Doctor Patient Relationship Yusuf Misau

Doctor-Patient Relationship/Public Health Specialist –Community Relationship

Dr. Yusuf Abdu MisauMBBS(ABU), MPH(UM), PhD Student(UM)

Department of Social and Preventive Medicine,

University of Malaya

Acknowledgement I wish to acknowledge A/P Nabilla Al-Sadat for

permission to use her slides in this presentation

04/11/23 2Yusuf Misau-Doctor-Patient Relationship

04/11/23 Yusuf Misau-Doctor-Patient Relationship 3

Objectives

Appreciate the social roles of doctors and patientsUnderstand the Types and Models of Doctor-

Patient Relationship (DPR)Understand the importance of effective

Communication in DPRAppreciate the `the changing scenario in DPR

Contents1. The nature of DPR

2. Person’s model of the sick role and doctor’s role

3. Factors influencing DPR

4. Types of DPR

5. Models DPR

1. Szasz and Hollender Model

2. Transactional Analysis

6. Doctors’ Communication skills

7. Changes in the Doctor-Patient Relationship



It is an emotional association (clinical encounter) between the doctor and a patient which arises when the doctor in a professional capacity; interact with the patient It is usually related to clinical events, but it is important to realize the association beyond the clinical premise e.g in the community (non clinical situation) Such meetings are a frequent & regular occurrence Depends not only on Drs’ clinical knowledge & skills but also the nature of the social relationship that exists between the DR & Patient

Nature of Doctor-Patient Relationship

Nature of Doctor-Patient Relationship


The Doctor and The Patient are on two opposite

ends

The Doctor has a high level of knowledge on a

problem the patient almost knows nothing about

The Doctor is often concern with the disease

diagnosis and treatment (find and fix approach)

The patient is concern with illness (disruption of

life)

Its entirely different from mechanic-client

relationship

DPR-Why is it relevant to us?


Because of our understanding of:

The Clinical Iceberg phenomena

The decision making process in illness behavior

The social triggers of decision to seek medical aid


PERCEPTIONS OF NEEDPERCEPTIONS OF NEEDTHE CLINICAL ICEBERG (ICEBERG

THEORY, LAST 1963)

Refers to the gap between the need for medical care and the utilization of professional services.

Health care professionals only see the tip of the iceberg with respect to the volume of illness in the community


Public’s perceived need for care


Public’s perceived need for care

Note the difference between actual and perceived need

Symptoms Do

nothingNo

symptom

s

Self-med,

Alternative med

SeeGP


IMPLICATIONSIMPLICATIONS Treated cases are not representative of

sufferers as a whole and that knowledge of disorders obtained by the study of such cases is likely to be biased

To reduce the gap Appropriate education of both groups Successful Doctor-Patient Consultation


THE DECISION-MAKING PROCESS THE DECISION-MAKING PROCESS 10 variables important in seeking of professional

advice (Mechanic,1968) By illness behaviour we mean the way symptoms are

perceived, evaluated and acted upon by a person who recognises some pain, discomfort or other signs of organic malfunction

Social triggers (Zola,1973) A model of Health and Illness behaviour in a multi-

ethnic society (Jaafar,1995)


THE DECISION-MAKING ROCESS Mechanic (1968)THE DECISION-MAKING ROCESS Mechanic (1968)

1. The visibility, recognizability & perceptual salience of the symptoms

2. The perceived seriousness of the symptoms

3. The extent to which symptoms disrupt work, family & other social activities

4. The frequency of the appearance of symptoms & their persistence or recurrence

5. The tolerance thresholds of others who are exposed to the symptoms

6. The knowledge, cultural assumptions & understanding of the person and relevant others

7. Other needs or practical matters competing with the illness response

8. Competing possible interactions which can be assigned to symptoms once recognized

9. Emotional barriers in the form of fear and anxiety which influence the choice of actions to deal with the problem

10. The availability, physical proximity and the financial and/or emotional costs of taking various courses of action


SOCIAL TRIGGERS (ZOLA, 1973)SOCIAL TRIGGERS (ZOLA, 1973)Non physiological ‘triggers’ to the decision to seek

medical aid:1. An interpersonal crisis 2. Perceived interference with personal relationships3. ‘Sanctioning’; that is, one individual taking primary

responsibility for the decision to seek medical aid for someone else (the patient)

4. Perceived interference with work or physical functioning

5. The setting of external time criteria (‘If it isn’t better in 3 days…..then I’ll take care of it’)

PARSONS’ MODEL OF SICK ROLE.


