Patient-Doctor Relationship, Handout

8/3/2019 Patient-Doctor Relationship, Handout

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The Patient-Doctor

RelationshipDiana M. de Castro, MD, FPPA


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An effective relationship is characterized

by good rapport.

Rapport is the spontaneous, conscious

feeling of harmonious responsiveness thatpromotes the development of aconstructive therapeutic alliance.

It implies an understanding and trustbetween the doctor and the patient.


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Ekkehard Othmer and Sieglinde Othmerdefined the development of rapport as

encompassing six strategies:

(1) putting patients and interviewers at ease;

(2) finding patients' pain and expressingcompassion;

(3) evaluating patients' insight and becoming anally;

(4) showing expertise;

(5) establishing authority as physicians andtherapists; and

(6) balancing the roles of empathic listener,expert, and authority.


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Empathy

Empathy is a way of increasingrapport.

It is an essential characteristic of

psychiatrists, but it is not a universal

human capacity.


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Transference

Transference is generally defined as

the set of expectations, beliefs, and

emotional responses that a patientbrings to the patient-doctor

relationship.


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Countertransference

Just as the patient brings

transferential attitudes to the patient-

doctor relationship, doctorsthemselves often havecountertransferential reactions to their

patients.


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Models of Interaction BetweenDoctor and Patient

The Paternalistic Model In a paternalistic relationship between the doctor

and patient, it is assumed that the doctor knows

best. He or she will prescribe treatment, and thepatient is expected to comply withoutquestioning.

Moreover, the doctor may decide to withhold

information when it is believed to be in thepatient's best interests.

In this model, also called the autocratic model,the physician asks most of the questions and

generally dominates the interview.


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The Informative Model The doctor in this model dispenses information.

All available data are freely given, but the choiceis left wholly up to the patient.

This model may be appropriate for certain one-time consultations where no established

relationship exists and the patient will bereturning to the regular care of a knownphysician.

At other times, the informative model places the

patient in an unrealistically autonomous role andleaves him or her feeling the doctor is cold anduncaring.


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The Interpretive Model Doctors who have come to know their patients better and

understand something of the circumstances of their lives,their families, their values, and their hopes andaspirations, are better able to make recommendationsthat take into account the unique characteristics of anindividual patient.

A sense of shared decision-making is established as thedoctor presents and discusses alternatives, with thepatient's participation, to find the one that is best for thatparticular person.

The doctor in this model does not abrogate theresponsibility for making decisions, but is flexible, and iswilling to consider question and alternative suggestions.


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The Deliberative Model

The physician in this model acts as afriend or counselor to the patient, not justby presenting information, but in activelyadvocating a particular course of action.

The deliberative approach is commonlyused by doctors hoping to modify injurious

behavior, for example, in trying to get theirpatients to stop smoking or lose weight.


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Illness Behavior

The term illness behavior describespatients' reactions to the experience ofbeing sick. Aspects of illness behavior

have sometimes been termed the sickrole, the role that society ascribes topeople when they are ill.

The sick role can include being excusedfrom responsibilities and the expectation ofwanting to obtain help to get well.


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Biopsychosocial Model

In 1977, George Engel at the University of Rochester,published a seminal paper that described the biopsychosocialmodel of disease, which stressed an integrated systemsapproach to human behavior and disease. Thebiopsychosocial model is derived from general systemstheory. The biological system emphasizes the anatomical,structural, and molecular substrate of disease and its effectson the patient's biological functioning; the psychologicalsystem emphasizes the effects of psychodynamic factors,motivation, and personality on the experience of illness andthe reaction to it; and the social system emphasizes cultural,

environmental, and familial influences on the expression andthe experience of illness. Engel postulated that each systemaffects, and is affected by, every other system. Engel's modeldoes not assert that medical illness is a direct result of aperson's psychological or sociocultural makeup but, rather,encourages a comprehensive understanding of disease andtreatment.


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Spirituality

The role of spirituality and religion insickness and health has gainedascendancy in recent years, with some

suggesting that it become part of thebiopsychosocial model. Some evidencesuggests that strong religious beliefs,

spiritual yearnings, prayer, and devotionalacts have positive influences on a person'smental and physical health.


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Beginning the Interview

How a physician begins aninterview provides a powerful firstimpression to patients, which can

affect the way the remainder of theinterview proceeds.


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Physicians should initially make sure that theyknow a patient's name and that the patientknows the physician's name.

