Doctor-Patient Relationship and Initial

Patient Interview

Michael Blumenfield, M.D.Professor of Psychiatry - NYMC

Director of Medical Student Education in Psychiatry

Director of C/L Psychiatry - Westchester Medical Center

“...Some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician.”HippocratesPrecepts, Chapter I

Placebo Effect

Placebo Effect is a combination of a psychological expectation blended with a neurochemical response that transforms an anticipated effect into a real effect

Placebo Effect

The Placebo Effect can positively or negatively effect pain, swelling, GI, CV, GU responses, mental state and side effects of treatment

Placebo Response

At least 20-30 % of patients have been shown to respond to treatment with placebo

Placebo pain response can be blocked by naloxone which suggests it is mediated by the endogenous opioid system

Transference

Expectation, beliefs and emotional responses that the patient brings to the doctor-patient relationship based on important relationships in the patient’s past

Positive Transference

Patient views doctor as good and has confidence in his or her ability

Can lead to over idealization and tremendous disappointment when doctor can’t solve all problems or is not always available

Positive Transference

Idealization of the the doctor can lead to having sexual feelings toward the doctor

Negative Transference

Patient views doctor as harsh punitive parent or authoritative figure who doesn’t care about well being and patient may be non-compliant

Negative Transference

Patient with experience with untrustworthy parent may seek many consultations and may be provocative to doctors

Countertransference

Refers to doctor’s reaction towards patient based on their own earlier experience

Countertransference

Doctors can feel guilty when they are unable to help patient

Doctor may have feelings towards patient who remind them of close relative or friend

Doctor may minimize the severity of another physician’s illness

Models of Doctor Patient Relationship

Model Physic ian'sRole

Patient'sRole

Application Prototype

Activity-Passivity

AutocraticWarm/detachedDominant

Passive Critical care oracutePatient needsstrong figure

Parent-InfantParent-Child

Guidance-Cooperation

Warm/detachedMakes plansAdvisesInformative

Cooperatesbut may begivenchoices

Above but morelikely subacute,chronic care &minor illness

Parent-ChildParent-Adolescent

Mutual-Partic ipation

Usually warmDiscusses planInteractiveHelps patienthelp selfInterpretive

Patientusesexpert butis active inown careInteractive

Possible withmost of above-more likely inchronic careandpsychotherapy

Elements ofabove butmostlyAdult-Adult

Doctor-Patient RelationshipAlternative Models

Model Physician'sRole

Patient'sRole

Application

Consumer Warm/detachedProvidesinformationAnswersquestions

Primarydecision makerInfluenced bythird party

Third Partyapproval isessential

Friendship Blurring of boundariesMutual sharing of personal information and valuesCan be quite dysfunctional if relationship becomesmain goal of interaction

Empathy

The ability to momentarily experience the the feelings of another person ( put yourself in another person’s place)

Empathy -Components

Transiently experience feelings of the patient and use those feelings to gain understanding of the the patient’s subjective experience

Communication of that understanding to the patient

Empathy-Techniques of Learning

Intuitive - Reflect on emotions when with patient

Cognitive - Ask self how would I feel in patient’s situation

Cognitive- Relate to similar situation in own life ( ie. threat to you or a parent)

Empathy- Examples of empathic responses

You seem understandably upset with how things are going

It must have been very painful after the injury until you received pain medication

I am sorry (when learning of death of family member or friend of patient)

Clinical Interview

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Clinical Interview

Be Polite Introduce yourself to patient Make the patient comfortable Initial Question-Invite the patient

to tell you how he or she came to be in the hospital (chief complaint )

Clinical Interview

Listen to patient- Don’t interrupt patient especially at the beginning of the interview

Begin each topic with open ended question and close with detailed specific question

Clinical Interview

Pay attention to patient’s associations so you can return later to get more information

Be empathic- Respond to patient’s emotional reactions

Usual Order of Interview

Chief Complaint History of Present Illness-

Elaborate all aspects of symptomsAggravating factorsAlleviating factorsAssociated manifestations

Past Illness Review of Systems

Usual Order of Interview

Mental Status Exam ( especially in psychiatric patients )

Let’s Go To The Video Tape !!!

Doctor-Patient Relationship and Initial

Patient Interview

Michael Blumenfield, M.D.Professor of Psychiatry - NYMC

Director of Medical Student Education in Psychiatry

Director of C/L Psychiatry - Westchester Medical Center