Personality Types and Patient Management in Family Practice

Prepared and Presented by

 Dr. Moosa M AL-Jowaiser

The Original paper presented for Association for Personality Types Conference XV,  21-25/7/2004, Toronto, Canada

CONTENTS:

• Family Practice and Personality Types

• Where we can apply Personality Type knowledge in Family Practice?

• How to apply?

• Expected Benefits from the Application

• Identifying behavioral cues of personality preferences

• Patient management in General Practice

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Introduction:

Effective Communication with patients is the most important skill every doctor should master. Results have shown that doctor excel in knowledge and medical thinking, but may not achieve the same result in communication. It has been advised by many medical authorities to teach communication skills for medical students as early as their beginning of their medical career. In fact, many respected medical colleges are now adopting this approach as part of the medical curriculum.

Personality Type is considered a very rich source for effective communication and patient management. In spite that it did not gain its proper position now, but the future is very promising.  The medical literature and the personality Type data base have been reviewed to find how doctors could master this art. Family Practice is chosen as an example for application.

Doctors, nurses and technicians from many specialties in Kuwait and UAE have contributed in designing this program. The result is a workable plan that every physician, nurse, technician or health worker should adopt on his daily work with patients.  

But, what exactly in Personality Types Knowledge can be used here? What about the scientific proof? And How to do that? The answers of these questions are discussed below. Let's state the Facts.

Family Practice and Personality Types:

Family Practice is a daily interaction with patients with a wide range of problems, physical, social and psychological. The problems may vary from a very simple problem to a highly complex one. The family practitioner needs a wide range of skills to fulfill his duty properly.

Clack GB et el⁽¹⁾ in his article has found that the findings do indicate that these doctors might benefit from education in the concept of psychological type differences and how these could affect communication with their patients. Training in how to "flex" their consultation style, when necessary, to take into account possible personality differences between themselves and their patients could enhance the outcome of the interaction for both parties.

Ryder-Smith J⁽²⁾ has also stated that The MBTI provides a logical framework of personality difference which increases mutual understanding, supports the different stages of Mobius conversations, and enables people to identify and respond positively to others who are unlike themselves. The impact of learning these models can be--and frequently is--dramatically improved outcomes.

Andrew Ml et al⁽³⁾ also found that the Results indicated that client variables of thinking-feeling and judgment-perception were related to amount of clinician feedback, client eye contact, ratio of clinician-client eye contact and amount of clinician explanation, clarity of explanation, clinician's initiative, and client eye contact, respectively. Clinicians' sensing-intuition was related to the amount of feedback to client and quality of the task sequence. Clinician's judgment-perception was related to amount of explanation and client's attention to clinician. Similarity in clinician-client sensing-intuition was related with task involvement of the client, clinician's attention to client, and clinician eye contact. Similarity in judgment-perception was related to greater use of counseling. Similarity in thinking-feeling was related to low amounts of clinician eye contact.

   Family practice is not only pure physical care. Management is an important part of it. Costello K⁽⁴⁾ found that The Myers-Briggs Type Indicator can be an enlightening experience for managers as it uncovers blind spots as well as provides insight into managerial styles. This tool offers a way to build communication patterns that meet nurse managers' needs and the needs of the people they supervise.

   Decision making play a crucial part of the family practitioner role. Fruend CM⁽⁵⁾ found that The MBTI is useful not only in identifying individual preferences, but also in developing effective managerial and working terms. Knowledge of one's own type and the type of others can help managers motivate others, maximize human resources, persuade others, and gain cooperation.

   Many researchers had pointed out the importance of Doctor Patient relationships. Feeling accepted, understood and taken care of are vital elements. Jenkins SJ⁽⁶⁾ et al had founded that  the Thinking-Feeling scale was significantly associated with ratings of empathy for 49 graduate students in counselor education. Other studies pointed also to the type of diseases and Personality Types. Thorne BM et el⁽⁷⁾ found that CHD patients were significantly more likely to prefer sensing and feeling. 