Physicians should introduce themselves to otherpeople who have come with the patient and

should find out if the patient wants anotherperson present during the initial interview.

The request for the presence of another personshould be granted, but the physician should also

attempt to speak with patients privately todetermine if there is anything that they want thedoctor to know but would be reluctant to say infront of someone else.


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The Interview Proper

In the interview proper, physiciansdiscover in detail what is troublingpatients.

They must do so in a systematic way thatfacilitates the identification of relevantproblems in the context of an ongoingempathic working alliance with patients.

The content of an interview is literally whatis said between doctor and patient: thetopics discussed, the subjects mentioned.


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Specific Techniques

Open-Ended Versus Closed-EndedQuestions

Interviewing any patient involves a fine balance

between allowing the patient's story to unfold atwill and obtaining the necessary data fordiagnosis and treatment.

Most experts agree that an ideal interview beginswith broad, open-ended questioning, continuesby becoming specific, and closes with detaileddirect questioning.


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Reflection In the technique of reflection, a doctor repeats to

a patient, in a supportive manner, somethingthat the patient has said.

The goal of reflection is twofold: to assure thedoctor that he or she has correctly understoodwhat the patient is trying to say and to let the

patient know that the doctor is perceiving what isbeing said.


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Facilitation

Doctors help patients continue in theinterview by providing both verbal andnonverbal cues that encourage patients to

keep talking.

Nodding one's head, leaning forward in thechair, and saying, Yes, and then ?or Uh-

huh, go on,are all examples offacilitation.


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Silence

Silence can be used in many ways in normalconversations, even to indicate disapproval ordisinterest.

In the doctor patient relationship, however,silence can be constructive and, in certainsituations, allow patients to contemplate, to cry,or just to sit in an accepting, supportive

environment in which the doctor makes it clearthat not every moment must be filled with talk.


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Confrontation

The technique of confrontation is meant topoint out to a patient something to whichthe doctor thinks the patient is not payingattention, is missing, or is in some waydenying.

The confrontation is meant to help patients

face whatever needs to be faced in adirect but respectful way.


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Clarification In clarification, doctors attempt to get

details from patients about what they havealready said.

For example, a doctor may say, You arefeeling depressed. When do you feel mostdepressed.


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Interpretation

The technique of interpretation is most oftenused when a doctor states something abouta patient's behavior or thinking of which the

patient may not be aware. The technique requires the doctor's careful

listening for underlying themes and patternsin the patient's story.

Interpretations usually help clarifyinterrelationships that the patient may notsee.


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Summation

Periodically during the interview, a doctorcan take a moment and briefly summarizewhat a patient has said thus far.

Doing so assures both the patient and doctorthat the doctor has heard the sameinformation that the patient has actually

conveyed. For example, the doctor may say, OK, I just

want to make sure that I've got everythingright up to this point.


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Explanation

Doctors explain treatment plans to patientsin easily understandable language andallow patients to respond and askquestions.


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Transition

The technique of transition allows doctors toconvey the idea that sufficient information has

been obtained on one subject; the doctor'swords encourage patients to continue on toanother subject.

For example, a doctor may say, You've givenme a good sense of that particular time in yourlife. Perhaps now you could tell me a bit moreabout an even earlier time in your life.


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Self-Revelation

Limited, discreet self-disclosure byphysicians may be useful in certain

situations if physicians feel at ease andcan communicate a sense of self-comfort.

Conveying this sense may involve

answering a patient's questions aboutwhether a physician is married and wherehe or she comes from.


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Positive Reinforcement

The technique of positive reinforcementallows patients to feel comfortable telling adoctor anything, even about such things asnoncompliance with treatment.

Encouraging a patient to feel that the doctoris not upset by whatever the patient has tosay facilitates an open exchange.

For example, a doctor might say, I

appreciate your telling me that you havestopped taking your medication.


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Reassurance Truthful reassurance of a patient can lead

to increased trust and compliance and canbe experienced as an empathic responseof a concerned physician.

False reassurance, however, is essentiallylying to a patient and can badly impair thepatient's trust and compliance. Falsereassurance is often given from a desire tomake a patient feel better, but once apatient knows that a doctor has not toldthe truth, the patient is unlikely to acceptor believe truthful reassurance.


