Doctor-patient relationship:Need and rational

Dr. Md. Nazmul HossainResident Surgeon,

Department of Surgery

Medical College for Women and Hospital, Uttara

Learning objectives

By the end of this session audience should be able to:

Describe the different types of doctor-patient relationships;

Social factors influencing this consultation; Outline some of the sociological

perspectives on the doctor-patient relationships.

Contents

Introduction Types of D-P relationship Barrier of good communication Art of interview Recommendation Take home massage

Stop and think!

In what ways are relationships

between doctors and their

patients different from other

social relationships (e.g. between

student and librarian or between

passenger and bus driver?

Social relationships

Perhaps patient has just met her doctor, but within seconds s/he tells the doctor very intimate personal details about his/her health.

AND within a minutes, s/he is prepared to

remove his/her clothes and submit to a physical examination.

Social relationships

This is a one-way process, it would be highly inappropriate if the doctor started to discuss his/her own bowel movements or if the patient asked his/her personal questions.

The doctor-patient interaction is shaped by their differing social roles and their different needs.

Current practice of “ConsultationConsultation”

Patients are likely to rely on the doctors because of Patients are likely to rely on the doctors because of their lower education and social status and their their lower education and social status and their high dependency on medical deliberation, and high dependency on medical deliberation, and obedience to authority; obedience to authority;

while doctors dominate the consultation process while doctors dominate the consultation process and the decision-making because they are the and the decision-making because they are the legalized profession, i.e. supported by our social legalized profession, i.e. supported by our social institutioninstitution

The status and power of physicians may encourage patient’s dependency The status and power of physicians may encourage patient’s dependency

and, influence how they perceive their healthand, influence how they perceive their health.

Disadvantages of the current practiceDisadvantages of the current practice

1.1. Restricts the patient’s inclination to help themselves.Restricts the patient’s inclination to help themselves.2.2. Restricts the patients in giving their own opinion.Restricts the patients in giving their own opinion.3.3. Reinforces the patient’s sick role.Reinforces the patient’s sick role.4.4. Reinforces the hierarchical relationship between Reinforces the hierarchical relationship between

doctor and patient.doctor and patient.5.5. Assumes the doctor knows everything about the patients Assumes the doctor knows everything about the patients rather than the patient knowing his or her own condition rather than the patient knowing his or her own condition

better (e.g. pain)better (e.g. pain)

Types Doctor-Patient Relationship

Physician control

Patient Control Low High

Low Default Paternalist

High Consumerist Mutuality

Paternalism

The traditional D-P relationship

Doctor Takes on role of “parent”

Patient submissive

But currently shift towards Mutuality

The Paternalistic Approach

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

Patient-controlled consultation

“You’re paid to do what I tell you!!”

Doctors’ barriers to effective communication

• lack of specific knowledge;

• lack of counselling skills;

• lack of time;

• lack of appropriate resources.

Patient barriers to effective communication

Educational level Sex Social Different languages Membership of an ethnic minority

Developing a REAL relationship

Have an „open” attitude: whatever is going on between us in interaction is important and intimate, no matter what is being discussed.

Develop in the interviewee a feeling that he/she is being treated

Concentrate all your attention on the interviewee Help the interviewee to express those contents which

are important for the diagnosis• Create a calm and unhurried atmosphere

• Listen kindly with empathy

• Do not express surprise

First minutes…

Try not to be late… Concentrate fully and only at the patient Take care of the patients comfort Organize the environment Pay attention to the physical distance Introduce yourself…

The Art of asking questions

The first question: general, open, refer to the interviewee’s general life situation or the presenting problem

• What brings you here?

• What can I do for you?

• What is your problem?

• Why are you here? (in the hospital)

• Could you tell me a bit more about …

The Art of asking questions

Narrowing down the questions (general to specific)

Progression (relatively benign to personal) Direct questions Leading questions (indirect) Postponed questions (change of context, better

moment) Projective questions („some people…”,

description of interpersonal situation)

Language…

The language must be matched to:• interviewee’s intelectual level

• verbal skills

• personal experience

Avoid the proffesional language and shortenings

When the interview comes to a close…

Check whether all problems have been discussed and leave some time for their discussion

When time is up – communicate it directly instead of constantly checking the time or „suggesting” that you have to go (e.g.. By gathering the notes impatiently)

Try to summarize the interview Finish the conversation stressing your interest in the

interviewee and in what has been said You can ask the patient to evaluate the conversation Say good-bye, get up and thank the interviewee for

coming.

How to maintain the rapport?

Verbal signals:• „Yes”, „I understand”, „Yhym”

• „Could you tell me more about this?”

• Paraphrasing

• Silence

Nonverbal signals:• Body posture

• Tilt of the head

• Facial expression

• Gestures

• Eye expression

• Smiling

• Synchronisation

Recommendation

Communication and Diagnosis

Patients who feel at ease and who are encouraged to talk freely are more likely to disclose the real reason for consulting

Communication and Treatment

Advice reassurance and support from the doctor can have a significant effect on recovery

The placebo effect

Recommendation

1.1. Both patient and doctor could participate in Both patient and doctor could participate in discussion and planning for treatments.discussion and planning for treatments.2. Increase health knowledge and understanding 2. Increase health knowledge and understanding among patients.among patients.3. Treat patients in a humanistic and adult manner 3. Treat patients in a humanistic and adult manner Empowerment of the ptsEmpowerment of the pts

Take home message

Thank you