 Where we can apply Personality Type knowledge in Family Practice?:

 There are many areas that Personality Type knowledge could be used. The Table 1 summarizes some possible applications.

Table 1 

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Family Practice is mainly a patient centered medical care. In each consultation the doctor has to fulfill the 4 stages of consultation:

1] Identification and Management of acute problem(s).

2] Identification and Management of Chronic Problem(s).

3] Modification of Help seeking Behavior.

4] Opportunistic Anticipatory Care.

Management patients start from the moment the patient entered the consultation room and sometimes even before that. During Consultation, the doctor offers time and space for the patient to tell his complaint. This is called Patient phase. Here the doctor sits quietly, hears the patient talking and asks relevant questions to understand the patient's complaint. The doctor then may wish to ask more question to clarify the patient complain, examine and then tell the patient his finding. This is the doctor's phase. The patient usually hears his family practitioner and may wish to discuss the finding or the management plan.

There are many steps to be taken in Patient Management (appendix p:10). They are:

• Reassurance / Explantation
• Advice
• Prescription
• Referral
• Investigation
• Observation (follow-up)
• Prevention

But how Personality Type knowledge can help in the patient Management. There are many model can be used here:

1] Communication using normal preference.

2] Explanation using the mental functions model.

3] David Keirsey Model.

4] Interaction Style Model.

5] MRT-I Model.

6] Flex Care Model (Appendix p: 8-9).

7] Speed Reading People Model.

8] Survival Games Model (especially for difficult and problematic patients).

There are certain remarks, one must pay attention to here.

• The Human Nature is a very complex one.
• No one Model is complete. All models have strength and weakness points.
• A good knowledge of personality types and these models is extremely important. But the depth of this knowledge depends on the level of the interaction needed. Average consultation is totally different fro counseling in Family Practice.

 Suggested Models in Personality Types and Patient Management  

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Suggested course of action (How to use the mental function during the patient’s management phase):

 Doctor’s role in patient management is much more than merely prescribing a drug or making an investigation. It is a holistic approach that takes into consideration the physical as well as the psychological and the social side of the problem. To do this effectively, the treating doctor must first identify certain behavioral cues in the patient, then he will be in a better position to plan his strategy for management. Identifying these behavioral cues¹⁶ is written below (table 2).

Step 1, the doctor should identify whether the patient prefer extroversion (i.e. Talk it out), or Introversion (Think it through). This is important because the plan for patient who prefers extroversion is different from introversion. For the patient who prefers extroversion, the doctor can make rapport with him through mimicking his approach; He can match his energy and animation. Also he can speak in a rapid flow in a lively way, talking in more than one subject in the same time.

   If the patient prefers introversion, the doctor must also mimic his behavior. He should match his reserve and calm body and making little body movements. He should speak in a low tone with some pauses to give the patient a time to think it through and reflect back. The talking should be in one subject at a time. By matching the patient behavior, rapport is gained early in the consultation.           This will make the doctor’s job much easier during the management phase.

Step 2, The doctor must identify certain behavioral cues to identify the patient’s possible mental functions¹⁷. By doing so, he will be more able to convince him quickly and efficiently. He must speak in the patient’s language. There are four possible combinations of the mental functions.

   Sensing and Thinking (ST) patient prefer the doctor to give them facts in a logical way and order. The doctor should be very practical with them, stressing what should be done in such situations. Also, he should provide concise and relevant evidence for this course of action. Furthermore, the doctor should avoid too much emotional talk and concentrate in facts. He should be brief and precise. Honesty is always the best policy.

   Sensing and feeling (SF) patient, on the other hand, also prefer fact and clear information, but in a more personalized way. The doctor should provide sympathetic and honest approach. He should be emotionally warm, friendly and stating facts in a practical way. Again, honesty is the best policy.

   Intuitive and Thinking (NT) patients prefer a different course of action. They prefer logical options. You must show your competence to them. You should be prepared to be questioned. “What if” is a common question they usually ask. You should be prepared to defend your diagnosis and line of treatment. Provide them with information, articles or studies that they can read and verify for themselves. If you don’t know the answer, say I don’t know and then tell them where to go. Again, Honesty is the best policy.

