Bias in assessment of patients on chronic dialysis

Journal

of Psychosomarx

Research

Vol

18. pp 217

to 221

Pergamon

Press.

1974

Prmrcd

m Great

BIAS IN ASSESSMENT OF PATIENTS CHRONIC DIALYSIS* A

KAPLAN DE-NOUR

and J W

Bntam

ON

CZACZKES~

(Recewed 3 January 1974) Abstract-This study concentrated on nephrologlsts’ reactions to chronic haemodlalysls High agreement was found (between seven nephrologlsts m charge of dialysis umts) on the criteria for good patient behavlour and condltlon These cnterla (expectations) to some extent mdlcate the nephrologists’ mablhty to regard the treatment as unpleasant or frightening It was found that some of the nephrologlsts assess how well a patient 1s domg mostly by his com-

pliance to the diet, functlonmg at work and emotlonal condltlon Other nepbrologlsts pave greater importance to other facets of the patient’s condltlon It was found that the majority of the nephrologlsts (five) overestimate then patients’ adJustment, e g use demal A tendency was found for patients to do better in units where less denial aas used by the nephrologlst m charge It was suggested that nephroioglsts use denial because dialysis IS stressful for them It aas further suggested that this denial has a negative influence on patients’ adjustment FROM THE begmnmg

of the psychlatrlc studies of patients on chrome haemodtalysls attentton was also patd to the emotional reactlons of the medtcai team [l] Already at that stage it was apparent that chrome haemodlalysls IS stressful also to the medlcal team and that the stresses are handled by a variety of mechanisms, mcludmg wlthdrawal and denial During the last 4 yr a study on the influence of the patients’ personahty on adjustment to chrome haemodlalysls was carried out in seven umts m the country In the course of that study we repeatedly exammed the patients m their own umts, which brought us in contact also with the different teams As a result the interest m teams’ reactions increased and some data were gathered on teams’ biases [2] and expectations [3] as well as preliminary data on the influence of teams’ attitudes on patients’ adjustment [4] None of these studies, however, concentrated on the physlclans Working m close contact with the physlclans of these units we were often struck by the discrepancy between their and our assessment on how well the patients are domg Often the physlclans seemed well satisfied with the patients’ adjustment, while we were of the opmion that the patients were domg rather badly. This raised the question whether there are basic differences in the criteria of adJustment or whether the criteria are similar but the observations differ The aim of the present study has been to gather data on physlclans’ cnterla for assessing adjustment and on how physicians assess their patients SUBJECTS

AND

METHODS

The physlclans partlclpatmg m the study were all senior nephrologlsts with long expenence m chronic haemodialysls The seven nephrologlsts m charge of the seven umts were included m the present study For obvious reasons neither the nephrologlsts nor their uruts ~111be ldenttied * Supported by Grant No 06-523-2 from the U S Department of Health, Education, and Welfare, Public Health Service t From the Department of Psychiatry and Nephrologlcal Service, Hadassah Umversq Hospital, Jerusalem, Israel 217

218

A KAPLAN

DE-NOUR

and J

W CZACZKES

Cr~terln for ad/ustment Data on that aspect was gathered by a 12 Items questlonnalre descrlbmg various aspects of patients’ behavlour and condmon, used already III previous studies [2-4] The Items Included comphance with the diet (fluId restrlctlon and potassmm restrlctlon), comphance with medlcal recommendations, punctuahty m commg to treatment and exactness m descrlbmg complamts, physlcal fitness (two Items), psychological condltlon (two Items) and emotlonal condltlon on dlalysls, as well as one Item dealmg with rehabdltatlon at work and one dealmg with soctal actlvltles and mvolvement m famdy hfe Each item was composed of five statements rangmg from strict demands to much less strict demands Each physIcIan was requested to describe along the 12 Items ha crlterla for good (not Ideal) patient behavlour and condltlon Physlclans’ assessment of the patients’ adJustment was gathered twice The first time, after fulfillmg the above described questronnalre, they were asked for a global assessment on what percentage of their patients are domg well, fairly well and poorly accordmg to their 12 Items’ defimtlon of the good patlent A few months later the physlclans were approached once more and asked what percentage of their patients are domg well m each of three major aspects of adjustment-comphance with the duet, functlonmg at work and emotional condltlon The patretzfs Patients about to start dlalysls m the seven uruts m a period of three years (December 1969-November 1972) underwent a predlalysls psychlatrlc exammatlon and perlodlc follow-ups, conslstmg of a medical and psychlatrlc exammatlon The detads of these exammatlons have been described elsewhere [5] and suffice here to say that at these follow-ups patients’ compliance with the diet and rehabdltatlon (functlonmg at work) were objectively determmed and the patients’ emotlonal condltlon was assessed by one and always the same psychlatrlst A total of 96 patients were followed up m this way at least once. The data gathered ~111be referred to as “objective assessment” As we wish to avold ldentlfymg the umts, and the results WIIIbe presented only m percents RESULTS (a) Physmutts

