Introduction

1. This is a unique social relationship where bonding is planned with the ultimate objective of assisting the patient to achieve treatment goals.
2. This approach requires the doctor (care provider) to take on the responsibility of directing, effecting and maintaining the therapeutic relationship, exhibiting a professional and ethical approach.

 

Why does it matter?

The patient-physician relationship is fundamental for providing

1. Excellent care
2. To the healing process
3. To improved outcomes

Therefore, it is important to understand what elements comprise the relationship and identify those that make it “good.”

 

Parsons’ model (1951)

1. Parsons” “Ideal Patient” (Sick Role)

Rights (Permitted) to:

Give some activities and responsibilities.

Regarded as being in need of care.

2. Obligations (In Return):

Must want to get better quickly.

Seek help and cooperate with a doctor.

 

 Parsons” “Doctor” (Doctors’ Role)

1. Apply a high degree of skill & knowledge to the problems of illness.
2. Act for welfare of patient and community rather then for own self interest, desire for money, advancement etc.
3. Be objective and emotionally detached.
4. Be guided by rules of professional practice.

 

 Doctor’s Right

1. Granted right to examine patients physically & to enquire into intimate areas of physical & personal life.
2. Granted considerable autonomy in professional practice.
3. Occupies position of authority in relation to the patient.

 

Types of Doctor-Patient Relationship

 

Paternalism

1. Is widely regarded as the traditional form of doctor-patient relationship.
2. A passive patient and a dominant doctor.

 

Advantages

1. The supportive nature of paternalism appears to be more important when patient are very sick.
2. Relief from the burden of worry is curative in itself, and the trust and confidence implied by this model allow doctor to perform “medical magic” →>placebo effect.

 

Disadvantages

1. Manipulation and exploitation of the vulnerable and ill.

 

Mutuality

1. The optimal doctor-patient relationship model.
2. This model views neither the patient nor the physician as standing aside.
3. Each of participants brings strengths and resources to the relationship.
4. Based on the communication between doctors and patients.

 

Patient’s role

1. Patients need to define their problems in an open and full manner.
2. The patient’s right to seek care elsewhere when demands are not satisfactorily met.

 

Doctor’s role

1. Physicians need to work with the patient to articulate the problem and refine the request.
2. 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

1. Patients can fully understand what problem they are coping with through physicians’ help.
2. Physicians can entirely know patient’s value.
3. Decisions can easily be made from a mutual and collaborative relationship.

 

Disadvantages

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

 

Consumerism

1. Reserve of the very basic nature of the power relationship.
2. Patient taking active role and doctor adopting a fairly passive role.

 

Patient’s role

1. Health shoppers

 

Indications of consumer behaviour:

1. Cost-consciousness
2. Information seeking
3. Exercising independent judgement.

 

Doctor’s role

1. Health care providers
2. Technical consultant
3. To convince the necessity of medical services

 

Advantages

1. Patients can have their own choices.

 

Disadvantages

1. When things seem to go wrong, when satisfaction is low, or when a patient suspect less than optimal care or outcome, patients are more likely to question physician authority.

 

Default

1. When patient and physician expectation are at odds, or when the need for change in the relationship can not be negotiated, the relationship may come to a dysfunction standstill.

 

Consultation styles

1. Doctor cantered

a. Paternalistic – doctor is the expert and patient expected to cooperate.

b. Tightly controlled interviewing style aimed at reaching an organic diagnosis.

c. Closed questions

d. ‘Voice of medicine’- focus on biomedical diagnosis and treatment as quickly as possible

 

2. Patient cantered

a. Mutuality

b. Less authoritarian – encourages patient to their own feelings and concerns

c. Open questions

d. ‘Voice of the patient’ – communication of patient’s beliefs, feelings & psychosocial context (bio psychosocial).

 

Key aspects of a of patient-centred consultation

1. Biopsychosocial perspective
2. Patient-as-a-person
3. Sharing power and responsibility
4. Therapeutic alliance
5. Doctor-as-a-person

 

Influences on The Doctor-patient Relationship

1. Influence of time – Average 6 minutes (avg 2-20 min)
2. Pressures of time- doctor centred consultation
3. However, doctors’ own style & approach influences than the time available.
4. Patient centric approach needs more time but overall reduces the number of return visits & thus the total consultation time.