   Intuitive and Feeling (NF) patients prefer a more emotional approach. They prefer a doctor who support their vision of the problem and not criticize them. They need the support and encouragement of the doctor rather than the scientific fact. They need to know what’s going on but in a more human and highly personalized way. Pay attention to their delicate nature and highly sensitive style. The statement like, “I am available for you” is much more pleasing and supporting for them than “This is your treatment”. They need to know the truth about their condition but in an emotional and supporting way. Again, Honesty is the best policy.

   Step 3, the treating doctor will decide the appropriate course of management. One other personality factor arise here, i.e. Judging / Perceiving. The patient who prefers judging is usually goal oriented. The management plan must be stated early and clearly. The patient must know “what to do”, “when”, “how”, “whom to contact”, “time and schedule” of management options and “when to come back” for follow up. Time is very valuable for them. So, the doctor should have a pre-made plan of management in such situations (i.e.. Protocol for Disease Management). Often, the patient is going to follow the agreed plan and will expect that his doctor will do the same. The date and time for further appointment are decided early. These patients are usually irritated by long procedures or by waiting for a long time.

   On the other hand, patients who prefer perceiving need a different strategy. These patients are usually concerned with “how” process (i.e. how he is going to take his medication, to contact you, to do investigation. etc.). They tend to respond in a spontaneous way rather than planning it ahead. Also, he may mention a statement like: “Oh, by the way doctor…”. Discussion may get off track with them, since there are a lot of issues to talk about. They may not stick to the agreed plan accurately and wait until the last moment to respond to it. These behaviors are well recognized in patients who prefer perceiving. The treating doctor should be prepared for such interactions. He needs to push his patient gently and wisely to the most important facts and priorities of the consultation.  He needs also to fragment the plan of management into small pieces. The patient will then be in a better position to follow it, rather than dictating the whole plan for him. Although this approach may put a lot of pressure on the doctor, but it can improve patient’s compliance.

How to apply?

Application of Personality Types different model needs mainly knowledge, understanding and practice. What most Family Practitioner may complain about is how to know the patient's preference accurately. There are many way and techniques. One of the most easy and practical ways is Speed Reading People model. Paul and Barbara Teiger gave a relatively easy and practical example to use. Their Model is explained in Table 2 (see below).

 Table 2 

 Expected Benefits from the Application:

?         Increase Rapport with patients.

?         Enhance Good Doctor Patient Relationship.

?         Improve therapeutic effect of communication of this consultation.

?         Decreases misunderstanding.

?         Increase Patient Satisfaction.

?         Saves doctor’s and patient’s Time.

What’s needed:

?         Knowledge of Personality Types.

?         Knowledge of Patient personality.

?         Preparation (mental. Psychological, room atmosphere, etc).

?         Evaluation for improvement.

?         Training

 
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Appendix

The four-part framework and the suggested course of action.

Allen J., Brock S. (2000) Tailoring the message – In physician-patient communication, patients’ personal styles call for different approaches, especially when the news is bad. Minnesota Medicine -  A Journal of Clinical and Health Affairs. May 2000, page: 45-48.

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Identifying behavioral cues of personality preferences. 

Allen J., Brock S. (2000) Tailoring the message – In physician-patient communication, patients’ personal styles call for different approaches, especially when the news is bad. Minnesota Medicine -  A Journal of Clinical and Health Affairs. May 2000, page: 45-48.

Eye on Type - Methods of Communication

Extraversion:

?         Communicate energy and enthusiasm

?         Respond quickly

?         Like to communicate with groups

?         Prefer face to face discussion over written communication, and voice mail over email In meetings, they like to talk out loud to build their ideas

Important Remarks in Extroversion:

?         Influence of personality and Culture (& subcultures) for doctor and patients.

?         Pay attention to external environment. i.e. atmosphere should be lively with low external interference so patient will concentrate on the doctor.

?         Point mentioned under extroversion are about how to communicate.