crrterra

There were few dlscrepancles m physlcrans’ crlterla for definmg good (not Ideal) patients’ behavlour and condltlon The fluId restrlctlon IS the mam dietary problem smce the protem Intake of dralysls patients 1s not very different from that of the healthy population of this country The demands m this aspect of SIX of the seven physIctans are of a between-dlalysls-weight-gam of 1 kg and Infrequently more One physIcIan (umt D) was more strict and “allowed” a weight gam of less than 1 kg High agreement was found also regardmg functlonmg, SIX of the seven physlclans require from good patients to work at least three-quarters One physIcIan (Umt G) expects even the good patients to work only about half time Regardmg the psychologlcal cond[tlon SIX of the physlclans allow the good patient to have only rarely symptoms of mild emotlonal disturbance One physIcIan (G) allows these disturbances to be frequent All agreed that the good patients are most of the time m good splrlts and that they feel “low” only infrequently It should be mentloned that these crlterla m the three aspects of adjustment agree blth our assessment of good comphance, high functlonmg and good emottonal condltlon (b) Physmuns’

global assessments

Table 1 presents the physlclans’ global assessment of their patients From this table It can be seen that the physlclans of the various umts differ notIceably m their assessmg of patients Some physrclans (umts A, E and F) assess that the majority of their patients are domg well Others (umts B and C) state that the maJorlty are domg only fairly well, while the maJorlty of the physlclans are of the opn-uon TABLE 1 -TREATING

Umt Umt Umt Umt Urut Umt Unit

A B C D E F G

PHYSICIANS' GLOBAL ASSESSMENT

Good patients (%)

Farr patients (%)

Bad patients (%)

70 25 30 33 60 85 20

25 50 60 33 30 15 40

5 25 10 33 10 0 40

219

Bias m assessment of patients on chrome dlalysls

that only few of their pattents are domg badly Knowmg the patients from repeated exammatlons it was difficult to accept these assessments We were of the opmlon that m most umts the patients are domg much less well than presented m these assessments Furthermore, It brought up the problem how the physlclans have arrived at those assessments Though they were asked to assess by the 12 crlterla mcluded m the questlonnalre, the questlon remamed what relative Importance and weight did the various physlclans give to each of the Items The physlclans therefore had to be approached once more and were asked about their assessment m specific areas of adJustment-comphance, rehablhtatlon and emotlonal con&tion The questlon was llmlted to what percentage of their patients were domg well m each of the three areas (Table 2) TABLE2-TREATIuG

PHYSICIANS' GLOBAL AND DETAILED COMPARED TO OBJECTIVE ASSESShfENTS

Good patients (X) Global assessment Unit Unit Unrt Umt Umt Umt ‘Jmt

A B C D E F G

(c) Phynclans

70 25 30 33 60 85 20

Patients domg well m comphance (“/,) ., “_ Treatmg physIcIan “Objective” 40 50 70 45 80 65 60

20 15 65 25 25 30 60

Patients domg well m rehablhtatlon (X) . “. Treatmg physIcIan “Objective” 75 65 40 25 55 100 80

ASSESSMENTS

Patients m good emotlonal condltlon (X)_. Treatmg physIcIan “Objective”

