The Doctor-Patient Relationship and Interviewing Techniques

The Doctor-Patient Relationship and Interviewing Techniques

Doctor-Patient Relationship- core of the practice of medicine- utmost concern to all physicians and should be evaluated

in all cases- patient expects a good relationship as much as cure - common experience: patient are most tolerant of the

therapeutic limitations of medicine when here is mutual respect between both parties

- Clinicians should consider:1. nature of the relationship2. factors in themselves and their patients that influence

the relationship3. manner in which good rapport can be achieved4.

Rapport- spontaneous, conscious feeling of harmonious

responsiveness that promotes the development of a constructive therapeutic relationship

- implies understanding and trust between the doctor and the patient

- with this, the patients feel accepted with both their assets and liabilities

- doctor: only person whom they can talk about things that they cannot tell anyone else

- patients trust doctors to keep secrets and this confidence must not be betrayed

- patients who feel that someone knows them, understand them, and accepts them find that a source of strength

Francis Peabody: “The secret of the care of the patient is in caring for the patient.”

Interpersonal factors- influenced whether or not the patient feel satisfied with their

visits to the doctor- the perception that the doctor is concerned, caring and

understanding – than by technical competence- holds true for patients whose purpose in visiting the doctor

is to receive medication or undergo a procedure- medicine is and intensely human and personal endeavor

the Doctor-Patient relationship itself becomes part of the therapeutic process

To keep the doctor-patient relationship a positive force the following are necessary:

1. self-reflection2. understanding

Doctors:1. must empathize with patients, but must not to the point of

assuming their patients’ burden or fantasizing that they can be their patients’ savior

2. should be able to leave their patients’ problems behind when away from the office/hospital

3. should not use their patients as substitute for intimacy or relationship that may be missing in their personal lives

- otherwise, they are handicapped in their efforts to help sick people, who needs sympathy and understanding, not sentimentality and overinvolvement

- sometimes prone to some defensiveness- sued, attacked and even killed because they did not give

particular patients the satisfaction they desired- so some may assume a defensive attitude towards all

patients- such rigidity may create the image of thoroughness and

efficiency inappropriate

Flexibility- necessary to respond to the subtle interplay between

doctor and patient and allows a certain tolerance for the uncertainty present in the clinical situation with any patient.

Physicians - must learn to accept that that although they may wish to

control everything in a patients’ care, this wish can be never be fully realized

- must also avoid sidestepping issues that they find difficult to deal with because of their own sensitivities, especially when these issues are important to a patient

THE BIOPSYCHOSOCIAL MODEL - 1977, George Engel, University of Rochester- seminal paper: articulated biopsychosocial model of

disease stressed an integrated approach to human behavior and disease

- biological system: refers to the anatomical, structural, and molecular substrates of disease and its effects on patients’ biological functioning

- psychological system: refers to the effects of psychodynamic factors, motivation, and personality on the experience of, and reaction to, illness

- social system: examines cultural, environmental and familial influences on the expression and experience of illness

- Engel postulates that each system affects and is affected by the others

- model does not treat medical illness as a direct result of a person’s psychological or sociocultural makeup but, rather, promotes a more comprehensive understanding of disease and treatment

- Ex. 1971 study of the relationship between sudden death an psychological factors observed that serious illness or even death might be associated with psychological stress or trauma potential triggering events: death of a close friend, grief, anniversary reactions, loss of self-esteem, personal danger or threat, the letdown after the threat has passed, and reunions or triumphs.

BEYOND THE BIOPSYCHOSOCIAL MODEL- while psychological and social variables are

unquestionably important in medicine, their proportional importance varies depending on the person and his/her medical circumstances

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Psychiatry

The Doctor-Patient Relationship

Wala ng Psych!!!

