The Doctor-Patient Relationship

Doctor Patient Relationship

At the end of this lecture you should be able to know the
Social roles of doctors and patients ( parsons model of the sick role and doctors role) Discuss the traditional view of the doctor-patient relationship and the potential problems with it. Describe the different types of doctor-patient relationships from the paternalist to the shared and consumerist approach. Explain the concepts of shared decision making and concordance and their relevance to medical practice

Introduction
It is an emotional association (clinical encounter) between the doctor and a patient which arises when the doctor in a professional capacity ; interact with the patient The relationship begins when a person who is ill or believe that he is ill consult a doctor. The success or otherwise depend on various factors including the nature of the relationship that exist between the doctor and the patient.

The History of the Doctor-Patient Relationship

20+ years ago... Lower rates of education Less access to good medical care Doctors trusted completely Doctor gave advice/medication and patient would take it Patients ideas, concerns & expectations not asked about Doctor treated- family cared Over the last 20 years Higher rates of education Medical advice on internet/libraries Better access and choice of good medical care High profile cases of doctors not acting professionallygeneral mistrust of doctors Broken families- doctors need to treat and care Patients want to make own decisions

Doctor Centred Approach

Doctor-patient relationship in the past

Paternalism Because physicians in the past are people who have higher social status doctor is seen as a sacred occupation which saves peoples lives The advices given by doctors are seen as paramount mandate

Doctor-patient relationship at present

Consumerism and mutuality Patients nowadays have higher education and better economic status The concept of patients autonomy The ability to question doctors

Social roles of doctors and patient

Occupying social role which facilitate interaction as they define the expectations and obligations of each participant. Ensure that patients return to health and normal role performance as soon as possible.

PARSONS MODEL OF SICK ROLE.

Parsons model
Parson saw the doctor and patient as fulfilling necessary functions in a well balanced and maintained social structure Sickness is considered to be a necessary, occasional respite, providing a brief exemption for patient from social responsibilities

Patients role
When sick, a patient is allowed the privileges of convalescence-he or she is not held responsible for poor health and is excused from everyday responsibilities In order to enjoy these privileges, the patient must seek technically competent help and comply with medical advice passive and dependent

Doctors role
Be guided by rules of professional practice Applying a high degree of skill and knowledge to the patients The doctor legitimates the patients illness and determines the course of treatment. In doing so, the physician is compelled by professional ethics to act only in his or her sphere of expertise, to maintain an emotional detachment and distance from the patient, and to act in the patients best interest professionally dominant and autonomous

Parsons Ideal Patient (Sick Role)

Rights (Permitted) to:

Give up some activities and responsibilities Regarded as being in need of care and unable to get well by his own decision & will Obligations (In Return) : Must want to get better quickly Seek professional medical advice and cooperate with the doctor.
Parsons, 1951

Expectations
Patient expects from doctor....
A cure Medication To be listened to Sympathy Advice- he understands The answer A sick note What they want (agenda) Comfort A chat No harm Professionalism & Respect To be told what to do To feel better The truth

Why a patient goes to doctor..

They feel ill physically They feel ill mentally They are lonely They want time off work Need advise Dont know who to turn to Marital/family problems Legal reasons

Expectations
Doctor expects from patient... Trust Compliance to treatment Agreement The truth Respect They want to get better To be listened to To obey the Rules!

If Expectations are not met...

Patient may...
Not take medication Not follow advice Choose another doctor Lose trust Complain Not come back Come back Become more ill/die Not tell doctor why they came Become Distressed/Sad/Angry

Doctor may... Become annoyed Become stressed Not be thorough Dread seeing patient again Refuse to see patient again Refer pt to another doctor (Balint calls this the collusion of anonymity ) Not listen

Problems with Persons model

Address acute problems (ignores chronic dx: imagine a cancer patient on medical leave for 10 year!) Clinically oriented Centered on individuals Rights do not always apply

Four proto types of doctor- patient relationship

Paternalistic Mutual Consumerist Default

Paternalistic relationship
Traditionally characterized medical consultation Autocratic model It is assumed that Dr knows best High physician control and low patient control The doctor is dominant and takes on role of parent Patient submissive Shift towards Mutuality

Communication in Paternalistic
Between doctor and patient

Foundation for diagnosis and treatment (elicit & convey information) Relationship has a therapeutic effect placebo effect of drug Doctor-centered consultation (Paternalistic style)
Closed nature questions e.g. How long have you had the pain? & is it sharp or dull? Diseased centered model talk

Paternalistic Relationship

If Ive told you once I told you 1,000 times, stop smoking!!