15 10 40 25 50 30 60

55 90 95 65 65 85 80

15 70 70 40 25 45 80

detalled assessment compared to global and objectroe assessments

Table 2 summarizes the assessments of the physlclans of percentage of patients domg well m compliance, rehabdltatlon and emotlonal condltlon compared to their global assessment and also to our objective assessments From the data presented m this table It becomes apparent that while m some umts the nephrologlst’s global assessment seems to be based on assessment of comphance, rehablhtatlon and emotlonal condltlon, e g umts E and F, m other umts it IS not so In some of the umts, e g B, C and G, the global assessment IS much lower than that of any of the three aspects The nephrologlsts seem quite satisfied with their patients’ emotlonal condltlon, ratmg more than half of the patients as bemg m good emotlonal condltlon In four umts 80 per cent or more of the patients were rated as being m good emotlonal condltlon Somewhat fewer patients were rated as good comphers with the diet, m three umts half orJust less than half of the patients, and m the other four umts 60-80 per cent of the patients The range of rehablhtatlon ISeven wider with one nephrologlst ratmg only 25 per cent of his patients as functlonmg well and another assessmg all his patients as functlonmg well In order to find out whether there IS a tendency of some nephrologlsts to under- or overestImate the percentage of patients domg well m all three aspects of adlustment, rank correlations were calculated and all were found below the level of statIstIca slgmficance Comparmg the “objective” assessment to the nephrologlsts’ assessments It becomes apparent that m two umts (C and G) there IS httle discrepancy between the two sets of assessments As far as comphance IS concerned great discrepancies were found between the two assessments m five of the umts (A, B, D, E and F), wtth the nephrologlsts rating twice to three times as high a percentage of their patients as domg well In assessmg rehabrhtatlon complete or near complete agreement was found m four of the umts (C, D, E and G) In the other three umts (A, B and F) extreme dlscrepancles were found with the phys,clans ratmg three to SIX times as many patients as domg well In comparmg assessment of emotlonal condltlon dlscrepancles m the same dlrectlon were found m SIX of the umts, but only m three of them (A, E and F) are the dlscrepancles big One could say, therefore, that there IS a general tendency m most of the umts to assess a much higher percentage of the patients as domg well compared to what was found m follow-ups DISCUSSION

The reason for the present study has been that havmg interviewed and exammed nearly one hundred patients on chronic haemodlalysls m seven umts, we often felt

220

A

KAPLAN

DE-NOURand J W CZACZKES

at odds with the physlclans in charge of these umts They would describe how well their patients are domg while on us they would make a different lmpresslon We started to think, therefore, that maybe our criteria for assessmg adjustment differ from those of the other physicians We asked the physlclans about their crlterla for defining patients as domg well and found, on the whole, a high agreement between the physicians, which also agreed with our crlterla This findmg mdlcates that by now dialysis IS an accepted routine method of treatment We then asked the physlclans for a global assessment of what percentage of their patients are well, fairly and poorly adjusted This mquu-y provided data showmg that some physicians are of the opmlon that the majority of their patients are doing well, and others that the majority are doing only fairly well No physlclans thought that the majority of their patients are doing badly These data were quite contrary to our observations but the mqulry, from a methodological point of view, was a poor one-we did not know how the different physicians arnved at the global assessment Furthermore, our assessments were of various aspects of adjustment and not global, and the two sets of observations could not be compared We therefore had to return to the physlclans and ask for their assessment of adjustment m each of three areas, compliance with the diet, rehablhtatlon and emotional condltlon The mformatlon thus received mdlcated that with some physlclans the global assessment is in the same range as the detalled one by aspects of adjustment assessment Other physicians’ global assessment was much lower than the detailed one The most acceptable explanation for this findmg 1s that these physlclans give greater weight to other factors of patients’ condltlon, behavlour or adjustment, such as physical condltlon or behavlour on dlalysls, etc The nephrologlsts’ assessments of their patients by the three aspects of adjustment presented a cheerful picture of the majority of the patients being m good emotional condltlon, a good many of them complymg well with the diet and also functlonmg well Out of the 21 assessments received from the nephrologlsts m charge of the umts, SIXagreed to ours, and m all the others the nephrologlsts’ assessment of the percentage of patients doing well was higher, often twice and more, than ours The fact that they overrate the percentage ofpatients domg emotionally well IS,to some extent, acceptable In most of the units the overrating was not extreme Furthermore, the two sets of assessments were gathered by different professionals, nephrologlsts vs psychlatnsts, and It seems logical that the psychlatrlst would find more symptoms of psychopathology than the nephrologlsts This explanation, however, 1s not vahd for the dlscrepancles m assessment m the other two areas The only explanation we can present for this finding 1s that some of the physlclans use demal when assessing how well their patients are domg Short and Wilson [6] have already described demal used by nurses and physlclans Calland [7] recently described how physlclans’ mltlal demal (or answering each complaint by “you are domg fine”) results m the patlent wlthholdmg complamts, resulting m the physIcIan bemg unaware of the patient’s trouble In the present study evidence was found, presented m numbers, that some physicians use denial concernmg at least three major aspects of the patients’ well-being From the data gathered so far It seems also that there IS a relatlonshlp between the physicians’ denial and the patients’ adjustment In the two umts found to have the best compliance no demal was used by the nephrologlsts concernmg this aspect

