1. The Doctor-patient relationship

2. Doctor Patient Relationship
At the end of this lecture you should be able to
Social roles of doctors and patients ( parson’s model of the sick role and doctor’s role)
Discuss the traditional view of the doctor‑patient relationship and the potential problems with it.
Describe the different types of doctor‑patient relationships from the paternalist to the shared and consumerist approach.
Explain the concepts of shared decision making and concordance and their relevance to medical practice

3. Introduction
It is an emotional association (clinical encounter) between the doctor and a patient which arises when the doctor in a professional capacity ; interact with the patient
The relationship begins when a person who is ill or believe that he is ill consult a doctor.
The success or otherwise depend on various factors including the nature of the relationship that exist between the doctor and the patient.

4. What is Doctor-Patient Relationship?
It is usually related to clinical events, but it is important to realize the association beyond the clinical premise e.g in the community (non clinical situation)
Such meetings are a frequent & regular occurrence
Depends not only on Drs’ clinical knowledge & skills but also the nature of the social relationship that exists between the DR & Patient

5. What is Doctor-Patient Relationship?
The Doctor and The Patient are on two opposite ends
The Doctor has a high level of knowledge on a problem the patient almost knows nothing about
The Doctor is often mechanistic (find and fix approach)
The patient is concern with illness (disruption of life)
But its entirely different from mechanic-client relationship

6. Social roles of doctors and patient
Occupying social role which facilitate interaction as they define the expectations and obligations of each participant.
Ensure that patients return to health and normal role performance as soon as possible.

7. DPR-Why is it relevant to us?
Because of our understanding of:
The Clinical Iceberg phenomena
The decision making process in illness behavior
The social triggers of decision to seek medical aid

8. PERCEPTIONS OF NEED:
Refers to the gap between the need for medical care and the utilization of professional services.
Health care professionals only see the tip of the iceberg with respect to the volume of illness in the community

9. THE CLINICAL ICEBERG
Public’s perceived need
for care

10. ICEBERG THEORY Self-med, No symptoms
Public’s perceived need for care
Symptoms Do
nothing
Note the difference between actual and perceived need
Alternative med
Self-med,
No symptoms

11. PARSONS’ MODEL OF SICK ROLE.

12. Parson’s model of the sick role and doctor’s role
As Sick person
Obligations and privileges
Doctor’s role
Expectations and right
Outcome
Restore a healthy status and normal role performance as quickly as possible resulting in a smooth functioning of the society.

13. Parsons’ “Ideal Patient” (Sick Role)
Rights (Permitted) to:
Give up some activities and responsibilities
Regarded as being in need of care and unable
to get well by his own decision & will
Obligations (In Return) :
Must want to get better quickly
Seek professional medical advice
Parsons, 1951

14. Patient who is sick Obligations and privileges
Motivated to get well as quickly as possible
Should seek professional medical advice and cooperate with the doctor.
Exemptions from normal activities and responsibilities( type depends on severity of illness)
In need of care and unable to get better by his or her own decisions and will.

15. Doctor: professional role
Expectations
Be guided by rules of professional practice
Applying a high degree of skill and knowledge to the patients
Granted right to examine patients physically & to enquire into intimate areas of physical & personal life
Granted considerable autonomy in professional practice
Occupies position of authority in relation to the patient
Act for welfare of the patient and community rather than for own self-interest.

16. Problems with Persons’ model
Address acute problems (ignores chronic dx: imagine a cancer patient on medical leave for 10 year!)
Clinically oriented
Centered on individuals
Rights do not always apply

17. Types of doctor- patient relationship
Paternalistic relationship
Mutual relationship
Consumerist relationship
Default relationship

18. Paternalistic relationship
Traditionally characterized medical consultation
High physician control and low patient control
The doctor is dominant and takes on role of “parent”
Patient submissive
Shift towards Mutuality

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

20. MUTUAL PARTICIPATION MODEL Regarded as optimal DPR
Active involvement of patients as more equal partners (‘meeting of experts’)
Both parties share power and responsibility, exchange of ideas & sharing of belief systems, need each other and will work towards choices and actions satisfying to them both
Open questioning, interested in psycho-social aspect of illness history & examination investigation results in a diagnosis
Hence there is integration

21. A consumerist relationship
The patients take the active role and the doctor assume a fairly passive role.
Trying to satisfy the patient need in term of referral to the hospital, usage of medication and sick leave.

22. Consumerism Patient controlled consultation
“You’re paid to do what I tell you!!”

23. Relationship of 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
Passive role by the patient and the doctor
Lack of sufficient direction in consultation
Ineffective in dealing with the illness.
Commonly occur in managing chronic illness e.g. diabetes mellitus and hypertension,

24. Patients beliefs and expectations
Influenced by: Previous experience, literature, the media; Family and friends; Cultural influences; Social significance. These beliefs influence outcomes

25. Influences on DPR Doctor’s orientation and practice style
Focus on the disease centered model – symptoms, diagnosis and treatment.
Traditional medical training, doctor is the expert and patient merely required to cooperate
Current approach –patient centered -is to consider the psychosocial aspect of an illness, their experience , impact of illness and everyday activity, diet etc
Increasing emphasis on holistic approach-listen to the voice of patient.

