The Doctor-patient relationship

Doctor Patient Relationship At the end of this lecture you should be able to Social roles of doctors and patients ( parson’s model of the sick role and doctor’s 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.

What is Doctor-Patient Relationship? It is usually related to clinical events, but it is important to realize the association beyond the clinical premise e.g in the community (non clinical situation) Such meetings are a frequent & regular occurrence Depends not only on Drs’ clinical knowledge & skills but also the nature of the social relationship that exists between the DR & Patient

What is Doctor-Patient Relationship? The Doctor and The Patient are on two opposite ends The Doctor has a high level of knowledge on a problem the patient almost knows nothing about The Doctor is often mechanistic (find and fix approach) The patient is concern with illness (disruption of life) But its entirely different from mechanic-client relationship

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.

DPR-Why is it relevant to us? Because of our understanding of: The Clinical Iceberg phenomena The decision making process in illness behavior The social triggers of decision to seek medical aid

PERCEPTIONS OF NEED: Refers to the gap between the need for medical care and the utilization of professional services. Health care professionals only see the tip of the iceberg with respect to the volume of illness in the community

THE CLINICAL ICEBERG Public’s perceived need for care

ICEBERG THEORY Self-med, No symptoms Public’s perceived need for care Symptoms Do nothing Note the difference between actual and perceived need Alternative med Self-med, No symptoms

PARSONS’ MODEL OF SICK ROLE.

Parson’s model of the sick role and doctor’s role As Sick person Obligations and privileges Doctor’s role Expectations and right Outcome Restore a healthy status and normal role performance as quickly as possible resulting in a smooth functioning of the society.

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 Parsons, 1951

Patient who is sick Obligations and privileges Motivated to get well as quickly as possible Should seek professional medical advice and cooperate with the doctor. Exemptions from normal activities and responsibilities( type depends on severity of illness) In need of care and unable to get better by his or her own decisions and will.

Doctor: professional role Expectations Be guided by rules of professional practice Applying a high degree of skill and knowledge to the patients Granted right to examine patients physically & to enquire into intimate areas of physical & personal life Granted considerable autonomy in professional practice Occupies position of authority in relation to the patient Act for welfare of the patient and community rather than for own self-interest.

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

Types of doctor- patient relationship Paternalistic relationship Mutual relationship Consumerist relationship Default relationship

Paternalistic relationship Traditionally characterized medical consultation High physician control and low patient control The doctor is dominant and takes on role of “parent” Patient submissive Shift towards Mutuality

If I’ve 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

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 “You’re 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,

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

Influences on DPR Doctor’s orientation and practice style Focus on the disease centered model – symptoms, diagnosis and treatment. Traditional medical training, doctor is the expert and patient merely required to cooperate Current approach –patient centered -is to consider the psychosocial aspect of an illness, their experience , impact of illness and everyday activity, diet etc Increasing emphasis on holistic approach-listen to the voice of patient.

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 patient’s worries and concern

Influence of structural context Influence by healthcare financing and local health system Private sector- (fee for service) spend more time with patient, greater availability of resources Need to achieve higher level of patient satisfaction GP - know the patient, past history, social situation etc Public – rapid turn over, different doctors, salaried basis Continuity of healthcare givers. Development of patient’s charter.

Patient’s expectation and participation Younger generation has a higher expectation than the older generation Patients with a high social and educational level has a higher expectation and participate more This is due to higher knowledge and confidence

Partnership in decision making Three models in decision making All corresponds with the three type of DPR Paternalist – doctor solely responsible Shared- share information, take steps to build a consensus for treatment -ideal Informed decision making – drs inform the risk and benefits and the patient makes the decision.

DOCTORS' COMMUNICATION SKILLS

Common complaints about doctor’s communication Doctors do not listen Will not give information Show lack of concern Show lack of respect for patient Thus many leave without asking questions

COMMUNICATION 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

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)

Good Communication Skills In Consultation Initiating the session ( initial rapport ) Gathering information (exploring the problem, understanding the patients views) Building the relationship (involving the patient) Explanation and planning (providing the appropriate amount & type of information, aiding accurate recall and understanding, achieving a shared understanding and planning) Closing the session

Patient’s perception of good communication Patient observant and sensitive to non verbal communication For illness involves fear, anxiety and emotional uncertainty They look for clues to assess their situation So what should you do? Maintain eye contact Look attentive Nod encouragingly and other gestures Facilitate their participation Physical proximity and relative positions of dr/patient

How do you assess good communication Patient’s body language Eye contact How he/she is feeling Tense Uneasy Anxious Angry or upset

Why is there poor communication? The influence of class and status Professional attitudes and interviewing styles Professional power

Advantages of improved communication Compliance with medical instructions and advice Low compliance Dr who do not seek pts’ active participation in the interview, are formal and distant in their mx of the pt by providing little in the way of feedback 2. Satisfaction with health care Goals of pt – dx and tt of any problems, relief of fear & anxiety 3. The social dimensions of healing Benefits of improved DPR – satisfactory recovery Significance of EMPOWERMENT

Challenges in special situations Language barrier especially with foreigners Disclosing diagnosis of cancer or other sad news Disclose or with hold? Depends on the doctor, patient and family Now most of them want to know the truth about their illness.

Shared knowledge about diseases and how they are related The importance of a good PATIENT DOCTOR RELATIONSHIP lies in the : Confidence Trust Knowledge Shared knowledge about diseases and how they are related

What brings patients to the clinic? Tolerance Limit Anxiety Limit Symptoms Prevention For administrative Reasons

What do patients look for in a doctor? Honesty Accuracy Competence Humaneness Openness Responsible Responsive Trust What do patients look for in a doctor?

The success of a good Doctor Patient Relationship is related to Amount of Information Quality of Information Accuracy of Diagnosis Effective Treatment Compliance

Physician superiority Perspective and Traditions Factors that affect a good relationship: Age Sex Physician superiority Cost Benefit Ratio Formal or Casual Perspective and Traditions Mental State Patient Context

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

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.

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