1. Doctor-patient relationship C H Chen

2. Why bother Important Essential component of medical care Patient satisfaction Patient participation Outcome of the medical care

3. Sackett 1976 / Reynold 1979 / Ley 1978 Only around 50% patients adherent to treatment prescribed. Forgetfulness Misleading information Poor DPR

4. Others 94 ‘ Lo et al,  40 % of patients go doctor shopping 93 ’ Joss & associates  Patient who will less satisfied with their physician if desire is not met  Emotional, family aspect, wanted information  Same for patient with chronic disease

5. Lancet ( march 2001 ) Study on 25 survey on DPR Good bed side manner had better impact than physician who were less personal Significantly influencing the outcome

6. Example Case example in MPF case book

7. Example ( MPF ) Doctor received a request for home visit by a mother of a 7-year-old boy This boy got headache, fever and possible delirium Diagnosed viral illness Concerned that the boy seemed to be more confused than a temp. of 38 degree

8. Recommended for hospitalization According to doctor, the family assured him that they would make their own transport arrangements He notified the hospital of the patient ’ s impending arrival

9. During home visit, the doctor was asked to examine the other family members It was alleged that he refused to do so The young boy and his sister were admitted to hospital, a diagnosis of carbon monoxide poisoning was made The mother and the grandmother were admitted to hospital on the following days with same diagnosis

10. Apparently caused by an incorrectly fitted boiler in the family home According to the doctor, he had not refused but explained that, as he would need to return to his car to get further forms for the other three patients. He claimed that the family then told him ‘ not to bother ’

11. It was alleged that the doctor did not exercise reasonable care for the health and safety of the family He failed to diagnose carbon monoxide poisoning in the young boy of to direct that he be taken to hospital by ambulance

12. He also failed to consider that other members of the family may be affected by the same condition

13. Discussion Why claims arised Could it avoided How is the DPR improvement

14. DPR Dynamic Subject to change ( improved / deteriated ) A process (takes time to develop ) rather than takes for granted Involves psychodynamic, behavioural and sociological perspective At best, DPR should be one of the trust, mutual respect and empathy

15. DPR Something more than common courtesy and concerns Social rather than professional skills

16. components Patients ’ expectation >Mass media >Peers >family/relatives >Personal experience

17. Transference A phenomenon readily ascribed to psychotherapy, occurs when we respond to a new relationship according to patterns from the past Tendency for us to carry over into the present attitudes and impressions gained from similar past experiences Could be positive or negative Involves in making relationship

18. components Patient ’ s needs Perception Beliefs Religious culture Identify the key person Others could be helpful in making good relationship with the patient

19. Components Doctor  Self esteem  Counter-transference ( the feelings that doctors have towards their patients )

20. Models Szasz and Holleder 1956  Activity – passivity : acute illness  Guidance – cooperative : less acute illness  Mutual participation : chronic illness

21. Models Stewart & Roter ( 1989 ) Paternalistic Mutual participation Default Consumerist

22. Models Negotiation models  newer perspective seen as patients have negotiating rights  Consumerist perspective  Patients better informed  Expect their own concerns to be addressed  If not, patient evaluation of consultation poor and satisfaction is low

23. Negotiation model Reflecting the growing consumer orientation of health care Patient being viewed as having rights to  Fair  Considerate treatment  Information  Consideration of their needs

24. Negotiation model Patient satisfactory measure

25. Difficult patient example

26. Mr. Kwan Only son in his family 40 years old lawyer

27. Mrs. Kwan Also only son in her family 37 years old History of 3 consecutive miscarriage Only son > Paul Mild puerperal depression

28. Paul The only son Bought to your clinic for 1 day history of fever Cough and vomiting Reassured with diagnosis of viral infection Symptomatic treatment

29. Paul Vomit violently at that night Subsequently convulsed Admitted and remained unconsicious Dx.> viral encephalitis You have been rung by physician for history this morning

30. Mr. Kwan Comes today without appt. Demands to see you right away !

31. Role play Difficult patient

32. What you expect Anger Grief Sadness Anxiety Quilt feeling A mixture of these

33. Address the patient Invite the patient into your consultation room Address him with appropriate name Show your concern ( eg. Facial expression) Quickly assess the non-verbal communication Active listening

34. Listen Encourage the patient to sit down and then sit yourself Better than talk, don ’ t interrupts Maintain eye contact Show your concern by using appropriate non-verbal behaviour Let patient ventilate and tell the part of the story

35. Listen Don ’ t argue Don ’ t be defensive Explore the reason for angering

36. Show empathy Understanding the feelings of the patient Tell him our understanding and check if he accepts your understanding

37. Apologize Apologize for causing another ’ s feeling is different from apologizing for being wrong

38. Establishing rapport Validate the person ’ s behaviour Offer support non-judgmentally

39. Do Listen Be calm Be comfortable Show interest and concern Be conciliatory Be genuine Allay any guilt

40. Do Be sincere Give time Arrange follow up Act as a catalyst and guide

41. Don ’ t Touch the patient Meet anger with anger Reject the patient Be a ‘ wimp ’ Evade the situation Be overfamiliar Talk too much

42. Don ’ t Be judgemental Be patronising

43. Improve DPR Privilege  Accessibility  Personal care as a whole  Family care  Comprehensive  Continuing care

44. Improve DPR Empathy Sympathy Honesty Respect both the patient and the assoicates

45. Erich Fromm ’ s ‘ the art of loving ’ Concern Responsibility Respect Knowledge

46. Demanding patient Eg. asks for SL

47. Demanding patient altitude Be calm Non-judgmental Show empathy Acknowledge Show willingness to help Be ready to listen

48. Demanding patient action Physically Socially ( family, work, finance, social support ) Psychologically ( anger, demanding behaviour) Explore > low self esteem, poor coping skill, depression, secondary gain, idea of concern, misconception Set limit to the demand with reasons Come to an agreement Follow up for progress

49. Psychosomatic patient (somatic symptoms with emotional stress )

50. Feeling understood Full history and physical exam Explore  Emotional clues  Social and family factors  Health beliefs, concerns, misconception, expectation, secondary gains, ticket of admission

51. Broaden the agenda Feedback the results of assessment Acknowledges the reality of symptoms Link physical to psychological events ( re-attribution method ) Reframe the complaints with psychosocial life events

52. Link symptoms to psychological problems Simple explanation ( low threshold for headache in anxious patient ) Demonstration ( painful when holding weigh with extending hand ) Projection of identification ( know persons who responded similarly )