Mental models, medical misunderstandings, and expressive and instrumental behaviour

By Gordon Rugg

A frequent and enduring topic of complaints about medical professionals is their bedside manner.

Three common complaints are:

  • My doctor won’t listen to me
  • My doctor is cold and impersonal
  • My doctor doesn’t give me the facts

These can be explained and handled via the concepts of instrumental and expressive behaviour. Instrumental behaviour is about getting the job done; expressive behaviour is about showing how you feel about something. I’ve blogged about these concepts and their implications here and here and here.

These categories are not mutually exclusive; some people are very strong both on instrumental and on expressive behaviour, for instance. However, people tend to incline more to one than the other. The “people person” with good social skills is typically good on expressive behaviour, while the archetypal “techie” is strong on instrumental behaviour.

The issue of expressive versus instrumental behaviour is a common cause of serious misunderstandings across many domains; medicine is a classic case. Fortunately, many of these misunderstandings can be fairly easily prevented. In this article, I’ll describe the underlying concepts, and how to use them to reduce the number and severity of complaints.

My doctor won’t listen to me: Being fobbed off or written off

One common complaint involves the accusation that the doctor isn’t really listening to the patient. This is often linked to the accusation that the doctor is fobbing off the patient by giving them placebos to keep them happy, or writing off the patient as just attention-seeking or hypochondriac, with no actual illness.

In terms of instrumental and expressive behaviour, the doctor in these cases is implicitly deciding whether the patient’s behaviour is primarily instrumental or expressive. The doctor probably won’t be using the concepts of instrumental and expressive behaviour by those names, since they’re not well known in medicine. Instead, the doctor will probably be using concepts that are similar but not identical, such as emotional versus practical. If the doctor decides that the patient’s behaviour is primarily expressive, then they will focus on the patient’s feelings, rather than on the patient’s facts.

A significant issue is that a doctor might treat a patient’s detailed account of their symptoms as just a particularly elaborate form of expressive behaviour (“look how many symptoms I’m telling you that I have”) rather than as an honest report that can be taken pretty much at instrumental face value.

My doctor/nurse is cold and impersonal, or my doctor/nurse won’t give me the facts

I’ve tackled these two complaints together, because they can be explained as two outcomes of the same underlying issue.

If we divide people into the categories of mainly instrumental and mainly expressive, then we can show what happens when these categories interact, as shown in the table below. For brevity, I’ve used the term “professional” to include doctors, nurses, paramedics, and other healthcare professionals.

If a healthcare professional and a patient are both in the same category, then their interaction is likely to go well. However, if they are in different categories, then their interaction is likely to go badly.

If the healthcare professional is instrumental and the patient is expressive, then the patient will view the professional as being cold and impersonal and uncaring.

Conversely, if the healthcare professional is expressive and the patient is instrumental, then the patient will think that the professional is not explaining or giving facts, and is being vague.

This model explains why a healthcare professional may be strongly liked by some patients and strongly disliked by others. It also explains why complaints about healthcare staff in a hospital or practice may appear to be mutually contradictory (e.g. too much focus on the bedside manner, or too little focus on the bedside manner).

Implications

Mismatches between professional and patient

I’ll deal with the mismatch issue first, because it can be handled fairly easily.

One simple strategy is to use the “sandwich approach”. For instance, the doctor can sandwich a chunk of instrumental information between two chunks of expressive behaviour. This would take the form of reassuring words, followed by factual information, followed by further reassuring words. This format has the advantage of containing both expressive and instrumental content, so that the doctor is giving the patient necessary factual information, as well as expressive reassurance. The ratio of reassurance to facts can be tweaked in light of the doctor’s judgment about the patient’s preferences.

Another strategy is to handle this via letting patients choose their own preferred doctor within a medical practice, if the practice uses that approach.

Fobbing off and writing off

The issue of fobbing off or writing off is more complex. When a patient shows up with a long, detailed story about medical problems, the doctor has to assess whether the patient is engaging in instrumental behaviour or expressive behaviour. In normal circumstances, it’s usually fairly easy to tell which type of behaviour a person is exhibiting. In the context of a patient with a long, detailed story, however, it’s more difficult.

If a patient has been suffering for an extended time from an undiagnosed physical problem, then they will not be at their best when seeing the doctor. Factors such as pain, exhaustion and frustration can easily turn into bursts of expressive behaviour such as anger, which will make the doctor more likely to think that the patient is being primarily expressive, and does not have a genuine underlying physical problem.

It’s not an easy call, and I don’t have any magic solution. However, I hope that this article will help to improve the overall quality of interaction between patients and medical professionals, even if it doesn’t cure all ills…

 

Notes and links

You’re welcome to use Hyde & Rugg copyleft images for any non-commercial purpose, including lectures, provided that you state that they’re copyleft Hyde & Rugg.

There’s more about the theory behind this article in my latest book:

Blind Spot, by Gordon Rugg with Joseph D’Agnese

http://www.amazon.co.uk/Blind-Spot-Gordon-Rugg/dp/0062097903

You might also find our website useful:

http://www.hydeandrugg.com/

 

Overviews of the articles on this blog:

https://hydeandrugg.wordpress.com/2015/01/12/the-knowledge-modelling-book/

https://hydeandrugg.wordpress.com/2015/07/24/200-posts-and-counting/

https://hydeandrugg.wordpress.com/2014/09/19/150-posts-and-counting/

https://hydeandrugg.wordpress.com/2014/04/28/one-hundred-hyde-rugg-articles-and-the-verifier-framework/

 

 

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