- chronic conditions (HPN/diabetes): affected by multiple aspects of personality and the social environment, however, the short-term treatment of an acute infection may not be

- biopsychosocial model offers no guidance on when and which psychological factors are important physicians are often left with the impression that they must know everything about every patient impossible fall back on a biomedical approach, focusing instead on physical pathology and the use of biological, physical interventions

- biopsychosocial model provides a conceptual framework for dealing with disparate information and serves as a reminder that there may be important issues beyond the purely biological; however, it is not a template for practicing medicine or for treating individual patients It cannot substitute a relationship between the patient and doctor that reflects warmth, genuine concern and mutual trust

SPIRITUALITY - the role of spirituality and religion in sickness and health

has gained ascendancy in recent years with some suggesting that it become part of the biopsychosocial model

- some evidence that strong religious beliefs, spiritual yearnings, prayers and devotional acts have positive influences on a person’s mental and physical health

- these issues are better attended to by the theologians however doctors need to be aware of spirituality in their patients’ lives and sensitive to their patients’ religious beliefs

- in some instances, religious beliefs may impedes medical care (ex. Refuse blood transfusion)

- when treating patients with strong religious belief, the wise physician will welcome the collaboration of the pastoral counselor

ILLNESS BEHAVIOR- describes patients’ reactions to the experience of being

sick- sick role: the role that society ascribes to people when

they are ill can include being excused from responsibilities and the expectation of wanting to obtain help to get well

- illness behavior and sick role: affected by people’s previous experiences with illness and by their cultural beliefs about disease

- the influence of culture on reporting and manifestation of symptoms must be evaluated

- relation of illness to family processes, class status, and ethnic identity is also important

- attitudes of peoples and cultures about dependency and helplessness greatly influence whether and how a person asks for help, as do such psychological factors as personality type and the personal meaning the person attributes to being ill

- people react to illness in different ways, which depend on their habitual modes of thinking, feeling, and behaving

- some people experience illness as overwhelming loss; others see in the same illness a challenge they must overcome or a punishment they deserve

MODELS OF INTERACTION BETWEEN DOCTOR AND PATIENT- interactions (the way in which news is conveyed and

treatment recommendations are made) can take different shapes

- think about relationships to formulate “models”- fluid concepts- a talented, sensitive physician will have different

approaches with different patients and indeed may have different approaches with the same patient as time and medical circumstances vary

1. Paternalistic Model- assumed that the doctor knows best - patient is expected to comply without questioning- the doctor may decide to withhold information when it is

believed to be in the patient’s best interests- aka AUTOCRATIC MODEL the physician asks most of

the questions and generally dominates the interview- circumstances in which a paternalistic model is desirable:

emergency situations doctor needs to take control and make potentially life-saving decisions without long deliberation.

- risks a clash of values (ex. A paternalistic OB, might insist on spinal anesthesia for delivery when the patient wants to experience natural birth)

2. Informative Model- the doctor dispenses information- all available data are freely given, but the choice is left

wholly up to the patient- ex. Doctors may quote 5-yr survival statistics for various

treatment of breast cancer and expect women to make up their own minds without suggestion or interference from them

- may be appropriate for certain one-time consultations where no established relationship exits and the patient will be returning to the regular care of a known physician

- at other times this purely informative approach is likely to be perceived by the patient as cold and uncaring, as it tends to see the patient as unrealistically autonomous

3. Interpretive Model- doctors who have come to know their patients better and

understand something of the circumstances of their lives, their families, their values, and their hopes and aspirations, are better be able to make recommendations that take into account the unique characteristics of an individual patient

- there will be a shared decision making as the doctor presents and discusses alternatives, to find, with the patient’s participation, the one that is best for that particular person

- the doctor does not abrogate the responsibility for making decisions, but is flexible, and is willing to consider criticism and alternative suggestions

4. Deliberative Model- the physician acts as a friend or counselor to the patient,

not just by presenting information, but in actively advocating a particular course of action

- commonly used by doctors hoping to modify injurious behavior, for example, in trying to get their patients to stop smoking or lose weight

- these models are only guides for thinking about the doctor-patient relationship

- one is not intrinsically superior to any other, and a physician may use approaches from all four in dealing with a patient during a single visit


