1. Physician-Patient Relationship SAMUEL AGUAZIM ( MD)

2. GENERAL RULES Theme: The physician-patient relationship is a potent healing partnership based on trust. In the setting of a productive alliance there are tremendous opportunities for clinical interventions that can significantly improve the patient's health and quality of life. The key is what the ideal physician should do.

3. Rule # 1 : Patient is number one; always place the interests of the patient first. a. Choose the patient's comfort and safety over yours or anyone else's. b. The goal is to serve the patient, not to worry about legal protection for the physician. c. Make it a point to ask about and know the patient's wishes.

4. Rule #2: Nothing should be between you and patient a. Get rid of tables and computers. If you must have a table, pick the smallest one. b. Ask family members to leave the room. If patient says that he or she wants them to stay, then that is okay.

5. Rule #3 Tell the patient everything, even if he or she does not ask. a. Answer any question that is asked. b. Respond to the emotional as well as the factual content of questions. c. Patient should know what you know and as soon as you know it. d. Do not force a patient to hear bad news if he does not want it at that moment, but do try to discuss it with him or her as soon as possible. e. If you have only partial information, say that it is partial and tell what you know. f. We tell them so they tell us. Make reciprocity the norm. g. Information should flow through the patient to the family, not the reverse.

6. Rule #4: Work on long-term relationships with patients, not just short-term problems. a. Each encounter is an opportunity to develop a better relationship. b. Make eye contact. c. Defined touch: tell him or her what you are doing. d. Talk to patient, not colleagues: patient is always the focus. e. Arrange seating for comfortable, close communication. f. Both patient and physician should both be sitting at the same eye level if at all possible.

7. Rule #5: Listening is better than talking. a. Be an "information sponge:' You know what matters, but they don't b. Getting the patient to talk is generally better than having the physician talk. c. Take time to listen to the patient before you, even if other patients or colleagues are waiting. d. Ask what the patient knows before explaining. e. End encounter by asking, "Is there anything else?" f. Listen without interrupting g. Allow silences while patients search for words

8. Rule #6: Negotiate rather than order. a. Treatment choices are the result of agreement, not commands by the physician. b. Remember, the patient makes medical decisions from the choices provided by the physician. c. Relationship and agreement support adherence.

9. Rule #7: Solve the problem presented a. Look for a "solution," not the "answer." b. Stay in the room; do not leave. c. Change your plan to deal with new information when it is presented. d. Don't assume that the patient likes or trusts you. e. Treat difficult or suspicious patients in a friendly, open manner.

10. Rule #8: Admit to the patient when you make a mistake. a. Everything is your responsibility. b. Take responsibility. Don't blame it on the nursing staff or on a medical student. c. Admit the mistake even if it was corrected and the patient is fine.

11. Rule #9: Never "pass off" your patient to someone else. a. Refer to psychiatrist or other specialist when beyond your expertise (but usually not the case). b. Refer only for ophthalmology or related subspecialties. c. You provide instruction in aspects of care, e.g., nutrition, use of medications.

12. Rule #10: Express empathy, then give control: 'Tm sorry, what would you like to do?" a. Important when faced with a patient who is grieving or is angry. b. Important when faced with angry or upset family members. c. Acknowledge and legitimize feelings

13. Rule #11 : Agree on problem before moving to solution. a. Discuss diagnosis fully before moving to treatment options b. Ask what patient knows about diagnosis before explaining it c. Tell the patient your perceptions and conclusions about the condition before moving to treatment recommendations. d. Informed consent requires the patient to fully understand what is wrong. e. Offering a correct treatment before the patient understands his or her condition is wrong.

14. Rule #12: Be sure you understand what the patient is talking about before intervening. a. Patients may present problems with much emotion without clearly presenting what they are upset about. b. Seek information before acting. c. When presented with a problem, get some details before offering a solution. d. Begin with open-ended questions, then move to closed ended questions.

15. Rule #13: Patients do not get to select inappropriate treatments. a. Patients select treatments, but only from presented, appropriate choices. b. If a patient asks for an inappropriate medication that he heard advertised, explain why it is not indicated c. Make conversations positive. Talk about options that are available; don't just say no to a patient's request.

16. Rule #14: Best answers serve multiple goals. a. Think broadly about everything you want to achieve. b. Consider both short- and long-term goals. c. Best answers deal with patients' health issues, while supporting relationships and acting ethically

17. Rule # 15: Never lie. a. There is no such thing as a "white lie." b. Do not lie to patients, their families, or insurance companies. c. Do not deceive to protect a colleague.

18. Rule #16: Accept the health beliefs of patients. a. Be accepting of benign folk medicine practices. Expect them. Diagnoses need to be explained in the way patients can understand, even if not technically precise. b. Offer to explain things to family members for the patients.

19. Rule #17: Accept patients' religious beliefs and participate if possible. a. Your goal is to make the patient comfortable. Religion is a source of comfort to many. b. A growing body of research suggests that patients who pray and are prayed for have better outcomes. c. Ask about a patient's religions beliefs if you are not sure (but not as a prelude to passing off to the chaplain!). d. Of course, you are not expected to do anything against your own religious or moral beliefs, or anything which risks patient's health.

20. Rule # 18: Anything that increases communication is good. a. Take the time to talk with patients, even if others are waiting. b. Ask "why?" c. Ask about the patient beyond the disease: job, family, children, etc. d. Be available. Take calls. Answer emails.

21. Rule # 19 : Rule # 1 9 : Be an advocate for the patient. a. Work to get the patient what he or she needs. b. Never refuse to treat a patient because he or she cannot pay.

22. Rule #20: The key is not so much what you do, but how you do it. a. Focus on the process, not just goals; focus on means, not just ends. b. Do the right thing, the right way. c. The right choices are those that are humane and sensitive, and put the interests of the patient first. d. Treat family members with courtesy and tact, but the wishes and interests of the patient come first

23. MISCELLANEOUS PHYSICIAN-PATIENT RELATIONSHIP TOPICS Types of Questions and Statements a. Open-ended question: allows broad range for answer b. Closed-ended question: limits answer, e.g., yes or no c. Leading question: suggests or indicates preferred answer d. Confrontation: brings to the patient's attention some aspect of appearance or demeanor e. Facilitation: gets the patient to continue a thought, talk more, "tell me about that.. :' f. Redirection: puts question back to the patient g. Direct question: seeks information directly. Avoid judgmental terms.