06 the Doctor Patient Relationship

8/4/2019 06 the Doctor Patient Relationship

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The Doctor Patient

Relationship


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Session Objectives

Define the physician patient relationshipin terms of: The nature of the relationship

Elements Changing patterns

Practical uses of the relationship

Required consultation skills andcompetence

Reasons for bad consultations


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Nature of Relationship

TRUST

RESPECT

EMPATHY


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ELEMENTS

THERAPEUTIC ALLIANCE

TRANSFERENCECOUNTER-TRANSFERENCE


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THERAPEUTIC ALLIANCE

Or working alliance

Refers to good working relationshipnecessary for transaction to be successful

Friendliness

Courtesy

Reliability

RAPPPORT- BUILDING


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TRANSFERENCE

The response to new relationshipsaccording from patterns of the past

The tendency to carry over into thepresent the attitudes and expressionsgained from a similar experience in thepast

E.g. Patients perception of the doctor as an

over-controlling parent or idealized son


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TRANSFERENCE

The doctor has the ability to switch to three interactionsthat of the parent, child and adult

according to the situation that he is in.

Eric Berne 1973


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COUNTER TRANSFERENCE

The feelings which the doctor hastowards his patients

One must know ones self

Sixth sense the emotional experienceevoked by a patient in us

Suppression of feelings may sometimes

lead to wrong actions


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Michael Balint 1986

It is not love or mutual respect or mutualidentification or friendship through elements ofall these enter into it. We termed itfor want of a

better terma mutual investment company.The general practitioner gradually acquires avaluable capital investment in his patient andvice versa, the patient acquires a valuable

capital bestowed in his general practitioner..


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The Changing Role of theRelationship

Some viewed the relationship assubjugating the sick and exploiting publicinterest (Illich & Kennedy)

Now, we strive to have well-informed andautonomous patients


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Empowered andWell-Informed Patients

Achieved through:

Public has greater access to healthinformation via media

Increased emphasis on personalresponsibility for health (health promotionactivities)

Creation of patient participation groups ( amarket-oriented approach to provision ofhealth care)


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Empowered andWell-Informed Patients

Achieved through

The role of the doctor as a health educator iswidely accepted

The need for doctors to be effectivecommunicators and skills training has beenrecognized by medical schools


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Practical Uses

1.) Diagnosis

The process of clinical reasoningleading to the identification of the

disease Requires the doctors prior knowledge

of the patient, including his attitudetowards the illness, personality, familybackground, and past medical history


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Practical Uses

2.) Whole Person Medicine

A good relationship heightens thedoctors awareness of the interplay

and relative importance of social,psychological and physical factors.


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Practical Uses

3.) Compliance

Helping patients learn and understand

their illness (hypertension)

Giving more accurate information

Letting the patient seek more information


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All happy familiesresemble each other.Each unhappy family

is unhappy in itsown way

Anna Karenina by Tolstoy


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Our Assumptive Worlds

Both doctor and patient bring to theconsultation their own set of attitudes, beliefs ,prejudices and expectations. These are

influenced by social class, age, ethnic origin,social and educational background and pastexperiences.

Browne & Feeling 1976


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Bad consultations result from havinginsufficient clinical knowledge, from failingto relate to patients or from failing to

understand patients behaviour , hisperception of his illness or its context..

Howie 1985


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Detachment

A degree of detachment is necessary inorder to arrive at an appropriate diagnosisand management.

Striking a balance between being caringand effective

Recognize the dangers of

over-commitment

Seen in the chronically sick or dying


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Anxiety

Too close relationship may increaseanxiety in the problem-solving process andmay impair judgment

May be impelled to inappropriately refer ororder a diagnostic test

Leads to the cascade effect or doctor

shopping


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The Difficult Patient

Demanding patients

Results when the relationship satisfies aneed which cannot be verbalized

Somatic fixation

Doctors feel frustrated or manipulated

Doctors may contribute to the problem Examples: patients with frequent attendance,

dependence (causing to lose autonomy)


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The Consultation


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The Consultation

The essential unit of medicalpractice is the occasion when, inthe intimacy of the consulting

room, a person who is ill orbelieves himself to be ill, seeksthe advice of a doctor whom hetrusts. This is a consultation and

all else in the practice ofmedicine derives from it.

Spence 1960


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Tasks of the Consultation

1. Identification and management ofpresenting problems

2. Management of continuing problems

3. Opportunistic anticipatory care

4. Modification of the patients help seekingbehavior


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Required Consultation Skills

Interpersonal skills The ability of communicate and make

relationships with patients

Reasoning skills Ability to gather appropriate information,

interpret and then apply it in both diagnosisand management

Practical skills Ability to perform physical examination and

use medical instruments


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7 Categories of ConsultationCompetence

Interview or history taking

Patient management

Problem solving Physical examination

Behavior /relationship with patients

Anticipatory care Record keeping

MostDifficultTo acquire


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Consultation Style

Area Traditional Present

Focus Doctor-centered

Authocratic,paternalistic,domineering

Patient-centered

Dialogue

Meeting between 2experts

Scope Limited to physicalsigns and symptoms

Disease & pathology

Allowing patients toreport their thoughtsand feeling about the

illnessPeople and theirproblems

Patients participation Passive Active


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Health Outcomes

More control by patients, more expressionof emotion (positive or negative) by eitherpatient or doctor and more information

sought by patients and given by thedoctor, were associated with better healthon follow-up especially as revealed in

functional capacity and physiologicalmeasurements.

Horder & Moore, 1990


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Evidence of Favorable Outcomes Usingthe Patient-Centered Approach

Diabetes mellitus

Hypertension

Peptic ulcers Headaches


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Bad consultations result from havinginsufficient clinical knowledge, from failingto relate to patients or from failing to

understand patients behaviour , hisperception of his illness or its context..

Howie 1985


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Thou Shall Not Neglect

Traditionalconsultation skills

History taking skills

Physical examinationskills

Patient management

Integrate


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06 the Doctor Patient Relationship