Bias m assessment

of patients

on chroruc

dlalysls

221

In the three units where better functlonmg was found, again no demal was evident This brings up the mterestmg question whether the two findings-high physIcIan demal and poor patient adjustment, are really related and, if so, which is cause and which IS effect’ Are the physicians usmg denial because their patients are “bad” ones, or, are there only few “good” patients m some of the units because their physicians are using denial? If the first IS true one might say, let the physicians keep up their denial and be happy, It 1s a necessity for them as well as for the patients If the second alternative 1s the correct one the conclusion 1s very different The denial might be important for the physlclans’ emotlonal welfare but harmful for the patients’ adJustment, and therefore somethmg must be done about It We do not have any clear cut evidence for either alternative We are Inclined, however, to belleve m the second one, I e , that the physlclans use demal not because they happen to have bad patients but because the dlalysls sltuatlon per se 1s stressful for them Some support for this 1s found when lookmg mto the physlclans’ expectations m other areas Of the seven physicians SIX expected the good patients to be relaxed on dlalysls and only rarely feel somewhat tense The seventh physician expects patients to feel always relaxed One might ask whether It IS reahstlc to expect patients to be relaxed on dialysis or whether this expectation IS the result of the physlclans’ mablhty to accept dialysis as stressful, frlghtenmg or unpleasant All the physlclans expect the good patient to describe his pams and symptoms exactly with neither dlsslmulatlon nor exaggeration Is this a reahstlc expectation? Are there patients who neither dlsslmulate nor exaggerate9 Furthermore, to mention Just one addltlonal Item, physlcal fitness, one of the physicians regarded that as Irrelevant m the assessment of “good” patients, one expected the good patient to feel no weakness and be as fit as when he was healthy, and the other five physlclans expect the good patients to feel only some weakness and only after dlalysls It 1s reahstlc to expect patients with a haematocrlt around 20 per cent not to feel a permanent weakness or IS that another sign of the physicians’ mablhty to accept that hfe on dlalysls IS not so easy and pleasant 7 It seems, therefore, that m the present study we found concrete numerlcal evidence to what has already been described, namely that physlclans workmg m chronic haemodlalysls use denial There also seems to be a tendency for more denial m umts where the patients are doing less well We are mclmed to suggest that some of these patients are doing less well because of the physlclans’ demal Addltlonal research IS necessary In order to prove or disprove this suggestion

REFERENCES 1 KAPLAN DE-NOUR A and CZACZKES J W EmotIonal problems and reactions of the medlcal team m a chroruc haemodlalysls un:t Lancet 2, 987 (1968) 2 KAPLAN DE-NOUR A and CZACZKES J W ProfessIonal team opmlon and personal bias-A study of a dralysls umt team J C/won Dls 24, 533 (1971) 3 KAPLAN DE-NOUR A, CZ~CZKES J W and LILOS P A study of chrome hemodlaiysls teamsDifferences m opuuons and expectations J Uzron Dls 25, 441 (1972) 4 KAPLAN DE-NOUR A and CZACZKES J W Team-patlent InteractIon m chrome hemodlalqsls umts Second Cong Int College of Psjchosomatlc Medrcme, Amsterdam (1973) 5 KAPLAN DE-NOUR A and CZACZKES J W Personahty and Adjustment to Chrome Hemodlalysls In L~\mg or Dymg Adaptatron to Hemodlalysw (EdIted by LEVY N B ) In press 6 SHORT M J. and WILSON W P Roles of demal m chrome hemodlalysls Archsgen Psychrat 20,

433 (1969) 7. CALLAND C H Iatrogemc

problems

m end-stage

renal

failure

New Engl J &fed 287, 334 (1972)