Doctor - Patient Relationship

Dr. Lynna Lidyana SpKJ

Doctor - Patient Relationship

Dr. Lynna Lidyana SpKJ

Medical Situation

Situation Related to the effort and process of treating a disease

Rapport, the Relationship of the Doctor and the Patient:

Core of Medical Practice

Influence the effort and process of treatment

Doctor A Sick person

Not just “ a diagnostic number “

• Good rapport :

Spontaneous team work

Conscious

Compatible

Constructive

Mutual Understanding & Trust

George Engel :

Integrated Biopsychosocial approach to Human Behavior and disease

Biological :

Anatomical, Structural, Molecular substrate of disease & its effects on the Patient Biological Functioning

Psychological

Effects of psycho dynamic factors, Motivations & Personality on the Experience of illness & The Reaction to it

Social :

Emphasize cultural, Environmental & Familial influences on the Expression & The Expression & The Experience of illness

Comprehensive Understanding of disease and treatment

• Illness Behavior & Sick Role

Affected by previous experience with illness, psychological factors & cultural background .

5 Stages ( Edward Suchman )

1. Symptom Experience

something is wrong

2. Assumption of the Sick role

one is sick & needs professional care

3. Medical care contact

seek professional care

4. Dependent - Patient role

transfer control to the doctor, follow prescribed treatment

5. Recovery , Rehabilitation

give up the patient role

Sick role ( peran sakit )

The Role that society ascribes to the Sick person

( excused from certain responsibilities , expected to obtain help to get well ).

Models of Doctor - Patient relationship .

Influence by Personalities, Expectations & needs of the Doctor & the Patient

Unspoken difference

Miscommunication & disappointment.

Flexible Needs of patient

& treatment Requirements

1, Active - Passive

The patient fully passive ( unconscious, immobilized, delirious ) & The Doctor taking Over totally the patient care & treatment

2. Teacher - Student

Doctor : dominant paternalistic , controlling.

Patient : dependence, acceptance ( recovery from surgery )

3. Mutual Participation

Both Doctor & Patient require and depend on each other’s input . Active participation of the Patient is needed

( chronic illness.)

4. Friendship / Socially intimate

Dysfunctional , Unethical.

Underlying psychological problem in the physician

Relation with the Patient is a substite for another broken Relationship.

Some characteristics of good Doctor - Patient

relationship. - Acceptance - honesty

- empathy - trust

Some Obstacles - sympathy

- transference

- Counter transference

Interview ( anamnesis )To obtain psychological background and symptoms

classification

proper diagnosis & treatment .

Psychiatric Examination - interview / anamnesis

Steps :

1. Establishing Rapport

Doctor - Patient at ease : Empathy to patient complaints, Express compassion, Evaluating the Patient’s insight and becoming an ally, showing expertise, establishing authority as physician and therapist; Balancing the roles of Emphatic listener, expert and authority.

2. Specify the chief complaint

3. Based on the chief complaint develop A provisional DD/

4. Probe DD/ by using focused and detailed Qs.

5. Clarify vague / obscure replies to get the right answer.

6. Let the patient talk freely enough to observe the coherency of his / her thoughts.

7. Use a mixture of open & closed ended Qs

8. Don’t be afraid / hesitate to ask difficult / embarrassing topics.

9. Ask about suicidal thoughts

10. Give the patient a chance to ask Qs at the end of the interview

11. Conclude the initial interview by confidence, and if possible, of hope.

Content vs process Content, what is verbally expressed between the

doctor and the patient

Process, what is occurring non verbally between the doctor and the patient

( feelings, reactions “body language” )

Technique : Open ended - closed ended Qs

Reflection Facilitation; Silence; Confrontation; Clarification Summation; Interpretation; Explanation; Transition; Self - Revelation Positive Reinforcement ; Reassurance; Advice.

Special Cases Some types of patient requre particular skill (patiency) of the physician to understand the covert emotions, fears, conflicts that the patient’s overt behavior represents.

Histrionic Seductive behavior emerge from an unconscious need for reassurance that she is still attractive even ill and from fear that she will not be taken seriously , unless she appear (sexually) attractive (actually she never want to seduce the doctor)

The Physician needs to be calm, reassuring , firm and non flirtations.

Demanding and Dependent

Often become angry or frightened if the doctor seems not taking their concern seriously.

Set necessary limits within the context of an expressed willingness to listen and to care for the patient.

Demanding and Impulsive

Difficult to delay gratification, demand that discomforts be eliminated immediately

Easily frustrated petulant, angry, aggressive, self destructive to get what they need must act in that inappropriate way . Firm not -angry limits from the outset, defining clearly acceptable and unacceptable behavior, while still treated with respect & care, He / She must be held responsible for their actions

Narcissistic Thought that He / She is superior to other, have a tremendous need to appear perfect arrogant, rude, abrupt, demeaning mask for a feeling of inadequacy , helplessness and emptiness .

Do not influence by the attitude of the patients even when he / she disdain the doctor is “ only an ordinary human being “.

Obsessive orderly, punctual, over concerned with detail, strong need to be in control of everything in the environment .

Strengthen the patient ‘s sense of control include as much as possible in their own care & treatment , give detail explanation about what is going on & what is being planned

Paranoid critical, suspicious, evasive, formal, explain in detail every decision and treatment procedure & react non defensively to the patient’s suspicion. Warmth and empathy are often viewed with suspicion

Isolated , Solitary detached, reclusive, do not need / want much contact with others.

Treat with as much respect for privacy as possible.

Complaining , Passive - aggressive complaints, disappointment, blaming others.

Give as much tolerance as possible & especially important involved with & support the (already very tired) family members.

Sociopathic & Malingering

Intelligent, charming, socially adept, never consciously aware of what is mean to be guilty.

Still treat he / she with respect but with heightened sense of vigilance, set firm limits on behavior, patient is held responsible for his / her action , doctors should not hesitate to ask for assistance.

Depressed & Potentially suicidal unable to give an adequate explanation about their illness.

Give specific, direct question about history and symptoms related to depression, including suicidal ideation. (suicide note, previous suicidal attempt, family history of suicide etc. ).

If not hospitalized the patient must be able to contact the doctor anytime, in general do not give premature reassurement, but that help and hope is certainly possible

Violent .With / without restraints patient should not be interviewed alone .

Asked specific Qs pertaining to the previous acts of violence and to violence experienced as a child.

Under what conditions the patients resorts to violence , to detect possible precipitating factors, .

If reality testing is so impaired medication could be given before started the interview.

Delusional delusion is patient’s defensive & self - protective , Albeit maladaptive , strategy against overwhelming anxiety , lowered self esteem, and confusion.

Do not challenge directly , do not agree , just “understand “ it.

Interviewing relativesImportant , ESP. If auto anamnesis is not possible (psychotic, severely depressed , suicidal ideation ) keep patient’s privacy ( secrets)