA Resolution Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment as “cruel, inhuman, or degrading.”
Endnotes
- United States Reservation I.1 of the Reservations, Declarations and Understandings to the United Nations Convention Against Torture (http://www.unhchr.ch/html/menu2/6/cat/treaties/convention-reserv.htm) stating, “the term ‘cruel, inhuman or degrading treatment or punishment’ means the cruel, unusual and inhumane treatment or punishment prohibited by the Fifth, Eighth, and/or Fourteenth Amendments to the Constitution of the United States.”
- Amendments V, VIII, and XIV of the U.S. Constitution. Amendment V
No person shall be held to answer for a capital, or otherwise infamous crime, unless on a presentment or indictment of a grand jury, except in cases arising in the land or naval forces, or in the militia, when in actual service in time of war or public danger; nor shall any person be subject for the same offense to be twice put in jeopardy of life or limb; nor shall be compelled in any criminal case to be a witness against himself, nor be deprived of life, liberty, or property, without due process of law; nor shall private property be taken for public use, without just compensation.
Amendment VIII
Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted.
Amendment XIV
Section 1. All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the state wherein they reside. No state shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any state deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.
- UN Universal Declaration of Human Rights, http://www.un.org/Overview/rights.html
- Basic Principles for the Treatment of Prisoners (http://www.ohchr.org/english/law/basicprinciples.htm) is a UN Human Rights Instrument adopted and proclaimed by General Assembly resolution 45/111 of 14 December 1990. It contains the minimum standards for treatment of prisoners as human beings as set forth in the Universal Declaration of Human Rights, the International Covenant on Economic, Social and Cultural Rights, and the International Covenant on Civil and Political Rights and the Optional Protocol.
- The United Nations Convention Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment (http://www.unhchr.ch/html/menu3/b/h_cat39.htm) is an international human rights instrument intended to prevent torture and other similar activities. According to the Convention, torture is defined as, “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.” The Convention also created the UN Committee Against Torture, which focuses on the duties of national leaders to serve in a preventive role concerning the use of torture and other cruel, inhuman, or degrading treatment or punishment.
- The United Nations International Covenant on Civil and Political Rights – http://www.ohchr.org/english/law/ccpr.htm
- The Military Commissions Act of 2006 – http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_bills&docid=f:s3930enr.txt.pdf
Opinions expressed by the voting members of the Executive Committee of the Society for the Study of Peace, Conflict, and Violence (Division 48, APA) may not reflect the opinions of other members of the Society or the American Psychological Association (APA). This is not a general membership-vote policy or position statement for either the Society or the APA.
June 27th, 2007