- difficulties are most likely to arise not from the use of one or another of the models, but with the physician who is rigidly fixed in one approach and cannot switch strategies, even when indicated and desirable

- models do not, moreover, describe the presence or absence of interpersonal warmth

- it is entirely possible for patients to see a paternalistic or autocratic physician as personable, caring and concerned. In fact, a common image of the small town or country doctor in the early part of the 20 th century was a man (seldom a woman) totally committed to the welfare of his patients, who would come in the middle of the night and sit at the bedside holding the patient’s hand, who would be invited to Sunday dinner, and who expected his instructions to be followed exactly and without question.

TRANSFERENCE AND COUNTERTRANSFERENCE - these are terms originating in psychoanalytic theory- purely hypothetical constructs, but they have proved

extremely useful as organizing principles for explaining certain developments of the doctor-patient relationship that can be upsetting and that can interfere with good medical care

TRANSFERENCE: describes the process of patients unconsciously attributing to their doctors aspects of important past relationships, especially those with their parents

- patient may come to see the doctor as cold, harsh, critical, threatening, seductive, caring, or nurturing, not because of anything the physician says or does, but because that has been the patient’s experience in the past

- the residue of the experience leads the patients unwittingly to “transfer” the feeling from past relationships to the doctor

- can be positive or negative, and it can swing back and forth – sometimes abruptly – between the two

- transference reactions may be strongest with psychiatrists for a number of reasons (ex. As part of intensive, insight-oriented psychotherapy, the encouragement of transference feelings is an integral part of treatment. In some types of therapy a psychiatrist is more or less neutral. The more neutral or less information the patient has about the psychiatrist, the more transferential fantasies and concerns are mobilized and projected onto the doctor. Once the fantasies are stimulated and projected, the psychiatrist can help patients gain insight into how these fantasies and concerns affect all the important relationships in their lives.)

- the words and deeds of doctors have power a power far beyond the commonplace because of their unique authority and the patients’ dependence on them

- how a particular physician behaves and interacts has a direct bearing on the emotional and even the physical reactions of the patient (ex. px high BP physician: cold, aloof and stern but normal BP doctor: warm, understanding, and sympathetic)

COUNTERTRANSFERENCE: when doctors unconsciously ascribes motives or attributes to patients that come from the doctor’s past relationships

- may take the form of negative, disruptive feelings, but it may also encompass disproportionately positive, idealizing, or even eroticized reactions

- just as patients have expectations for physicians – for example, competence, objectivity, comfort, and relief –

physicians often have unconscious or unspoken expectations of patients

- most commonly patients are thought of as “good” patients:1. if their expressed severity of symptoms correlates with an

overtly diagnosable biological disorder2. if they are compliant and generally nonchallenging with

treatment3. if they are emotionally controlled4. if they grateful- I these expectations are not met, even if this is a result of

unconscious unrealistic needs on the part of the physician, the patient may be blamed and considered unlikable, untreatable, or “difficult”

- physician who actively dislikes a patient is apt to be ineffective in dealing with him/her

- emotions breeds counteremotion

- patients’ responses to their doctors are not invariably trasferential and may be based on the real interaction between them

- doctors need to be aware of the distorting and disruptive power of transference, but they must not use transference as an excuse for failing to consider the real relationship and the effects their actions have on patients

INTERVIEWING EFFECTIVELY - one of a physician’s most important tools- through a skilled interview, physicians can gather data

necessary to understand and treat patients and, in the process, to increase patients’ understanding of, and compliance with, the physician’s advice

- many factors influence both the content and the process of interviews:

1. patients’ personalities and character styles: influence reactions as well as the emotional context

2. various clinical situations: includes whether patients are seen on a general hospital ward, on a psychiatric ward, in an emergency room, or as outpatients shape the questions asked and the recommendations offered

3. technical factors: such as telephone interruptions, the use of an interpreter, note taking, and the patient’s illness itself ( in acute stage or in remission) influence the content and process of the interview

