Physician Patient Relationship

Doctor-Patient relationships express the values of medical profession.
The relationship should not be fish and fisherman.
It should always be like fish and water.

1. Physician-Patient Relationship AB.RAJAR. ASSISTANT PROFESSOR. COMMUNITY HEALTH SCIENCES. AB.RAJAR/[email protected] Physician-Patient Relationship

2. Learning Objectives. Introduction. Why does it matter? Types of relationships. What is the ideal patient-physician relationships ? Ethical Models of Physician-Patient Relationship. Relationship of the 21st century Conclusion. AB.RAJAR/[email protected] Physician-Patient Relationship

3. INTRODUCTION Doctor-Patient relationships express the values of medical profession. The relationship should not be fish and fisherman. It should always be like fish and water. Physician-Patient Relationship AB.RAJAR/[email protected]

4. Hippocrates viewed the physician as 'captain of the ship' and the patient as someone to take orders AB.RAJAR/[email protected] Physician-Patient Relationship

5. Why Does It Matter The patient-physician relationship is fundamental for providing and receiving, Excellent care To the healing process To improved outcomes Therefore, it is important to understand what elements comprise the relationship and identify those that make it "good." AB.RAJAR/[email protected] Physician-Patient Relationship

6. Why Does It Matter Because of the rapidly changing environment that characterizes health care today, We need to understand what physicians and patients must do to protect and nurture the relationship. AB.RAJAR/[email protected] Physician-Patient Relationship

7. The Patient P atients are individual human beings with problems that all to often transcend their physical complaints. The patient are not „cases” or „admissions” or „diseases” AB.RAJAR/[email protected] Physician-Patient Relationship

8. Parsons’ model The nature of relationships determines the success of the treatment/intervention. PARSON was one of the earliest sociologist to examine the patient doctor relationship. He regarded illness as a form of social deviance (impairs normal role performance, affects smooth functioning of the society). The amount of illness is controlled by socially prescribed roles for doctors and patients. AB.RAJAR/[email protected] Physician-Patient Relationship

9. 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 necessary, providing a brief exemption for patient from social responsibilities AB.RAJAR/[email protected] Physician-Patient Relationship

10. Parsons’ “Ideal Patient” Permitted to: Give up- some activities. responsibilities Regarded as being in need of care In Return : Must want to get better quickly Seek help from and cooperate with a doctor AB.RAJAR/[email protected] Physician-Patient Relationship

11. Parsons’ “ Ideal Doctor” Apply a high degree of- skill and knowledge Acts for the good of the patient Remain objective and emotionally detached Respect the position of privilege AB.RAJAR/[email protected] Physician-Patient Relationship

12. DOCTOR’S ROLE. Health care provider. Technical consultant. To convince the necessity of medical services. A tendency for the “ Consumer to be right.” Physician-Patient Relationship AB.RAJAR/[email protected]

13. DOCTOR COMPETENCIES Patient care. Medical knowledge. Practice-based learning (PBL) and improvement. Interpersonal skills. Communication skills. Professionalism. System-based practice. Physician-Patient Relationship AB.RAJAR/[email protected]

14. Patient’s role. Health shoppers indicators of consumer behavior Cost consciousness. Information seeking. Exercising independent judgment. Consumer knowledge. Physician-Patient Relationship AB.RAJAR/[email protected]

15. CONFLICT OF INTEREST Interests of patient Vs society. Interests of patient Vs other patients. Problems of confidentiality. Physician-Patient Relationship AB.RAJAR/[email protected]

16. The Physician Charter. Principle includes: Patient welfare. Patient autonomy . Commencements Includes: Honesty with Patients. Patient confidentiality. Maintaining appropriate relationships with patients. AB.RAJAR/[email protected] Physician-Patient Relationship

17. PATIENTS BELIEFS & EXPECTATIONS Influenced by: Previous experience. Literature. The media. Family and friends. Cultural influences. Social significance. These beliefs influence in outcome. AB.RAJAR/[email protected] Physician-Patient Relationship