 

 Characteristics and Behaviours

The patient’s ability to exercise and control depends on a number of factors:

1. Age
2. Social and educational level
3. Sex
4. Different languages

 

Influence of structural context

1. Hospital situation/ Ward
2. Fee-for service

 

Health literacy

1. Definition—the ability to obtain, process, and understand basic information and services needed to make appropriate health decisions.
2. Low health literacy reduces the success of treatment and Increases the risk of medical error.
3. Health literacy is of continued and increasing concern for health professionals, as it is a primary factor behind health disparities.

 

Tests to identify health literacy

1. Medical Term Recognition Test (METER)
2. Rapid Estimate of Adult Literacy in Medicine (REALM) Test
3. The Short Assessment of Health Literacy in Spanish and
4. English populations (SAHL-S&E)
5. The Critical Health Competence Test (CHC-Test)

 

Intervention

1. Teach back method.
2. Ask Me 3” is designed to bring public and physician attention to this issue, by letting patients know that they should ask three questions each time they talk to a doctor, nurse, or pharmacist:

a. What is main problem?

b. What do I need to do?

c. Why is it important for me to do this?

 

 Partnerships In Treatment Decision Making 

Models of decision making

1. 3 models – paternalist

a.  Shared

b. Informed

Paternalist model

1. The doctor, as medical expert, as solely responsible for treatment decisions with the patient expected merely to cooperate with advice and treatment.

 

Shared decision-making

1. Both doctor and patient are involved in the decision-making process
2. both parties share information
3. Both parties take steps to build a consensus about the preferred treatment
4. An agreement (consensus) is reached on the treatment to implement

 

 Informed model

1. Partnership between doctor and patient – division of labour
2. Doctor – information on all relevant options
3. Decision-making- patient

 

Shared decision making -impetus

1. Increased medical knowledge among patients
2. Prevailing social values- individual autonomy and responsibility
3. Chronic illness
4. To make choices between the treatment options and to balance risks & benefits -medical uncertainty.
5. Doctors make inaccurate guesses about patients concerns & their preferences and treatment choices differ

 

 Patients’ preferences for participation

1. Patient’s state of health
2. Patients in crisis situations
3. Patients feel weak or distressed
4. Differences in the desire for involvement

 

Consent

1. Definition—When two or more persons agree upon the same thing in the same sense they are said to Consent.

(section 13 of Indian Contract Act, 1872)

 

Who can give consent?

1. Any person who is conscious,
2. Mentally sound and
3. >12 years of age

 

When a consent is not valid?

1. Under fear
2. Fraud
3. Misrepresentation of facts
4. By a person who is ignorant of the implications of the consent
5. Who is under 12 years of age is invalid?

 

Depending upon the circumstances in each case Consent may be

1. Implied
2. Express – verbal / written
3. Informed

 

Doctors Communication skills

1. Patients perception of inadequacies of communication arise from.
2. Content skills – what doctors say, e.g., the substance of the questions asked, the answers received, the information given, the differential diagnosis list, and the doctors medical knowledge base.
3. The content of communication is influenced by a number of practical and situational factors (time available, initial or subsequent visit, private patient).
4. Process skills – how doctors say it, e.g., how the doctor asks questions, how well he listens, how he sets up explanation and planning with the patient, how he structures his interaction and makes that structure visible to the patient through signposting or transitions &how he builds relationships with patients.

 Barriers In Communication 

Barrier to effective communication

1. Lack of specific knowledge
2. Lack of counselling skills
3. Lack of time
4. Lack of appropriate resources
5. Sex
6. Social and educational level
7. Different languages
8. Membership of an ethnic minority

Doctor-Patient relationship In The Past

1. Paternalism
2. Because physicians in the past were people who have higher social status
3. “doctor” is seen as a sacred occupation which saves people’s lives
4. The advices given by doctors are seen as Paramount mandate

 

 Doctor-Patient relationship At Present 

1. Consumerism and mutuality
2. Patients nowadays have higher education and better economic status
3. The concept of patient’s autonomy
4. The ability to question doctors

 

 Improving Doctor Patient Relationship 

1. Active Listening
2. Nonverbal Communication
3. Agendas
4. Empathize
5. Educating Patients
6. Active Listening
7. Nonverbal Communication
8. Agendas
9. Empathize
10. Educating Patients

 

Conclusion

1. The doctor-patient relationship is at the core of the practice of healthcare.
2. Essential for the delivery of high-quality health care in the diagnosis and treatment of disease.
3. The Doctor-Patient Relationship itself is part of the therapeutic process.
4. Many issues may complicate or negatively affect the doctor patient relationship if not taken properly into consideration.