The Doctor-Patient

Relationship

Doctor Patient Relationship

At the end of this lecture you should be able to know the

• Social roles of doctors and patients ( parson’s model of the sick role and doctor’s role)

• Discuss the traditional view of the doctor patient ‑relationship and the potential problems with it.

• Describe the different types of doctor patient ‑relationships from the paternalist to the shared and consumerist approach.

• Explain the concepts of shared decision making and concordance and their relevance to medical practice

Introduction

• 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

• The relationship begins when a person who is ill or believe that he is ill consult a doctor.

• The success or otherwise depend on various factors including the nature of the relationship that exist between the doctor and the patient.

The History of the Doctor-Patient Relationship

20+ years ago...• Lower rates of education• Less access to good medical

care• Doctors trusted completely• Doctor gave

advice/medication and patient would take it

• Patients’ ideas, concerns & expectations not asked about

• Doctor treated- family cared

• Doctor Centred Approach

Over the last 20 years• Higher rates of education• Medical advice on

internet/libraries• Better access and choice of

good medical care• High profile cases of doctors

not acting professionally- general mistrust of doctors

• Broken families- doctors need to treat and care

• Patients want to make own decisions

Doctor-patient relationship in the past

• Paternalism

• Because physicians in the past are people who have higher social status

• “doctor” is seen as a sacred occupation which saves people’s lives

• The advices given by doctors are seen as paramount mandate

Doctor-patient relationship at present

• Consumerism and mutuality

• Patients nowadays have higher education and better economic status

• The concept of patient’s autonomy

• The ability to question doctors

Social roles of doctors and patient• Occupying social role which facilitate

interaction as they define the expectations and obligations of each participant.

• Ensure that patients return to health and normal role performance as soon as possible.

PARSONS’ MODEL OF SICK ROLE.

Parsons’ model

• Parson saw the doctor and patient as fulfilling necessary functions in a well balanced and maintained social structure

• Sickness is considered to be a necessary, occasional respite, providing a brief exemption for patient from social responsibilities

Patient’s role

• When sick, a patient is allowed the privileges of convalescence-he or she is not held responsible for poor health and is excused from everyday responsibilities

• In order to enjoy these privileges, the patient must seek technically competent help and comply with medical advice

→passive and dependent

Doctor’s role Be guided by rules of professional practice Applying a high degree of skill and knowledge to the

patients• The doctor legitimates the patient’s illness and

determines the course of treatment.

• In doing so, the physician is compelled by professional ethics to act only in his or her sphere of expertise, to maintain an emotional detachment and distance from the patient, and to act in the patient’s best interest

→professionally dominant and autonomous

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 & willObligations (In Return) :Must want to get better quickly Seek professional medical advice and

cooperate with the doctor.Parsons, 1951

ExpectationsPatient expects from doctor....• A cure• Medication• To be listened to• Sympathy• Advice- he understands• The ‘answer’• A sick note• What they want (agenda)• Comfort• A chat• No harm• Professionalism & Respect• To be told what to do• To feel better• The truth

Why a patient goes to doctor..

• They feel ill physically• They feel ill mentally• They are lonely• They want time off work• Need advise• Don’t know who to turn to• Marital/family problems• Legal reasons

Expectations

Doctor expects from patient...

• Trust• Compliance to treatment• Agreement• The truth• Respect• They want to get better• To be listened to• To obey the ‘Rules’!

If Expectations are not met...

Patient may...

• Not take medication• Not follow advice• Choose another doctor• Lose trust• Complain• Not come back• Come back• Become more ill/die• Not tell doctor why they came• Become Distressed/Sad/Angry

Doctor may...

• Become annoyed• Become ‘stressed’• Not be thorough• Dread seeing patient again• Refuse to see patient again• Refer pt to another doctor

(Balint calls this ‘the collusion of anonymity’ )

• Not listen

Problems with Persons’ model

• Address acute problems (ignores chronic dx: imagine a cancer patient on medical leave for 10 year!)