4. interviewers’ styles, experiences and theoretical orientations

5. timing of interjections: such as “uh huh” can influence when patients speak and what they do or do not say as they unconsciously try to follow the subtle leads and cues provided by the doctor

Psychiatric versus Medical-Surgical Interview- Mack Lipkin, Jr., described 3 functions of medical

interviews: (SEE TABLE 1-2)1. to assess the nature of the problem2. to develop and maintain a therapeutic relationship3. to communicate information and implement a treatment

plan - these functions are exactly the same as those of

psychiatric and surgical interviews- also universal are the predominant coping mechanisms,

both adaptive and maladaptive- mechanisms include such reactions as anxiety, depression,

regression, denial, anger, and dependency


- physicians must anticipate, recognize, and address such reactions if any treatment and intervention are to be effective

Psychiatric interviews - have two major technical goals:

1. recognition of the psychological determiants of behavior

2. symptom classification - these goals are reflected in two styles of interviewing

1. Insight-oriented or psychodynamic style: attempts to elicit unconscious conflicts, anxieties and defenses

2. Symptom-oriented or descriptive style: emphasizes the classification of patients’ complaints and dysfunctions as defined by specific diagnostic categories

- the approaches are not mutually exclusive and, in fact, can be compatible

- a diagnosis can be described as precisely as possible by eliciting such details as symptoms, course of illness, and family history and by understanding a patient’s personality, development history, and unconscious conflicts

- psychiatric patients must often contend with stresses and pressures that differ from those suffered by patients who do not have a psychiatric disorder

- these stresses include the:1. stigma attached to being a psychiatric patient2. communication difficulty because of disorders of

thinking 3. oddities of behavior and impairments of insight and

judgment that might make compliance with treatment difficult

- because psychiatric patients often find it difficult to describe fully what is going on, physicians must be prepared to obtained information from other sources: family members, friends and spouses can provide critical data such as past psychiatric history, responses to medication, and precipitating stress that patients may not be able to describe themselves

- psychiatric patients may not be able to tolerate a traditional interview format, especially in the acute stages of disorder, in such cases, physicians must be prepared to conduct multiple brief interaction over time, for as long as the patient is able, then stopping and returning when the patient appears to tolerate more

- physicians particularly must be prepared to use their powers of observation with psychiatric patients who cannot communicate well verbally specific observations should include patients’ general appearance, behavior, and body language and the ways in which these factors provide diagnostic clues

- according to the American Psychiatric Association’s “Practice Guidelines for Psychiatric Evaluation of Adults” the psychiatrists’ assessment tool “is the face-to-face interview of the patient: evaluations based solely on review of records and interviews of persons close to the patient are inherently limited”

- all physicians who treat psychiatric patients should be familiar with this guideline because many nonpsychiatric physicians see psychiatric patients

- nonpsychiatric physicians should be knowledgeable about the special problems of psychiatric patients and the specific techniques used to treat them

Rapport

- establishing rapport is the first step of a psychiatric interview and interviewers often use their own empathic responses to facilitate the development of rapport

- Ekkehard and Sieglinde Othmer defined the development of rapport as encompassing six strategies:1. putting patients and interviewers at ease2. finding patients’ pain and expressing compassion3. evaluating patients’ insight and becoming an ally4. showing expertise5. establishing authority as physicians and therapists6. balancing the roles of emphatic listener, expert, and

authority - as part of the strategy for increasing rapport, Othmer nad

Othmer developed a checklist that enables interviewers to recognize problems and refine their skills in establishing rapport

- physicians’ failure to establish good rapport with patients accounts for much of the ineffectiveness of care

- rapport implies understanding and trust between doctor and patient

- psychosocial and economic factors exert a profound influence on human relations, and physicians should have as much understanding as possible of the patients’ subcultures

- differences in social, intellectual, and educational status can interfere seriously with rapport

- evaluating the social pressures in patients’ early lives helps psychiatrists better understand the patients

- emotional reactions, healthy or unhealthy, are the result of a constant interplay of biological, sociological, and psychological forces

