the Patient-doctor Relationship

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    THE PATIENT DOCTORRELATIONSHIP

    Prof. Dr. Tuti Wahmurti, dr., SpKJ (K)

    Reference :Kaplan & Sadocks Synopsis of Psychiatry, Behavioral Sciences / ClinicalPsychiatry 10 th ed., 2007, 1-

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    INTRODUCTION (1)

    The quality of patient doctor relationship is crucial to the

    practice of medicine.

    The capacity to develop an effective relationship requires asolid appreciation of the complexities of human behavior andrigorous education in the techniques of talking and listening to

    people

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    An effective relationship is characterized by good rapport.Rapport is the spontaneous, conscious feeling of harmoniousresponsiveness that promotes the development of aconstructive therapeutic alliance.

    an understanding and trust between

    the doctor and the patient.

    INTRODUCTION (2)

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    Frequently, the doctor is the only person to whom the patientcan talk about things that they cannot tell anyone else.

    Patient trust their doctor to keep secrets.

    This confidence must not be betrayedPatients who feel that someone :

    knows themunderstand themaccept them

    INTRODUCTION (3)

    }find

    a source of strength

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    ESTABLISHING RAPPORT

    1. Putting patients and interviewers at ease.2. Finding patients pain and expression compassion. 3. Evaluating patients insight and becoming an ally. 4. Showing expertise.5. Establishing authority as physians.6. Balancing the roles of emphatic listener, expert, and

    authority.

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    EMPATHY

    Is a way increasing rapport. Normal understanding of what other people are feeling

    the skills in establishing and maintaining rapport

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    TRANSFERENCE

    As the set of expectations, beliefs, and emotional responsesthat a patient brings to the patient doctor relationship.

    They are based on repeated experiences the patient has hadwith other important authority figures throughout life.

    The patients attitude toward the physician is apt to be arepetation of the attitude he or she has had toward authority

    figures.

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    COUNTERTRANSFERENCE

    Just the patient brings transferencial attitudes to the patient doctor relationship, doctors themselves often havecountertransferential reactions to their patients.

    It can take the form of negative feelings that are disruptive tothe patient doctor relationship.

    It can also encompass disproportionately positive, reaction to patients.

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    MODELS OF INTERACTION BETWEENDOCTOR AND PATIENT

    1. The paternalistic model.2. The informative model.

    3. The interpretive model.4. The deliberative model.

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    The paternalistic model

    = the autocratic model.It is assumed that the doctor. knows best.The doctor will prescribe treatment, and the patient is expectedto comply without questioning.The physician ask most of the questions and generallydominates the interview.Circumstances arises in which a paternalistic approach isdesirable :

    Emergency situations life saving decisions withoutlong deliberations.Some patients who feel overwhelmed by their illnessand are comforted by a doctor who can take charge.

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    The informative model

    The doctor dispenses information.All available data are freely given, but the choice is left whollyup to the patient.

    expect the patients to make up theirown minds without suggestion orinterference from them.

    This model may be appropriate for certain onetimeconsultations where no established relationship exist regularcare of a known physician.

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    The interpretive model

    A sense of shared decision-making is established as the doctor presents and discusses alternatives, with the patients participation to find the one.That is best for the particular person.The doctor does not abrogate the responsibility for makingdecisions, but is flexible, and is willing consider question andalternative suggestions.

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    The deliberative model

    The physician acts as a friend or counselor to the patient, inactively advocating a particular course of acion.The deliberative approach is commonly used by doctorshoping to modify injurious behavior,e.g. to stop smoking.

    to lose weight

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    THREE FUNCTION OF THE MEDICALINTERVIEW

    1. Determining the nature of problem.

    Knowledge base of disease, disorders, problems, andclinical hypothesis from multiple conceptual domains :

    biomedical, sociocultural, psychodynamic,and behavioral.Ability to elicit data.

    2. Developing and maintaining a therapeutic relationship.

    3. Communicating information and implementing a treatment plan.

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    INTERVIEWING EFFECTIVELY (1)

    1. Beginning the interview :Provides a powerful first impression to patients.

    Establish rapport quickly, put the patient at case,

    show respect.

    A productive exchange of information.

    Making a correct diagnosisEstablishing treatment goal

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    2. The interview proper :

    Physician discover in detail what is troubling patients.

    Do in a systematic way that facilities the identificationof relevan problems in the contex of an ongoingemphatic working alliance with patients.

    INTERVIEWING EFFECTIVELY (2)

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    COMMON INTERVIEW TECHNIQUES (1)

    1. Establish rapport as early as possible.2. Determine the patients chief complaint. 3. Use the chief complaint to develop a provisional differential

    diagnosis.4. Rule the various diagnostic possibilities out or in by usingfocused and detailed questions.

    5. Follow up on vague or obscure replies with enough persistence

    to acurately determine the answer to the question.

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    6. Let the patient talk freely enough to observe how tightly thethoughts are connected.

    7. Use a mixture to open ended and closed-ended questions8. Give the patient a chance to ask questions at the end of the

    interview.9. Conclude the initial interview by conveying a sense of

    confidence and, if possible, of hope.

    COMMON INTERVIEW TECHNIQUES (2)

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    Checklist for Clinicians

    1. I put the patient at ease.

    2. I recognized the patients state of mind.

    3. I help the patient warm up

    4. I help the patient suspiciousness

    5. I stimulated the patients verbal production.

    6. I understood the patients suffering

    7. I tuned in the patients effect.

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    8. I became aware of the patients revel of insight.

    9. I assumed the patients view of the disorder.

    10. I had a clear perception of the overt and therapeutic goals of

    treatment.

    11. I stated the overt goal of treatment to the patient.

    12. I let the patient know that he or she is not alone with the

    illness.13. The patient thank me and made another appointment.

    Checklist for Clinicians