• Clinically oriented• Centered on individuals• Rights do not always apply

Four proto types of doctor- patient relationship

• Paternalistic• Mutual• Consumerist• Default

Paternalistic relationship

• Traditionally characterized medical consultation• Autocratic model• It is assumed that Dr knows best• High physician control and low patient control• The doctor is dominant and takes on role of “parent”• Patient submissive• Shift towards Mutuality

Communication in Paternalistic Between doctor and patient• Foundation for diagnosis and treatment (elicit &

convey information)• Relationship has a therapeutic effect placebo effect

of drug• Doctor-centered consultation (Paternalistic style)

‘Closed’ nature questions e.g. “How long have you had the pain? & is it sharp or dull?”

Diseased centered model talk

If I’ve told you once I told you 1,000 times, stop smoking!!”

Paternalistic Relationship

MUTUAL PARTICIPATION MODEL Regarded as optimal DPR

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

Open questioning, interested in psycho-social aspect of illness history & examination investigation results in a diagnosis

Hence there is integration

COMMUNICATION

Between 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)

Patient’s role in mutual relationship

• Patients need to define their problems in an open and full manner

• The patient’s right to seek care elsewhere when demands are not satisfactorily met

Doctor’s role in mutual relationship

• Physicians need to work with the patient to articulate the problem and refine the request

• The physician’s right to withdraw services formally from a patient if he or she feels it is impossible to satisfy the patient’s demand

Advantages

• Patients can fully understand what problem they are coping with through physicians’ help

• Physicians can entirely know patient’s value

• Decisions can easily be made from a mutual and collaborative relationship

Disadvantages

• Physicians do not know what certain degree should they reach in communication

• If the communication is fake, both physicians and patients do not have mutual understanding, making decision is overwhelming to a patient

A consumerist relationship

• The patients take the active role and the doctor assume a fairly passive role.

• Trying to satisfy the patient need in term of referral to the hospital, usage of medication and sick leave.

Consumerism Patient controlled consultation

“You’re paid to do what I tell you!!”

Relationship of default• When patient and physician expectation are at

odds• Or when the need for change in the

relationship cannot be negotiated• The relationship may come to a dysfunction

standstill• Passive role by the patient and the doctor• Lack of sufficient direction in consultation• Ineffective in dealing with the illness.• Commonly occur in managing chronic illness

e.g. diabetes mellitus and hypertension,

Changes in Doctor Patient Relationship• Individual DPR is replaced by relationships with

different members of the primary care team/ hospital.

• New methods involving patients• Interactive multimedia systems provide the

information they want.• Widespread use of computers in consultation• Greater access to internet, communication via

google group/email/facebook• Use of telemedicine/ teleconsulting from homes

Changes in DPR: Patients beliefs and expectations

Influenced by:

Previous experience, literature, the media;Family and friends; Cultural influences;Social significance.

These beliefs influence outcomes

Influence of time• Shortage of time is a major constraint –

paternalistic approach• Less attention paid to social and

psychological aspect• Unnecessary prescription issued• Increase in the number of visits• Thus more time required for participative

patient centered consultation, listen to patient’s worries and concern

The importance of a good

PATIENT DOCTOR RELATIONSHIP

lies in the :

• Confidence

• Trust

• Knowledge

• Shared knowledge about diseases and how they are

related

The success of a good Doctor Patient Relationship is related to

• Amount of Information

• Quality of Information

• Accuracy of Diagnosis

• Effective Treatment

• Compliance

Relationships based on openness, trust and good communication will enable you to work in partnership with your patients to address their individual needs.

To fulfil your role in the doctor-patient partnership you must:a. be polite, considerate and honestb. treat patients with dignityc. treat each patient as an individuald. respect patients' privacy and right to confidentialitye. support patients in caring for themselves to improve and maintain their healthf. encourage patients who have knowledge about their condition to use this when they are making decisions about their care.

IN SUMMARY

•PATIENT SATISFACTION

•CONTINUITY

•GOOD OUTCOMES

HOW TO FIND OUT IF IT WAS A GOOD DOCTOR PATIENT RELATIONSHIP