- each stress leaves behind a trace of its influence and continues to manifest itself throughout life in proportion to the intensity of its effect and the susceptibility of the human being involved

- stresses and strains should be determined to the fullest extent possible

- the significant point may not be a stress itself but a person’s reaction to it

Beginning the Interview- how a physicians begins an interview provides a powerful

first impression to patients, and the manner in which a doctor opens communication with a patient can affect the way the remainder of the interview proceeds

- patients: often anxious on first encounters with physicians and feel both vulnerable and intimidated

- physician who can establish rapport quickly put the patient at ease, and show respect is well on the way to conducting a productive exchange of information exhange: critical to making a correct diagnosis and to establishing treatment goals

- physicians should initially make sure that they know a patient;’s name and that the patient knows the physician’s name should introduce themselves to other people who have come with the patient and should find out if the patient wants another person present during the initial interview

- the request for the presence of another person should be granted, but the physician should also attempt to speak with patients privately to determine if there is anything they want the doctor to know but were reluctant to say in front of someone else


- patients have the right to know the position and professional status of the persons involved in their care

- after the introduction and other initial assessments have been made, a useful and appropriate opening remark is “Can you tell me about the troubles that bring you in today?” or “Tell me about the problems you have been having/.”

- following up with a second one such as “ What other problems have you been experiencing?” often elicits information that patients were reluctant to give initially also indicates that the doctor is interested in hearing as much as a patient wants to say

- a less directive approach is to ask a patient “Where shall we start?” or “Where should you prefer to begin?”

- if a patient has been referred by another doctor for consultation, the initial remarks can indicate that the consulting doctor already knows something about the patient “Your doctor has told me something about what has been troubling you but I’d like to hear from you in your own words what you’ve been experiencing.”

- most patients do not speak freely unless they have privacy and are sure that their conversations cannot be overheard

- physicians who make sure at the beginning of an interview that such factors as privacy, quiet, and a lack of interruptions are attended to convey to patients that what they say is important and worthy of serious considerations

- px: will appear frightened at the beginning of an interview and may not want to answer questions physician: comment on this impression directly in a gentle and supportive way and encourage the patient to talk about his/her feelings about the interview itself acknowledging a patient’s anxiety: 1st step in understanding and reducing it

- another important initial question is “Why now?” a physician should be clear about why a patient has chosen that particular time to ask for help

- people seek out doctors as the result of particular events that have increased stress these events may be thought of as precipitants, and they often contribute significantly to patients’ current problems physicians who are unaware of such stresses in people’s lives may miss unspoken fears and questions that can compromise the patient’s care and well-being

The Interview Proper- physicians discover in detail what is troubling the patients- must do so in a systematic way that facilitates the

identification of relevant problems in the context of an ongoing emphatic working alliance with patients

- content: literally what is said between the doctor and patient: the topics discussed, the subjects mentioned

- process: is what occurs nonverbally between doctor and patient, that is, what is happening in the interview beneath the surface involves feelings and reactions that are unacknowledged or unconscious

- patients may use body language to express feelings they cannot express verbally

- px may also shift the interview away from an anxiety-provoking subject onto a neutral topic without realizing that they are doing so

- px may return again and again to a particular topic, regardless of what direction the interview appears to be taking

- trivial remarks and apparently casuals asides may reveal serious underlying concerns

Specific Techniques (TABLE 1-6)1. Open-ended versus closed-ended questions (TABLE 1-7)- interviewing: involves a fine balance between allowing the

patient’s story to unfold at will and obtaining the necessary data for diagnosis and treatment

- ideal interview: an interviewer begins with broad, open-ended questioning, continues by becoming specific, and closes with detailed direct questioning

- early part of the interview: generally the most open ended physicians allow patients to speak as much as possible in their own words

- a closed-ended/directive question: one that asks for specific information and allows a patient few options in answering

- too may closed-ended questions, esp in the early part of the interview, can restricts patients’ responses

- sometimes, directive qs are necessary to obtain important data, but when they are used too often, a patient may think that information is to be given only in response to direct questioning by the doctor

- ex. Open-ended question: “Can you tell me more about that?”; Closed-ended question: “How long have you been taking the medication?”

