Doctor-Patient Relationship and Initial Patient Interview Michael Blumenfield, M.D. Professor of Psychiatry - NYMC Director of Medical Student Education in Psychiatry Director of C/L Psychiatry - Westchester Medical Center

“...Some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician.” Hippocrates Precepts, Chapter I

Placebo Effect Placebo Effect is a combination of a psychological expectation blended with a neurochemical response that transforms an anticipated effect into a real effect

Placebo Effect The Placebo Effect can positively or negatively effect pain, swelling, GI, CV, GU responses, mental state and side effects of treatment

Placebo Response At least 20-30 % of patients have been shown to respond to treatment with placebo Placebo pain response can be blocked by naloxone which suggests it is mediated by the endogenous opioid system

Transference Expectation, beliefs and emotional responses that the patient brings to the doctor-patient relationship based on important relationships in the patient’s past

Positive Transference Patient views doctor as good and has confidence in his or her ability Can lead to over idealization and tremendous disappointment when doctor can’t solve all problems or is not always available

Positive Transference Idealization of the the doctor can lead to having sexual feelings toward the doctor

Negative Transference Patient views doctor as harsh punitive parent or authoritative figure who doesn’t care about well being and patient may be non-compliant

Negative Transference Patient with experience with untrustworthy parent may seek many consultations and may be provocative to doctors

Countertransference Refers to doctor’s reaction towards patient based on their own earlier experience

Countertransference Doctors can feel guilty when they are unable to help patient Doctor may have feelings towards patient who remind them of close relative or friend Doctor may minimize the severity of another physician’s illness

Models of Doctor Patient Relationship

Doctor-Patient Relationship Alternative Models

Empathy The ability to momentarily experience the the feelings of another person ( put yourself in another person’s place)

Empathy -Components Transiently experience feelings of the patient and use those feelings to gain understanding of the the patient’s subjective experience Communication of that understanding to the patient

Empathy-Techniques of Learning Intuitive - Reflect on emotions when with patient Cognitive - Ask self how would I feel in patient’s situation Cognitive- Relate to similar situation in own life ( ie. threat to you or a parent)

Empathy- Examples of empathic responses You seem understandably upset with how things are going It must have been very painful after the injury until you received pain medication I am sorry (when learning of death of family member or friend of patient)

The Interview Process The Interview Process INE HRAA-VF- WAY5 To MAV WE mvF- WAY5TOMA14F- ~ WE RA.VF- Clinical Interview

Clinical Interview Be Polite Introduce yourself to patient Make the patient comfortable Initial Question-Invite the patient to tell you how he or she came to be in the hospital (chief complaint )

Clinical Interview Listen to patient- Don’t interrupt patient especially at the beginning of the interview Begin each topic with open ended question and close with detailed specific question

Clinical Interview Pay attention to patient’s associations so you can return later to get more information Be empathic- Respond to patient’s emotional reactions

Usual Order of Interview Chief Complaint History of Present Illness- Elaborate all aspects of symptoms Aggravating factors Alleviating factors Associated manifestations Past Illness Review of Systems

Usual Order of Interview Mental Status Exam ( especially in psychiatric patients )

Let’s Go To The Video Tape !!!

Doctor-Patient Relationship and Initial Patient Interview Michael Blumenfield, M.D. Professor of Psychiatry - NYMC Director of Medical Student Education in Psychiatry Director of C/L Psychiatry - Westchester Medical Center