Introversion:

?         Keep their energy and enthusiasm inside

?         Pause and reflect before responding

?         Thoroughly consider ideas, thoughts, and impressions before talking Like to communicate one-to-one Prefer written over face-to-face communication, email over voice mail In meetings, they verbalize ideas that have been thought through

Important Remarks in Extroversion:

?         Room atmosphere should be quit for concentration and reflection.

?         Credibility is important for all preference, but its importance is increased with introversion; otherwise introverted patient will be hesitant to disclose himself to the doctor. Doctor’s credibility will enhance effective DPR.

?         Points mentioned under introversion are about how to communicate.

Sensing:

?         Like to have evidence presented first (facts, details, examples) Want practical and realistic applications that are clearly explained Rely on direct experience Use an orderly approach in conversations Like ideas that are straightforward and feasible Usually refer to specific examples

Intuition:

?         Like global schemes and broad issues presented first

?         Want to consider future possibilities

?         Rely on insights and imagination

?         Use a roundabout approach in conversations

?         Like ideas that are novel and unusual

?         Usually refer to general concepts

 Thinking:

?         Prefer to be brief and concise

?         Want to know the pros and cons of alternatives

?         Can be intellectually critical and objective

?         Convinced by cool, impersonal reasoning

?         Present goals and objectives first

?         Use emotions and feelings as secondary data

Feeling:

?         Prefer to be personable and agreeable

?         Want to know how alternatives impact people

?         Can be interpersonally appreciative and accepting

?         Convinced by personal authenticity

?         Present points of agreement first

?         Concentrate on subjective issues. Use logic and objectivity as a tool to enhance it.

 Judging:

?         Want to agree on schedules and reasonable deadlines

?         Dislike surprises

?         Expect people to follow through

?         State their positions as final

?         Want to hear about results and achievements

?         In meetings, they concentrate on completing tasks

 Perceiving:

?         Willing to discuss schedules but resist tight deadlines

?         Enjoy surprises

?         Expect others to respond to situational requirements

?         State their views as tentative and modifiable

?         Want to hear about options and opportunities

?         In meetings, they concentrate on the process being used

Patient management in General Practice:

 Reassurance and / or Advice:

·          Must be considered specific and related to the patient’s perception of the problem. Its success as a management technique depends on communication and trust.

Advice:

·          Must be tailored to the personality and circumstances of the individual patient.

Prescription:

·          The decision whether to prescribe or not must take into account the patient’s expectations and autonomy. The clinical aims of prescribing can be therapeutic, tactical or both. If in doubt whether or not to give a drug, don’t.

Referral:

·          Whenever a referral is made, the general practitioner should  act as a reference point coordinator and source of information and explanation for the patient, drawing together the skills associated with the whole person medicine and continuity of care.

Investigation:

·          Investigations should be considered in terms of their cost-benefit and risks, and should be performed only when their results will directly assist in the diagnosis or have an effect on subsequent management.

Observation:

·          Ensures that a doctor can monitor a patient’s clinical progress and take any appropriate action.

Prevention:

·          Involves health promotion and disease prevention; these are increasingly important in clinical practice in reducing premature death and disability.

Fraser, R. C. (1999). Clinical Method – A general practice approach. 3^rd. Butterworth – Heinmann. Page: 59-74.

Articles:

1.      Clack GB, Allen J, Cooper D, Head JO. Personality differences between doctors and their patients: implications for the teaching of communication skills. Med Educ. 2004 Feb;38(2):177-86

2.      Ryder-Smith J. Dearden Management, Bristol, UK. The secret of good conversation--investing in success. Health Manpow Manage.1998;24(1):38-9.

3.      Andrews ML, Schmidt CP. Department of Speech and Hearing Sciences, Indiana University, Bloomington 47405, USA. Congruence in personality between clinician and client: relationship to ratings of voice treatment. J Voice. 1995 Sep;9(3):261-9.

4.      Costello K. The Myers-Briggs type indicator--a management tool. Nurs Manage. 1993 May;24(5):46-7, 50-1.

5.      Jenkins SJ, Stephens JC Jr, Chew AL, Downs E. Examination of the relationship between the Myers-Briggs Type Indicator and empathetic response. Percept Mot Skills. 1992 Jun;74(3 Pt 1):1003-9.

