1. Doctor patient relationship
8th nov. 2015

2. Seeking medical care
Patients’ behavior when ill and their expectations of physicians are influenced by their:
culture,
previous experiences with medical care,
physical and mental conditions,
personality styles (Table 21.1) and
coping skills.
Only about one-third of Americans with symptoms seek medical care; most people contend with illnesses at home with over-the- counter medications and home management.

4. Seeking psychiatric care
In the US, there is a stigma to having a psychiatric illness. Psychiatric symptoms are considered by many Americans to indicate a moral weakness or a lack of self-control. Because of this stigma, many patients fail to seek help. It is important for patients to seek help since there is a strong correlation between psychological illness and physical illness. Morbidity rates and mortality rates are much higher in patients who need psychiatric attention.

5. The “sick role”
A person assumes a particular role in society and certain behavioral patterns when he or she is ill (the “sick role,” described by T. Parsons). The sick role includes: 1. exemption from usual responsibilities, 2. expectation of care by others, and 3. working toward becoming healthy and cooperating with health care personnel in getting well.

6. Critics of the sick role theory argue that it applies only to middle-class patients with acute physical illness, emphasizes the power of the physician, and undervalues the individual’s social support network in getting well.

7. Telling patients the truth
In the US, adult patients generally are told the complete truth about the diagnosis, the management and its side effects, and the prognosis of their illness. Falsely reassuring or patronizing statements in response to patient questions (e.g., “Do not worry, we will take good care of you” or “You still have one child” [after a miscarriage]) are not appropriate.

8. Information about the illness must be given directly to the adult patient and not relayed to the patient through relatives. Parents decide if, how, and when such information will be given to an ill child.
a. With the patient’s permission, the physician can tell relatives this information in conjunction with, or after, telling the patient.
b. Relieving the fears of close relatives of a seriously ill patient can bolster the support system, and thus help the patient.

9. Special situations
Patients may be afraid to ask questions about issues that are embarrassing (e.g., sexual problems) or fear- provoking (e.g., laboratory results). A physician should not try to guess what is troubling a patient; it is the physician’s responsibility to ask about such issues in an open-ended fashion and address them truthfully and fully with the patient.

10. Physicians have the primary responsibility for dealing with adherence issues (see II below), as well as with angry, seductive, or complaining behavior by their patients (Table 21.2).
Referrals to other physicians should be reserved only for medical and psychiatric problems outside of the treating physician’s range of expertise.

13. ADHERENCE
Patient characteristics associated with adherence Adherence refers to the extent to which a patient follows the recommendations of the physician, such as taking medications on schedule, having a needed medical test or surgical procedure, and following directions for changes in lifestyle, such as diet or exercise. Patients’ unconscious transference reactions to their physicians, which are based in childhood parent–child relationships, can increase or decrease adherence. Only about one-third of patients adhere fully to management recommendations, one-third adhere some of the time, and one-third do not adhere to such recommendations.

14. Factors that increase and decrease adherence
Adherence is not related to patient intelligence, education, sex, religion, race, socioeconomic status, or marital status. Adherence is most closely related to how well the patient likes the doctor. The strength of the doctor–patient relationship is also the most important factor in whether or not patients sue their doctors when an error or omission is made or when there is a poor outcome.

17. THE CLINICAL INTERVIEW
Communication skills Patient adherence with medical advice, detection of both physical and psychological problems, and patient satisfaction with the physician are improved by good physician–patient communication.

18. a. Private… no desk or other obstacle …. eye level b
a. Private… no desk or other obstacle …. eye level b. ..first establish trust and rapport and then gather information c. educate and motivate to adhere to mx plan d. Dangerous or threatening patients..

19. When interviewing young children the physician should
a. First establish rapport by interacting with the child in a nonmedical way, for example, drawing pictures. b. Use direct rather than open-ended questions, for example, “What is your sister’s name?” rather than “Tell me about your family.” c. Ask questions in the third person, for example, “Why do you think that the little boy in this picture is sad?”

20. Direct questions are used to elicit specific information quickly from a patient in an emergency situation (e.g., “Have you been shot?”) or when the patient is seductive or overly talkative. Open-ended questions are more likely to aid in obtaining information about the patient, and to encourage the patient to speak freely.

21. Interviewing techniques:
Support and empathy……………….
Validation …………………………………Rapport
Facilitation
Reflection
Silence………………………………………Gather info.
Confrontation
Recapitalulaiton ……………………… Clarify