18. TYPES OF RELATIONSHIPS Paternalism (Doctor centered, Disease Model). Mutuality (Patient centered, Illness model). Consumerism (Typical in private practice) Default. Conflict. Physician-Patient Relationship AB.RAJAR/[email protected]

19. 1.Paternalism Traditional form of doctor-patient relationship Doctor takes on role of parent Doctor is the expert and patient expected to cooperate Tightly controlled interviewing style aimed at reaching an organic diagnosis P assive patient and a dominant doctor Focus is on care , rather than autonomy AB.RAJAR/[email protected] Physician-Patient Relationship

20. PATERNALISM Making of decisions by professionals on behalf of patients. Dirty word- OUT -AUTONOMY- is IN . Liberty,diginity,individuality,independence,accepting responsibility, self assertion, knowledge of one’s own interests,privacy,voluntarieness,freedom from deception. Physician-Patient Relationship AB.RAJAR/[email protected]

21. The Paternalistic Approach “ If I’ve told you once I told you 1,000 times, stop smoking!!” AB.RAJAR/[email protected] Physician-Patient Relationship

22. Advantages The supportive nature of paternalism appears to be important when patients are very sick at their most vulnerable Relief from the burden of worry is curative in itself, and the trust and confident implied by this model allows doctor to perform “medical magic” AB.RAJAR/[email protected] Physician-Patient Relationship

23. 2.Mutuality The optimal doctor-patient relationship model This model views neither the patient nor the physician as standing aside Each of participants brings strengths and resources to the relationship Based on the communication between doctors and patients AB.RAJAR/[email protected] Physician-Patient Relationship

24. 2.Mutuality Cont... Patients need to define their problems in an open and full manner The patient has right to seek care elsewhere when demands are not satisfactorily met. 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 AB.RAJAR/[email protected] Physician-Patient Relationship

25. 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 AB.RAJAR/[email protected] Physician-Patient Relationship

26. Disadvantages Physicians do not know what certain degree should they reach in communication Is the patient capable of making the important therapeutic . AB.RAJAR/[email protected] Physician-Patient Relationship

27. 3.Consumerism We can simplify the complicated relationship with “buyer and seller” relationship, is it good or bad? What is your opinion? The patient can challenge to unilateral decision making by physicians in reaching diagnosis and working out treatment plans Reversing the very basic nature of the power relationship. AB.RAJAR/[email protected] Physician-Patient Relationship

28. 4.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. AB.RAJAR/[email protected] Physician-Patient Relationship

29. Patient Centred consultation style Dr is less authoritarian , encourages patients to express their own feelings and concerns , empathic , listen more than talk . Dr use open end questioning , show interest in psycho-social aspect of patient’s illness . AB.RAJAR/[email protected] Physician-Patient Relationship

30. Length of Consultation Average 8 minutes makes... Patient centred consultation styles more difficult. AB.RAJAR/[email protected] Physician-Patient Relationship

31. Consultation style. It’s serious, isn’t it doctor ? Sustained physician patient partnerships with bonds of trust and knowledge of patients were correlate of three outcomes of care… Adherence. Satisfaction. Improved health status . Physician-Patient Relationship AB.RAJAR/[email protected]

32. Types of Dr-Pt relationship Doctor controlled Patient controlled AB.RAJAR/[email protected] Physician-Patient Relationship

33. Prototypes of doctor-patient relationship Physician control (Low) Physician control (High) Patient control (Low) Default Paternalism Patient control (High) Consumerism Mutuality AB.RAJAR/[email protected] Physician-Patient Relationship

34. Patient controlled consultation “You’re paid to do what I tell you!!” AB.RAJAR/[email protected] Physician-Patient Relationship

