06 the Doctor Patient Relationship
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Transcript of 06 the Doctor Patient Relationship
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The Doctor Patient
Relationship
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Session Objectives
Define the physician patient relationshipin terms of: The nature of the relationship
Elements Changing patterns
Practical uses of the relationship
Required consultation skills andcompetence
Reasons for bad consultations
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Nature of Relationship
TRUST
RESPECT
EMPATHY
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ELEMENTS
THERAPEUTIC ALLIANCE
TRANSFERENCECOUNTER-TRANSFERENCE
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THERAPEUTIC ALLIANCE
Or working alliance
Refers to good working relationshipnecessary for transaction to be successful
Friendliness
Courtesy
Reliability
RAPPPORT- BUILDING
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TRANSFERENCE
The response to new relationshipsaccording from patterns of the past
The tendency to carry over into thepresent the attitudes and expressionsgained from a similar experience in thepast
E.g. Patients perception of the doctor as an
over-controlling parent or idealized son
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TRANSFERENCE
The doctor has the ability to switch to three interactionsthat of the parent, child and adult
according to the situation that he is in.
Eric Berne 1973
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COUNTER TRANSFERENCE
The feelings which the doctor hastowards his patients
One must know ones self
Sixth sense the emotional experienceevoked by a patient in us
Suppression of feelings may sometimes
lead to wrong actions
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Michael Balint 1986
It is not love or mutual respect or mutualidentification or friendship through elements ofall these enter into it. We termed itfor want of a
better terma mutual investment company.The general practitioner gradually acquires avaluable capital investment in his patient andvice versa, the patient acquires a valuable
capital bestowed in his general practitioner..
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The Changing Role of theRelationship
Some viewed the relationship assubjugating the sick and exploiting publicinterest (Illich & Kennedy)
Now, we strive to have well-informed andautonomous patients
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Empowered andWell-Informed Patients
Achieved through:
Public has greater access to healthinformation via media
Increased emphasis on personalresponsibility for health (health promotionactivities)
Creation of patient participation groups ( amarket-oriented approach to provision ofhealth care)
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Empowered andWell-Informed Patients
Achieved through
The role of the doctor as a health educator iswidely accepted
The need for doctors to be effectivecommunicators and skills training has beenrecognized by medical schools
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Practical Uses
1.) Diagnosis
The process of clinical reasoningleading to the identification of the
disease Requires the doctors prior knowledge
of the patient, including his attitudetowards the illness, personality, familybackground, and past medical history
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Practical Uses
2.) Whole Person Medicine
A good relationship heightens thedoctors awareness of the interplay
and relative importance of social,psychological and physical factors.
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Practical Uses
3.) Compliance
Helping patients learn and understand
their illness (hypertension)
Giving more accurate information
Letting the patient seek more information
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All happy familiesresemble each other.Each unhappy family
is unhappy in itsown way
Anna Karenina by Tolstoy
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Our Assumptive Worlds
Both doctor and patient bring to theconsultation their own set of attitudes, beliefs ,prejudices and expectations. These are
influenced by social class, age, ethnic origin,social and educational background and pastexperiences.
Browne & Feeling 1976
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Bad consultations result from havinginsufficient clinical knowledge, from failingto relate to patients or from failing to
understand patients behaviour , hisperception of his illness or its context..
Howie 1985
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Detachment
A degree of detachment is necessary inorder to arrive at an appropriate diagnosisand management.
Striking a balance between being caringand effective
Recognize the dangers of
over-commitment
Seen in the chronically sick or dying
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Anxiety
Too close relationship may increaseanxiety in the problem-solving process andmay impair judgment
May be impelled to inappropriately refer ororder a diagnostic test
Leads to the cascade effect or doctor
shopping
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The Difficult Patient
Demanding patients
Results when the relationship satisfies aneed which cannot be verbalized
Somatic fixation
Doctors feel frustrated or manipulated
Doctors may contribute to the problem Examples: patients with frequent attendance,
dependence (causing to lose autonomy)
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The Consultation
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The Consultation
The essential unit of medicalpractice is the occasion when, inthe intimacy of the consulting
room, a person who is ill orbelieves himself to be ill, seeksthe advice of a doctor whom hetrusts. This is a consultation and
all else in the practice ofmedicine derives from it.
Spence 1960
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Tasks of the Consultation
1. Identification and management ofpresenting problems
2. Management of continuing problems
3. Opportunistic anticipatory care
4. Modification of the patients help seekingbehavior
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Required Consultation Skills
Interpersonal skills The ability of communicate and make
relationships with patients
Reasoning skills Ability to gather appropriate information,
interpret and then apply it in both diagnosisand management
Practical skills Ability to perform physical examination and
use medical instruments
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7 Categories of ConsultationCompetence
Interview or history taking
Patient management
Problem solving Physical examination
Behavior /relationship with patients
Anticipatory care Record keeping
MostDifficultTo acquire
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Consultation Style
Area Traditional Present
Focus Doctor-centered
Authocratic,paternalistic,domineering
Patient-centered
Dialogue
Meeting between 2experts
Scope Limited to physicalsigns and symptoms
Disease & pathology
Allowing patients toreport their thoughtsand feeling about the
illnessPeople and theirproblems
Patients participation Passive Active
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Health Outcomes
More control by patients, more expressionof emotion (positive or negative) by eitherpatient or doctor and more information
sought by patients and given by thedoctor, were associated with better healthon follow-up especially as revealed in
functional capacity and physiologicalmeasurements.
Horder & Moore, 1990
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Evidence of Favorable Outcomes Usingthe Patient-Centered Approach
Diabetes mellitus
Hypertension
Peptic ulcers Headaches
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Bad consultations result from havinginsufficient clinical knowledge, from failingto relate to patients or from failing to
understand patients behaviour , hisperception of his illness or its context..
Howie 1985
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Thou Shall Not Neglect
Traditionalconsultation skills
History taking skills
Physical examinationskills
Patient management
Integrate
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