Parsons’ “Ideal Patient” (Sick Role)Rights (Permitted) to:Give up some activities and responsibilitiesRegarded as being in need of care and unable

to get well by his own decision & will

Obligations (In Return) :Must want to get better quickly Seek help from and cooperate with a doctor

Parsons, 1951



Apply a high degree of skill & knowledge to the problems of illness

Act for welfare of patient and community rather then for own self interest, desire for money, advancement etc

Be objective and emotionally detached Be guided by rules of professional practice

Parsons, 1951

Parsons’ “Doctor” (Doctors’ Role)


Doctor’s RightDoctor’s Right

Granted right to examine patients physically & to enquire into intimate areas of physical & personal life

Granted considerable autonomy in professional practice

Occupies position of authority in relation to the patient

Parsons, 1951

Implications of Parsons’ theory Protection for the vulnerable

From threatening symptoms From exploitation Doctor-patient relationship unequal

Correction of societal deviance Being sick is ‘social threat’ Society may be exploited


Problems with Persons’ model Address acute problems (ignores chronic dx) Clinically oriented Centered on individuals Rights do not always apply Ignores ‘lay referral system’ Ignores differential treatment of pt by Doctors


Factors influencing DPR


Factors influencing DPR

Conflict of Interest Interests of patient vs. society Interests of patient vs. other patients Problems of confidentiality


Factors influencing DPRDifferences in perspectives

social classethnicitygenderclinical-practice styleTypes and models of doctor-patient

relationships


Recap….. What do you understand by DPR? Why do you think it is important? What are the factors influencing DPR? What are the implications and flaws of Parsons’

Model of Sick role?



TYPES OF DOCTOR-PATIENT RELATIONSHIP

TYPES OF DOCTOR-PATIENT RELATIONSHIP

Types of doctor-patient relationships


1. Default

2. Paternalism (Doctor-centred, Disease model)

3. Consumerism (typical in private practice)

4. Mutuality (Patient-centred, illness model)

5. conflict


Types of doctor-patient relationshipsTypes of doctor-patient relationships

PATIENT CONTROL

DOCTOR CONTROL

LOW HIGH

LOW DEFAULT PATERNALISM

HIGH CONSUMERISM MUTUALITY

CONFLICT

MODELS OF DPR


Szasz and Hollender 1956 - Parson’s concept

Transactional Analysis- Eric Berne


MODELS OF DPR MODELS OF DPR

Szasz and Hollender 1956 - Parson’sconcept

Activity-passivity ModelGuidance-cooperation ModelMutual Participation Model


MODELS OF DPR MODELS OF DPR

Szasz and Hollender 1956 - Parson’s concept

Activity-passivity Model

Doctor assumes complete responsibilityfor the pt’s treatment (Pt on the operating table )


MODELS OF DPRMODELS OF DPRSzasz and Hollender 1956 - Parson’s conceptGUIDANCE-COOPERATION MODEL

Paternalistic relationship (high physician control & low patient control)

Dr is dominant & acts as a parent figure Decides for patient’s best interest Traditional medical consultation Reliance on doctors for decision making


MODELS OF DPRMODELS OF DPR

Szasz and Hollender 1956 - Parson’s ConceptMUTUAL PARTICIPATION MODEL

Active involvement of patients as more equal partners (‘meeting of experts’)

Both parties share power and responsibility, exchange of ideas & sharing of belief systems, need each other and will work towards choices and actions satisfying to them both


MODELS OF DPRTransactional Analysis or TA (Eric Berne 1986)

Describes and explains how we relate to each

other by looking at 3 ego states.

Ego states: ParentAdultChild

Transactional Analysis


Parent

Adult

Child

Parent

Adult

Child

Doctor Patientreciprocal

crossed

Duplex/covert


SZASZ and HOLLENDER’S MODEL Vs.

TRANSACTIONAL ANALYSIS

ACTIVITY-PASSIVITY MODEL (Parent & child) Dr assumes complete responsibility for the pt’s treatment

GUIDANCE-COOPERATION MODEL (Parent & child) Instructions given by the doctors and patients cooperate by

following this advice. Most common model used

MUTUAL PARTICIPATION MODEL (Adult-Adult) Both parties share power and responsibility, need each other and will

work towards choices and actions satisfying to them both



A MODEL OF THE COMMUNICATION PROCESS

SENDER RECEIVERENCODING DECODINGCHANNELCHANNEL

Transmit Message ReceiveMessage


COMMUNICATIONBetween doctor and patient Foundation for diagnosis and treatment (elicit

& convey information) Relationship has a therapeutic effect

placebo effect of drug Doctor-centred consultation (Paternalistic

style) ‘Closed’ nature questions e.g. “How long have

you had the pain? & is it sharp or dull?” Diseased centred model talk


COMMUNICATIONBetween doctor and patient ‘Patient-centered’ approach (Mutuality)

Encourage & facilitate their patients to participate

Use of ‘open’ questions e.g. ‘tell me about your pain’, ‘how do you feel? & ‘what do you think is the cause of the problem?’

Active listening skills, requires more time (participative style)


COMMUNICATION STUDIESCOMMUNICATION STUDIESStudies on medical practitioners:1.Kincey et al (1975)

In US only 56% felt that they had been fully informed of dx, aetiology, tt and prognosis of their condition

2. Cartwright & Anderson (1981) In UK 23% felt their Dr

was not good at explaining things to them

Studies on dentists:1. Collet (1969) About 25% of pts left a dental

practice over a 5-yr period because of poor dentist-pt communication

2. Corah (1974) Reported loss of pts as

high as 50%

3. Schouten et al (2002)• Pts’ satisfaction is

positively related to the communicative behaviour of dentists


COMMUNICATION STUDIESCOMMUNICATION STUDIESInfluence on time:1. Howey et al (1992)

Pressure on time result in fewer psychological problem are identified & more prescriptions are issued (2-20 min, average 6 minutes)

2. Ridsdale et al, 1992 Increase to 10 minutes

resulting in all Drs asking more questions.