- closed-ended questions can be effective in:a. generating specific and quick responses

about a clearly delineated topicb. eliciting information about the absence of

certain symptomsc. assessing such factors as the frequency,

severity, and duration of symptoms

2. Reflection- a doctor repeats to a patient, in a supportive manner,

something that the patient has said- goal is twofold: to assure the doctor that he/she has

correctly understood what the patient is trying to say and to let the patient know that the doctor is perceiving what is being said

- an emphatic response meant to let the patient know that the doctor is both listening to the patient’s concerns and understanding them

- is not an exact repetition of what the patient has said, but rather a paraphrase that indicates the doctor has perceived the essential meaning

3. Facilitation- doctors help patients continue in the interview by providing

both verbal and nonverbal cues that encourage the patients to keep talking

4. Silence- can be used in many ways in a normal converstion, even to

indicate disapproval or disinterest- in doctor-px relationship: it may be constructive and in

certain situations may allow patients to contemplate, to cry, or just to sit in accepting, supportive environment in which the doctor makes it clear that not every moment must be filled with talk

5. Confrontation- meant to point out to a px something that the doctor thinks

the patient is not paying attention to, is missing, or is in some way denying

- must be don skillfully so that pxs are not forced to become hostile and defensive


- meant to help pxs face whatever needs to be faced in a direct but respectful way

6. Clarification- doctors attempt to get details from patients about what they

have already said 7. Interpretation- most often used when a doctor states something about a

patient’s behavior or thinking that he patient may not be aware of

- follows on the doctor’s careful listening to the underlying themes and patterns in the patient’s story

- usually help to clarify interrelationships that the patient may not see

- is a sophisticated technique and should generally be used only after the doctor has established some rapport with the patient and has a reasonably good idea of what some interrelationships are

8. Summation- doctor summarizes what a patient has said thus far- assures both the patient and doctor that the doctor has

heard the same information that the patient has actually conveyed

9. Explanation- doctors explain treatment plans to patients in easily

understandable language and allow patients to respond and ask questions

10. Transition- allows doctors to convey the idea that enough information

has been obtained on one subject; the doctor’s words encourage patients to continue on to another subject

11. Self-revelation- limited, discreet and self-disclosure by physicians may be

useful in certain situations, and physicians should feel at ease and should communicate a sense of self-comfort involve answering an patient’s question whether about whether a physician is married and where he/she comes from

- a doctor who practice self-revelation excessively, however, is using a patient to gratify unfulfilled needs in his/her own life and is abusing the role of physician

- if a doctor thinks that a piece of information will help a patient be more comfortable, the doctor can decide on each case whether to be self-revealing decision: depends on whether the information will further a patient’s care or if it wil provide nothing useful

- many questions, esp personal ones, covey not just natural curiosity but also hidden concerns about the doctor that should not be ignored

12. Positive Reinforcement- allows patients to feel comfortable telling a doctor anything,

even about such things as noncompliance with treatment- encouraging a px to feel that the doctor is not upset by

whatever the patient has to say facilitates an open exchange

13. Reassurance- truthful reassurance of a px can lead to increased trust and

compliance and can be experienced as an emphatic response of a concerned physician

- false reassurance, however, is essentially lying to a patient and can badly impair the patient’s trust and compliance is often given from a desire to make a patient feel better, but once a px knows that a doctor has not told the truth, the px is unlikely to accept or believe truthful reassurance

14. Advice

- it is not only acceptable but desirable for doctors to give patients advice

- to be effective and to be perceived as emphatic rather than inappropriate or intrusive, the advice should be given only after pxs are allowed to talk freely about their problems so that physicians have an adequate information base from which to make suggestions