35. ETHICAL MODELS AT GLANCE. PATERNALISTIC MODEL. INFORMATIVE MODEL. INTERPRETIVE MODEL. DELIBERATIVE MODEL. AB.RAJAR/[email protected] Physician-Patient Relationship

36. PETERNALISTIC MODEL Principle. The doctor should make all the decisions for the patient. Assumptions. People are not always rational/mature. Experts knows better about the needs of patients. Qualified doctors have good will. Sources: Hippocratic oath. Problems: Are the needs of patients objective? How can we be sure that doctors have good will? AB.RAJAR/[email protected] Physician-Patient Relationship

37. INFORMATIVE MODEL Principle. The doctor should provide all the relevant information for the patient to make a decision, and provide the selected intervention on this basis. Assumptions. A fact/value division of labor yields the best medical results. What is good for a patient depends on what his/her personal values. Consumerism. Problems . What if patient is unconcious,incompetent and making choices totally unacceptable by our ethical standards? AB.RAJAR/[email protected] Physician-Patient Relationship

38. INTERPRETIVE MODEL Principle. The doctor should help the patient to articulate his/her values through interpretation, and provide intervention which is truly wanted. Assumptions. Patients have unconscious and inconsistent desires. Their conscious decisions may not reflect their deepest values. Limitations. All that a doctor can do is to help the patient see his/her own desires/values more clearly, but not to criticize them. AB.RAJAR/[email protected] Physician-Patient Relationship

39. DELIBERATIVE MODEL Principle. The doctor should help the patient to deliberate well through dialog and discussion, and , So develop values which are objective and truly worthy. Assumptions. The objectivity of values. The patient’s good life consist not in the satisfaction of desires, but maturity and rationality. Problems. Is the model different from the paternalistic model? What is the difference b/w dialog and persuasions? AB.RAJAR/[email protected] Physician-Patient Relationship

40. The Patient "nothing about me without me." AB.RAJAR/[email protected] Physician-Patient Relationship

41. Doctor-patient relationship in the past Paternalism Because physicians in the past were 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 AB.RAJAR/[email protected] Physician-Patient Relationship

42. 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. AB.RAJAR/[email protected] Physician-Patient Relationship

43. Principal elements that are essential to the relationship Communication. Office Experience. Hospital Experience. Education. Integration. Decision-Making. Outcome. AB.RAJAR/[email protected] Physician-Patient Relationship

44. Communication and Treatment Advice reassurance and support from the doctor can have a significant effect on recovery. The placebo effect AB.RAJAR/[email protected] Physician-Patient Relationship

45. Communication with pt includes An integrated approach to information gathering. Seeking to identify physical psychological and social factors Will likely to produce a better outcome of health care. Physician-Patient Relationship AB.RAJAR/[email protected]

46. Elements of Communication Seven Essential Elements in Physician-Patient Communication Build the doctor-patient relationship Open the discussion Gather information Understand the patient’s perspective Share information Reach agreement on problems and plans Provide closure AB.RAJAR/[email protected] Physician-Patient Relationship

47. Gathering data to understand the patient Nonverbal skills Attentive and interested body posture Facial expression Appropriate eye contact Touch AB.RAJAR/[email protected] Physician-Patient Relationship

48. AB.RAJAR/[email protected] Physician-Patient Relationship

49. Who are “difficult” patients? What characteristics make a patient “difficult”? Mental health disorders Multiple symptoms Chronic pain Functional impairment Unmet expectations Lower satisfaction with care High users of health care services Dr. Tom O’Dowd coined the term “ heartsink patient ” BMJ, 1988 AB.RAJAR/[email protected] Physician-Patient Relationship

50. Conclusion Relationship between patients and doctors are often unstated, and they are dynamic. As conditions change, the kind of relationship that works best for a patient may change. Doctors and patients should choose a “relationship fit”. effectiveness of the patient-physician relationship directly relates to health outcomes . AB.RAJAR/[email protected] Physician-Patient Relationship

51. AB.RAJAR/[email protected] Physician-Patient Relationship