Patient characteristics & behaviours

Mutual participation more among younger than elderly people

Pts with high SES ask more Qs & explanation than pts from lower SES

Social class difference 27% working class compared to 45% middle-class pts sought clarification (Tuckett, 1985)

Drs offer more explanations to some groups eg educated pts nad male pts (Street, 1991)

Influence of structural context1. Hospital situation discourage

personal continuity of care compared to general practice

2. Financing of health care• Fee-for-service encourage

longer consultation and increase pt satisfaction compared to per capita or salaried basis


Why is there poor communication?Why is there poor communication?

The influence of class and status

Cognitive failure

Professional attitudes and interviewing styles

Professional power


Good Communication Skills In ConsultationGood Communication Skills In Consultation

1. Initiating the session ( initial rapport ) 2. Gathering information (exploring the problem,

understanding the patients views)3. Building the relationship (involving the patient) 4. Explanation and planning (providing the appropriate

amount & type of information, aiding accurate recall and understanding, achieving a shared understanding and planning)

5. Closing the sessionSilverman et al, 1998


Non-verbal (Body language) Verbal

Greet patient, SMILE, polite and gentle - Social exchanges Forewarn patient of your next action - Address the patient

accordingly Facial expression - Avoid compound

question Listening - Open and focused

questions Eye contact - Facilitate talking: “Go

on…” Posture - Restating: repeat what patient say in your own words. Proximity Position - Simple words and speak

clearly Body contact


Advantages of improved communicationAdvantages of improved communication1. Compliance with medical instructions and advice

• Low compliance Dr who do not seek pts’ active participation in the interview, are formal and distant in their mx of the pt by providing little in the way of feedback

2. Satisfaction with health care• Goals of pt – dx and tt of any oral problems, relief

of fear & anxiety

3. The social dimensions of healing• Benefits of improved DPR – satisfactory recovery• Significance of EMPOWERMENT


Wersch & Eccles, 2001 (Development of clinical guidelines for practice)

• Philosophy of patient-centred care • Shift towards shared treatment decisions• Greater access to high quality medical information

on the internet will increase the no. of ‘information-rich’ pts

Changes in the DPR


Ridsdale & Hudd, 1994• The widespread use of computers in the

consultation Position of pt from the screen Drs’ ability to maintain their personal touch through verbal

skills and eye contact Confidentiality of data maintain TRUST

The use of telemedicine as a means of delivering health care

Changes in the DPR


Strategies for improvement of DPR Strategies for improvement of DPR 1. Understanding illness

How pts and those around him view origin, significance & prognosis of the condition & how it affects other aspects of life

Info about pts’ cultural, religious, social & economic background, his previous experience of ill-health, & if possible his view of misfortune in general

2. Improving communication“Language of distress” - culturally specific folk illnesses

(Mechanic)

Helman, 2000


Strategies for improvement of DPR Strategies for improvement of DPR 3. Increasing reflexivity (self-awareness)4. Treating ‘illness’ and ‘disease’

Do not deal with physical abnormalities/malfunctions

The many dimensions of “ILLNESS” 5. Respecting diversity – health beliefs and practices6. Assessing role of context (social, economic,

environmental factors - focus on who?)Helman, 2000


The proposed conceptual model: Patients preferences in dentist communication

skills in the Malaysian Army

DPR

SOCIOEMOTIONAL BEHAVIOUR

TECHNICAL COMPETENCY

INTERPERSONAL COMPETENCY

•GOOD TREATMENT

•FRIENDLY

•COMPETENT & SKILFUL•CAREFUL & DON’T RUSH ++•Accurate ++ decision

COGNITIVE & INFORMATION GIVING

CONFLICT RESOLUTION& NEGOTIATION

Ref: Zainal Abidin Z. MCD 1997


CONCLUSIONCONCLUSION

Goal of consultation is not only to arrive at diagnosis and formulating a treatment plan

But also, to develop common understanding between patient and doctor

To help patients develop self control over their illness and its course


REFERENCESREFERENCES

1. Cecil G Helman. Culture, Health and Illness. Wright 20002. David Armstrong. Outline of Sociology as Applied to Medicine.

Butterworth Heinemann. 1994.3. Graham Scambler (ed). Sociology as Applied to Medicine.

Saunders 2003.4. David Tuckett (ed). An introduction to Medical Sociology.

Tavistock Publications. 1976.5. Fredric D. Wolinsky. The sociology of Health: Principles,

Professions and Issues. Little, Brown and Company Ltd. 1980. n CG. Culture, Health and Illness. 4th ed. 2001; Butterworth Heinemann, London. Chapter, pp. 79-107.


Health & Medicine

Doctor Patient Relationship Yusuf Misau