- at times, after a doctor has listened carefully to a px, it becomes clear that the px does not, in fact, want advice as much as an objective, caring, non-judgmental ear

- giving advice too quickly can lead a px to feel that the doctor is not really listening, but, rather, is responding, either out of anxiety or from the belief that the doctor inherently knows better than the px what should be done in a particular situation

15. Ending the Interview- physicians want pxs to leave an interview feeling

understood and respected and believing that all the pertinent and important information has been conveyed to an informed, emphatic listener

- to this end, doctors should give pxs a chance to ask questions, should let pxs know as much as possible about future plans, should thank patients for sharing the necessary information and let pxs know that the information conveyed has been helpful in clarifying the next steps

- any prescription of medication should be spelled out clearly and simply, and doctors should ascertain whether pxs understand the prescription and how to take it

- doctors should make another appointment or give a referral and some indication about how patients can reach help quickly if it is necessary before the next appointment

COMPLIANCE- Also known as adherence- A degree to which a patient carries out the clinical

recommendations of the treating physician.- Examples: keeping appointments, taking medications

correctly, following recommended changes in diet and behavior.

- Depends on the clinical situation, nature of illness and the treatment program.

- Generally, 1/3 complies with tx, 1/3 comply w/ certain aspects of tx, and 1/3 never comply w/ tx.

Noncompliance- Associated with physicians perceived to be rejecting and

unfriendly- Increased complexity of regimen- When they take more than three kinds of medication- Psychiatric pxs- Associated with asking a px for information and not giving

them feedbacks- Associated with failure of physician to explain diagnosis- When pxs find the effects intolerable- Pxs like the symptoms and don’t want to be treated- When pxs cant afford the medication

Compliance decreases- When px and doctor have different priorities, beliefs, styles

of communication and medical expectations.- When there are problems in communication

Compliance increases


- When physicians have characteristics like enthusiasm and nonpunitive behavior.

- When seen by older doctors w/ experience- Increase time talking to px (good communication)- Short waiting room time- Increased frequency of visits from the doctor- When physicians explain to the patient the value of a

particular tx outcome and emphasizes the recommendations that will produce the outcome.

- When the px knows the names and effects of each drug they use.

- When patients believe that they are ill.- When doctors are aware of px’s belief system, feelings,

and habits.

SPECIFIC ISSUES IN PSYCHIATRY1. Fees- Discuss these issues can minimize misunderstanding.- Most pxs have medical insurance through health

maintenance organizations.- HMOs pay for doctor’s visits in whole or in part but only if

the doctor is a member of the the px’s plan.- Some plans offer partial payments if the doctor is not a

member2. Confidentiality- Physicians should discuss the extent and limitation of

confidentiality with the px.- Physician must legally and ethically respect the pxs’

confidentiality- Issues of confidentiality include:

1. Who have access to the px’s medical records2. Info required by the insurance companies3. The degree to which the px’s case will be used for

teaching purposes- In all circumstances, the px must give his or her

permission.3. Supervision- It is necessary for doctors in training to receive supervision

from experienced physicians.- When young doctors are receiving supervision, they must

inform the px.- If patient is curious about the level of the treating doctor’s

expertise, the doctor or the medical students must answer in complete honesty nad not mislead the px.

4. Missed Appointments and Length of Session- Px must be informed of the policies of the doctor regarding

missed appointments and length of session.- Psychiatrists generally see pxs for 15-45 mins.- Nonpsychiatric pxs may schedule from 30 mins to an hour.- Some doctors ask for 24hrs notice to avoid being billed for

a missed session.- Others bill for missed sessions regardless of notice.- Some doctors state that if they could receive advance

notice and they could fill up the vacant appointment time, they won’t charge missed session.

5. Availability of the Doctor- Once a px enters into a contract to receive care from a

particular physician, the doctor is responsible for providing emergency service outside scheduled appointment times

- If the physician is going to away for a short period of time, coverage by another physician is necessary and px must be informed how to reach the covering doctor.

6. Follow-Up- Px must be assured that regardless of what occurs in the

course of a particular doctor-px relationship, their care will be ongoing.

