The Doctor Patient Relationship

Session Objectives
Define the physician patient relationship in terms of:
The nature of the relationship Elements Changing patterns

Practical uses of the relationship Required consultation skills and competence Reasons for bad consultations

Nature of Relationship

EMPATHY

TRUST

RESPECT

ELEMENTS
THERAPEUTIC ALLIANCE

COUNTERTRANSFERENCE

TRANSFERENCE

THERAPEUTIC ALLIANCE
Or working alliance Refers to good working relationship necessary for transaction to be successful Friendliness RAPPPORT- BUILDING Courtesy Reliability

TRANSFERENCE
The response to new relationships according from patterns of the past The tendency to carry over into the present the attitudes and expressions gained from a similar experience in the past
E.g. Patients perception of the doctor as an over-controlling parent or idealized son

TRANSFERENCE

The doctor has the ability to switch to three interactions that of the parent, child and adult according to the situation that he is in.

Eric Berne 1973

COUNTER TRANSFERENCE
The feelings which the doctor has towards his patients One must know ones self Sixth sense the emotional experience evoked by a patient in us Suppression of feelings may sometimes lead to wrong actions

Michael Balint 1986

It is not love or mutual respect or mutual identification or friendship through elements of all these enter into it. We termed it for want of a better term a mutual investment company. The general practitioner gradually acquires a valuable capital investment in his patient and vice versa, the patient acquires a valuable capital bestowed in his general practitioner..

The Changing Role of the Relationship

Some viewed the relationship as subjugating the sick and exploiting public interest (Illich & Kennedy) Now, we strive to have well-informed and autonomous patients

Empowered and Well-Informed Patients

Achieved through:
Public has greater access to health information via media Increased emphasis on personal responsibility for health (health promotion activities) Creation of patient participation groups ( a market-oriented approach to provision of health care)

Empowered and Well-Informed Patients

Achieved through
The role of the doctor as a health educator is widely accepted The need for doctors to be effective communicators and skills training has been recognized by medical schools

Practical Uses
1.) Diagnosis The process of clinical reasoning leading to the identification of the disease Requires the doctors prior knowledge of the patient, including his attitude towards the illness, personality, family background, and past medical history

Practical Uses
2.) Whole Person Medicine A good relationship heightens the doctors awareness of the interplay and relative importance of social, psychological and physical factors.

Practical Uses
3.) Compliance
Helping patients learn and understand their illness (hypertension) Giving more accurate information Letting the patient seek more information

All happy families resemble each other. Each unhappy family is unhappy in its own way
Anna Karenina by Tolstoy

Our Assumptive Worlds

Both doctor and patient bring to the consultation their own set of attitudes, beliefs , prejudices and expectations. These are influenced by social class, age, ethnic origin, social and educational background and past experiences.
Browne & Feeling 1976

 Bad consultations result from having insufficient clinical knowledge, from failing to relate to patients or from failing to understand patients behaviour , his perception of his illness or its context..
Howie 1985

Detachment
A degree of detachment is necessary in order to arrive at an appropriate diagnosis and management. Striking a balance between being caring and effective Recognize the dangers of over-commitment Seen in the chronically sick or dying

Anxiety
Too close relationship may increase anxiety in the problem-solving process and may impair judgment May be impelled to inappropriately refer or order a diagnostic test Leads to the cascade effect or doctor shopping

The Difficult Patient

Demanding patients Results when the relationship satisfies a need 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)

The Consultation

The Consultation
The essential unit of medical practice is the occasion when, in the intimacy of the consulting room, a person who is ill or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it. Spence 1960

Tasks of the Consultation

1. Identification and management of presenting problems 2. Management of continuing problems 3. Opportunistic anticipatory care 4. Modification of the patients help seeking behavior

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 diagnosis and management

Practical skills
Ability to perform physical examination and use medical instruments

7 Categories of Consultation Competence

Interview or history taking Most Patient management Difficult To acquire Problem solving Physical examination Behavior /relationship with patients Anticipatory care Record keeping

Consultation Style
Area
Focus

Traditional
Doctor-centered Authocratic, paternalistic, domineering Limited to physical signs and symptoms

Present
Patient-centered Dialogue Meeting between 2 experts Allowing patients to report their thoughts and feeling about the illness People and their problems Active

Scope

Disease & pathology Patients participation Passive

Health Outcomes
More control by patients, more expression of emotion (positive or negative) by either patient or doctor and more information sought by patients and given by the doctor, were associated with better health on follow-up especially as revealed in functional capacity and physiological measurements.
Horder & Moore, 1990

Evidence of Favorable Outcomes Using the Patient-Centered Approach

Diabetes mellitus Hypertension Peptic ulcers Headaches

 Bad consultations result from having insufficient clinical knowledge, from failing to relate to patients or from failing to understand patients behaviour , his perception of his illness or its context..
Howie 1985

Thou Shall Not Neglect

Traditional consultation skills History taking skills Physical examination skills Patient management
Integrate