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Advice

In many situations it is not only acceptable but

desirable for doctors to give patients advice. Tobe effective and to be perceived as empathicrather than inappropriate or intrusive, the adviceshould be given only after patients are allowed

to talk freely about their problems so thatphysicians have an adequate information basefrom which to make suggestions.

Giving advice too quickly can lead a patient to

feel that the doctor is not really listening but,rather, is responding, either out of anxiety orfrom the belief that the doctor inherently knowsbetter than the patient what should be done in a

particular situation.


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Ending the Interview Physicians want patients to leave an interview feeling

understood and respected and believing that all the pertinent

and important information has been conveyed to an informed,empathic listener.

To this end, doctors should give patients a chance to askquestions and should let patients know as much as possibleabout future plans.

Doctors should thank patients for sharing the necessaryinformation and let patients know that the information conveyedhas been helpful in clarifying the next steps.

Any prescription of medication should be spelled out clearly and

simply, and doctors should ascertain whether patientsunderstand the prescription and how to take it.

Doctors should make another appointment or give a referraland some indication about how patients can reach help quicklyif it is necessary before the next appointment.


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Specific Issues in Psychiatry

Fees Before clinicians can establish an ongoing

relationship with patients, they mustaddress certain issues.

For instance, they must openly discusspayment of fees.

Discussing these issues and any other

questions about fees from the beginning ofthe relationship can minimizemisunderstanding later.


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Confidentiality

Psychiatrists and mental health professionalsshould discuss the extent and limitations ofconfidentiality with patients, so that patients are

clear about what can and cannot remainconfidential.

As much as physicians must legally and ethicallyrespect patients' confidentiality, it may be wholly

or partially broken in some specific situations.


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Supervision

It is both commonplace and necessary fordoctors in training to receive supervisionfrom experienced physicians.

This practice is the norm in large teachinghospitals, and most patients are aware ofit.

When young doctors are receivingsupervision from senior physicians,patients should know from the beginning.


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Missed Appointments and Length ofSessions

Patients need to be informed about a doctor'spolicies for missed appointments and length ofsessions. Psychiatrists generally see patients inregularly scheduled blocks of time ranging from

15 to 45 minutes. At the end of this time, psychiatrists expect

patients to accept the fact that the session isover.

Nonpsychiatric physicians may schedulesomewhat differently, by putting aside 30minutes to an hour for an initial visit and thenperhaps scheduling patient visits every 15 to 20

minutes for follow-up appointments.


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Availability of Doctor

What are a doctor's obligations to be availablebetween scheduled appointments? Is itincumbent on physicians to be available 24hours a day? Once a patient enters into acontract to receive care from a particular

physician, the doctor is responsible for having amechanism in place for providing emergencyservice outside scheduled appointment times.Patients should be told what the mechanism is,whether it is an emergency phone number or a

covering physician. If the physician is going tobe away for a period of time, coverage byanother physician is necessary, and patientsmust be informed how to reach the coveringdoctor.


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Follow-Up

Many events can disrupt the continuity ofthe patient-doctor relationship.

Some of these events are routine, such asresidents ending their training and moving

on to another hospital; others are out ofthe ordinary and thus unpredictable, forexample, when physicians become ill andcan no longer take care of their patients.

Patients must be assured that regardlessof what occurs in the course of a particularpatient-doctor relationship, their care willbe ongoing.


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Character and Qualities of thePhysician*

Imperturbability. The ability to maintain extreme calmand steadiness

Presence of mind. Self-control in an emergency orembarrassing situation so that one can say or do the

right thing Clear judgment. The ability to make an informedopinion that is intelligible and free of ambiguity

Ability to endure frustration. The capacity to remainfirm and deal with insecurity and dissatisfaction

Infinite patience. The unlimited ability to hear pain ortrial calmly Charity toward others. To be generous and helpful,

especially toward the needy and suffering


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Character and Qualities of thePhysician*

The search for absolute truth. To investigatefacts and pursue reality

Composure. Calmness of mind, bearing, andappearance

Bravery. The capacity to face or endure eventswith courage

Tenacity. To be persistent in attaining a goal oradhering to something valued

Idealism. Forming standards and ideals andliving under their influence Equanimity. The ability to handle stressful

situations with an undisturbed, even temper

*After William Osler, M.D.


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Learning to balance theseinterrelated aspects of thephysician's role allows the

doctor to cope productivelywithin daily work that involves

illness, pain, sadness,suffering, and death.

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Patient-Doctor Relationship, Handout