6.      Freund CM. University of North Carolina School of Nursing, Chapel Hill. Decision-making styles: managerial application of the MBTI and type theory. J Nurs Adm. 1988 Dec;18(12):5-11.

7.      Thorne BM, Fyfe JH, Carskadon TG. Mississippi State University. The Myers-Briggs type indicator and coronary heart disease. J Pers Assess. 1987 Winter;51(4):545-54.

Books:

• Teaching Interactive Skills in Health Care. Ann Faulkner, 1993. Chapman & Hall. (The Skills of Communication, p: 117-125)
• Talking with Patients – A Basic Clinical Skill. Philip R. Myerscough, 1989. Oxford Medical Publication.
• The Person as Patient – Psychological Perspective for Health Professional. Elsa L. Ramsden, 1999. WB Saunders. (Chapter 11: The Relationship between Health Practitioner and Patient, P: 197-211).
• Logic In Medicine – Second Edition, By Calbert I Philip. BMJ Publishing Group. (Chapter 3: Diagnostic Logic, p: 62-73; 96-99).
• Health Psychology, Second Edition 1991. By Shelley E Taylor. McGrraw – Hill Inc. (P: 301-328)
• Effective Patient Education – A Guide to increased Compliance, by Donna R Flavo. 1985, An Aspen Publication. (Chapter 6: Communicating Health dvice).
• Primary Care Medicine – Office Evaluation and Management to the Adult Patient – 4^th Edition. By Allan H. Goroll, Albert G. Mulley, Jr. Lippincott Williams & Wilkins. (Page : 1-4).

Other References:

1] Smith, V. and Bass, T. (1982) Communication for the Health Care Team. Page 5. Harper & Row, London.

2] MacLeod Clark, J. (1985) The development of research in interpersonal skills in nursing in Interpersonal skills in Nursing: Research and Applications (ed. C. Kagan), Croom Helm, London.

3] McGhee A. (1961) The patient’s attitude to nursing care. E. & S. Livingstone, Edinburgh.

4] Kincey J., Bradshaw P., & Ley P. (1975) Patient’s satisfaction and reported acceptance  of advice in general practice. J. R. Coll. Gen. Pract. 25, 558-62.

5] Pettegrew, L. (1982). Some boundaries and assumptions in health communication in straight talk: Exploration in Provider and Patient Interaction. (eds L. Pettegrew, P. Arntson, D. Bush and K. Zoppi), Humana, Louisville, Kentucky.

6] Palmer K. T. Notes for the MCRGP. Second edition (1992). P: 66-69. Blackwell Scientific Publication.

7] Francis V., Korsch B. M. & Morris M. J. (1969) Gaps in doctor-patient communication: patient’s response to medical advice. N. Engl. J. Med. 280, 535-40.

8] Gerrard, B., Boniface, W., and Love, B. (1980) Interpersonal skills for health professionals, Reston Publishing Company, Reston.

9], 10], 11] Quenk, N. L. Essentials of Myers Briggs Type Indicator Assessment. (2000). John Wiley & Sons, INC.

12] Allen J., Brock S. (2000). Health Care Communication, Using Personality Types. Patient Are different. Routledge. Page: 2-4.

13] Stott, N. C. and Davis, R. H. (1979) The exceptional potential in each primary consultation. Journal of Royal College of General Practitioners, 29, 201.

14] Fraser, R. C. (1994). The Leicester Assessment Package. 2^nd. Glaxo Medical Fellowship.

15] Fraser, R. C. (1999). Clinical Method – A general practice approach. 3^rd. Butterworth – Heinmann. Page: 59-74.

16], 17] Allen J., Brock S. (2000) Tailoring the message – In physician-patient communication, patients’ personal styles call for different approaches, especially when the news is bad. Minnesota Medicine - A Journal of Clinical and Health Affairs. May 2000, page: 45-48.

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