- In complex situations when the physician becomes ill, they will have to interrupt therapy and clear arrangements for referrals to another doctor will be made.

7. Problem patients and special interview situations

Histrionic patients- Have a dramatic, emotional and impressionistic style.- They may be seductive to their physicians- They fear that they will not be taken seriously unless they

are sexually desirable.- Overly emotional and flirtatious- Physician needs to be calm, reassuring and accepting of

such patients

Dependent patients- Needs inordinate amount of attention and yet never seem

reassured.- Likely to make repeated urgent calls and demand special

consideration- Doctor needs to be firm in establishing limits while

reassuring patients that his or her needs are taken seriously and treated professionally.

Demanding Patients- Patients having difficult time delaying gratification- Demand that their discomforts be eliminated immediately- Easily frustrated and can become petulant or even angry

and hostile if they do not get what they want.- May be impulsive to do something destructive- Appear manipulative and attention seeking- Underneath their surface behavior is the feeling that they

will never get what they need from others and thus must act in an inappropriately aggressive manner

- Doctors must be firm with the patient from the outset and clearly define acceptable and unacceptable behavior

- Must treat px with respect and care but must also be confronted with their behavior so that they would learn to be responsible.

Narcissistic Patients- Act as though they are superior to everyone around them,

including the doctor.- They have the tremendous need to appear perfect and are

contemptuous of others whom they perceive to be imperfect.

- May be rude, abrupt, arrogant, and demanding.- They feel desperately inadequate and feel that others can

see through them.

Suspicious patients- Usually those with paranoid personality- Have a chronic, deeply ingrained suspicion that other

people what to cause them harm.- Misinterpret neutral events as evidences of conspiracy

against them.- Critical and evasive- Sometimes called “grievance collectors” because they

blame others if something bad happened to themTRANS GROUP: 2D--- Kiilala nyo nman cguro kme??? Page 7 of 11

- Extremely mistrustful- Physician must try to be respectful but somewhat formal

and distant approach- Doctor should explain every decision and planned

procedure and should try to respond nondefensively to the px’s suspiciousness.

Isolated pxs- Do not appear to need or want much contact with other

people.- Prefer to take care of themselves without the doctor’s help.- Withdrawn, absorbed in a world of fantasy- Unable to talk about their feelings.- Doctor should treat them with must respect for their privacy- Doctors should not expect they will be responded to in

kind.

Obsessive Pxs- Orderly, punctual, and so contained in detail that they don’t

see the bigger picture.- Unemotional, aloof- Strong need to be in control of everything- Struggle with the doctor when they feel that decisions are

being imposed- Frightened of losing control and becoming helpless and

dependent- Physician should try to include them in their own care and

treatment.- Explain in every detail everything that is going on to make

sure that patient’s can make decision in his own behalf.

Help- Rejecting Complainer- Communicate through a long litany of complaints, and

disappointments.- Blame others for their problems. - Make people guilty about not doing or caring enough- May not be able to express angry feelings directly thus

express them passively.

- Doctors should take px’s concern seriously.- Physicians can offer the reassurance of frequent and

regular scheduled appointments.

Manipulative Pxs- Antisocial personality traits- Do not experience appropriate guilt or may not be aware of

how to feel guilty- On the surface, they could be charming, intelligent and

socially adept but these poses are perfected through the years.

- They have histories of crimes and get in the world by lying and manipulation

- Physician must treat them w/ respect but with high sense of vigilance.

- Firm limits must be set on behavior- They must be made responsible for their own actions.

STRESSES ON THE PHYSICIAN- Physician must develop the capacity of balancing

compassionate concern with dispassionate objectivity, the wish to relieve pain with the ability to make painful decisions and the desire to cure and control with an acceptance of one’s human limitations.

- Balance is essential to allow doctor to cope productively within daily work that involves illness, pain, sadness, suffering and death.





Documents

The Doctor-Patient Relationship and Interviewing Techniques