MUTUAL PARTICIPATION MODEL Regarded as optimal DPR

Active involvement of patients as more equal partners (meeting of experts) Both parties share power and responsibility, exchange of ideas & sharing of belief systems, need each other and will work towards choices and actions satisfying to them both Open questioning, interested in psycho-social aspect of illness history & examination investigation results in a diagnosis Hence there is integration

COMMUNICATION
Between doctor and patient Patient-centered approach (Mutuality) Encourage & facilitate their patients to participate

Use of open questions e.g. tell me about your pain, how do you feel? & what do you think is the cause of the problem? Active listening skills, requires more time (participative style)

Patients role in mutual relationship

Patients need to define their problems in an open and full manner The patients right to seek care elsewhere when demands are not satisfactorily met

Doctors role in mutual relationship

Physicians need to work with the patient to articulate the problem and refine the request The physicians right to withdraw services formally from a patient if he or she feels it is impossible to satisfy the patients demand

Advantages
Patients can fully understand what problem they are coping with through physicians help Physicians can entirely know patients value Decisions can easily be made from a mutual and collaborative relationship

Disadvantages
Physicians do not know what certain degree should they reach in communication If the communication is fake, both physicians and patients do not have mutual understanding, making decision is overwhelming to a patient

A consumerist relationship
The patients take the active role and the doctor assume a fairly passive role. Trying to satisfy the patient need in term of referral to the hospital, usage of medication and sick leave.

Consumerism Patient controlled consultation

Youre paid to do what I tell you!!

Relationship of default
When patient and physician expectation are at odds Or when the need for change in the relationship cannot be negotiated The relationship may come to a dysfunction standstill Passive role by the patient and the doctor Lack of sufficient direction in consultation Ineffective in dealing with the illness. Commonly occur in managing chronic illness e.g. diabetes mellitus and hypertension,

Changes in Doctor Patient Relationship

Individual DPR is replaced by relationships with different members of the primary care team/ hospital. New methods involving patients Interactive multimedia systems provide the information they want. Widespread use of computers in consultation Greater access to internet, communication via google group/email/facebook Use of telemedicine/ teleconsulting from homes

Changes in DPR: Patients beliefs and expectations

Influenced by: Previous experience, literature, the media; Family and friends; Cultural influences; Social significance. These beliefs influence outcomes

Influence of time
Shortage of time is a major constraint paternalistic approach Less attention paid to social and psychological aspect Unnecessary prescription issued Increase in the number of visits Thus more time required for participative patient centered consultation, listen to patients worries and concern

The importance of a good PATIENT DOCTOR RELATIONSHIP lies in the :

Confidence

Trust
Knowledge

Shared knowledge about diseases and how they are related

The success of a good Doctor Patient Relationship is related to

Amount of Information Quality of Information

Accuracy of Diagnosis
Effective Treatment Compliance

IN SUMMARY
Relationships based on openness, trust and good communication will enable you to work in partnership with your patients to address their individual needs. To fulfil your role in the doctor-patient partnership you must: a. be polite, considerate and honest b. treat patients with dignity c. treat each patient as an individual d. respect patients' privacy and right to confidentiality e. support patients in caring for themselves to improve and maintain their health f. encourage patients who have knowledge about their condition to use this when they are making decisions about their care.

HOW TO FIND OUT IF IT WAS A GOOD DOCTOR PATIENT RELATIONSHIP

PATIENT SATISFACTION CONTINUITY GOOD OUTCOMES