26. Influence of time
Shortage of time is a major constraint – paternalistic approach
Less attention paid to social and psychological aspect
Unnecessary prescription issued
Increase in the number of visits
Thus more time required for participative patient centered consultation, listen to patient’s worries and concern

27. Influence of structural context
Influence by healthcare financing and local health system
Private sector- (fee for service) spend more time with patient, greater availability of resources
Need to achieve higher level of patient satisfaction
GP - know the patient, past history, social situation etc
Public – rapid turn over, different doctors, salaried basis
Continuity of healthcare givers.
Development of patient’s charter.

28. Patient’s expectation and participation
Younger generation has a higher expectation than the older generation
Patients with a high social and educational level has a higher expectation and participate more
This is due to higher knowledge and confidence

29. Partnership in decision making
Three models in decision making
All corresponds with the three type of DPR
Paternalist – doctor solely responsible
Shared- share information, take steps to build a consensus for treatment -ideal
Informed decision making – drs inform the risk and benefits and the patient makes the decision.

30. DOCTORS'
COMMUNICATION SKILLS

31. Common complaints about doctor’s communication
Doctors do not listen
Will not give information
Show lack of concern
Show lack of respect for patient
Thus many leave without asking questions

32. COMMUNICATION
Between doctor and patient
Foundation for diagnosis and treatment (elicit & convey information)
Relationship has a therapeutic effect placebo effect of drug
Doctor-centered consultation (Paternalistic style)
‘Closed’ nature questions e.g. “How long have you had the pain? & is it sharp or dull?”
Diseased centered model talk

33. COMMUNICATION
Between doctor and patient
‘Patient-centered’ approach (Mutuality)
Encourage & facilitate their patients to participate
Use of ‘open’ questions e.g. ‘tell me about your pain’, ‘how do you feel? & ‘what do you think is the cause of the problem?’
Active listening skills, requires more time (participative style)

34. Good Communication Skills In Consultation
Initiating the session ( initial rapport )
Gathering information (exploring the problem, understanding the patients views)
Building the relationship (involving the patient)
Explanation and planning (providing the appropriate amount & type of information, aiding accurate recall and understanding, achieving a shared understanding and planning)
Closing the session

35. Patient’s perception of good communication
Patient observant and sensitive to non verbal communication
For illness involves fear, anxiety and emotional uncertainty
They look for clues to assess their situation
So what should you do?
Maintain eye contact
Look attentive
Nod encouragingly and other gestures
Facilitate their participation
Physical proximity and relative positions of dr/patient

36. How do you assess good communication
Patient’s body language
Eye contact
How he/she is feeling
Tense
Uneasy
Anxious
Angry or upset

37. Why is there poor communication?
The influence of class and status
Professional attitudes and interviewing styles
Professional power

38. Advantages of improved communication
Compliance with medical instructions and advice
Low compliance Dr who do not seek pts’ active participation in the interview, are formal and distant in their mx of the pt by providing little in the way of feedback
2. Satisfaction with health care
Goals of pt – dx and tt of any problems, relief of fear & anxiety
3. The social dimensions of healing
Benefits of improved DPR – satisfactory recovery
Significance of EMPOWERMENT

39. Challenges in special situations
Language barrier especially with foreigners
Disclosing diagnosis of cancer or other sad news
Disclose or with hold?
Depends on the doctor, patient and family
Now most of them want to know the truth about their illness.

40. Shared knowledge about diseases and how they are related
The importance of a good
PATIENT DOCTOR RELATIONSHIP
lies in the :
Confidence
Trust
Knowledge
Shared knowledge about diseases and how they are related

41. What brings patients to the clinic?
Tolerance Limit
Anxiety Limit
Symptoms
Prevention
For administrative Reasons

42. What do patients look for in a doctor?
Honesty
Accuracy
Competence
Humaneness
Openness
Responsible
Responsive
Trust
What do patients look for in a doctor?

43. The success of a good Doctor Patient Relationship is related to
Amount of Information
Quality of Information
Accuracy of Diagnosis
Effective Treatment
Compliance

44. Physician superiority Perspective and Traditions
Factors that affect a good relationship:
Age
Sex
Physician superiority
Cost Benefit Ratio
Formal or Casual
Perspective and Traditions
Mental State
Patient Context

45. Changes in Doctor Patient Relationship
Individual DPR is replaced by relationships with different members of the primary care team/ hospital.
New methods involving patients
Interactive multimedia systems provide the information they want.
Widespread use of computers in consultation
Greater access to internet, communication via google group/ /facebook
Use of telemedicine/ teleconsulting from homes

46. IN SUMMARY
Relationships based on openness, trust and good communication will enable you to work in partnership with your patients to address their individual needs.
To fulfil your role in the doctor-patient partnership you must:
a. be polite, considerate and honest
b. treat patients with dignity
c. treat each patient as an individual
d. respect patients' privacy and right to confidentiality
e. support patients in caring for themselves to improve and maintain their health
f. encourage patients who have knowledge about their condition to use this when they are making decisions about their care.

47. PATIENT SATISFACTION CONTINUITY GOOD OUTCOMES
HOW TO FIND OUT IF IT WAS A GOOD DOCTOR PATIENT RELATIONSHIP
PATIENT SATISFACTION
CONTINUITY
GOOD OUTCOMES