Doctor-patient relationship

C H Chen

Why bother

Important

Essential component of medical care

Patient satisfaction

Patient participation

Outcome of the medical care

Sackett 1976 / Reynold 1979 / Ley 1978

Only around 50% patients adherent to treatment prescribed.

Forgetfulness

Misleading information

Poor DPR

Others

94‘ Lo et al, 40 % of patients go doctor shopping

93’ Joss & associates Patient who will less satisfied with their physic

ian if desire is not met Emotional, family aspect, wanted information Same for patient with chronic disease

Lancet ( march 2001 )

Study on 25 survey on DPR

Good bed side manner had better impact than physician who were less personal

Significantly influencing the outcome

Example

Case example in MPF case book

Example ( MPF )

Doctor received a request for home visit by a mother of a 7-year-old boyThis boy got headache, fever and possible deliriumDiagnosed viral illnessConcerned that the boy seemed to be more confused than a temp. of 38 degree

Recommended for hospitalization

According to doctor, the family assured him that they would make their own transport arrangements

He notified the hospital of the patient’s impending arrival

During home visit, the doctor was asked to examine the other family members It was alleged that he refused to do soThe young boy and his sister were admitted to hospital, a diagnosis of carbon monoxide poisoning was madeThe mother and the grandmother were admitted to hospital on the following days with same diagnosis

Apparently caused by an incorrectly fitted boiler in the family homeAccording to the doctor, he had not refused but explained that , as he would need to return to his car to get further forms for the other three patients.He claimed that the family then told him ‘not to bother’

It was alleged that the doctor did not exercise reasonable care for the health and safety of the family

He failed to diagnose carbon monoxide poisoning in the young boy of to direct that he be taken to hospital by ambulance

He also failed to consider that other members of the family may be affected by the same condition

Discussion

Why claims arised

Could it avoided

How is the DPR

improvement

DPR

Dynamic

Subject to change ( improved / deteriated )

A process (takes time to develop ) rather than takes for granted

Involves psychodynamic, behavioural and sociological perspective

At best, DPR should be one of the trust, mutual respect and empathy

DPR

Something more than common courtesy and concerns

Social rather than professional skills

components

Patients’ expectation

>Mass media

>Peers

>family/relatives

>Personal experience

Transference

A phenomenon readily ascribed to psychotherapy, occurs when we respond to a new relationship according to patterns from the pastTendency for us to carry over into the present attitudes and impressions gained from similar past experiences Could be positive or negativeInvolves in making relationship

components

Patient’s needs

Perception

Beliefs

Religious culture

Identify the key person

Others could be helpful in making good relationship with the patient

Components

Doctor Self esteem Counter-transference ( the feelings that

doctors have towards their patients )

Models

Szasz and Holleder 1956 Activity – passivity

: acute illness Guidance – cooperative

: less acute illness Mutual participation

: chronic illness

Models

Stewart & Roter ( 1989 )

Paternalistic

Mutual participation

Default

Consumerist

Models

Negotiation models newer perspective seen as patients have

negotiating rights Consumerist perspective Patients better informed Expect their own concerns to be addressed If not, patient evaluation of consultation poor

and satisfaction is low

Negotiation model

Reflecting the growing consumer orientation of health care

Patient being viewed as having rights to Fair Considerate treatment Information Consideration of their needs

Negotiation model

Patient satisfactory measure

Difficult patient

example

Mr. Kwan

Only son in his family

40 years old

lawyer

Mrs. Kwan

Also only son in her family

37 years old

History of 3 consecutive miscarriage

Only son > Paul

Mild puerperal depression

Paul

The only son

Bought to your clinic for 1 day history of fever

Cough and vomiting

Reassured with diagnosis of viral infection

Symptomatic treatment

Paul

Vomit violently at that night

Subsequently convulsed

Admitted and remained unconsicious

Dx.> viral encephalitis

You have been rung by physician for history this morning

Mr. Kwan

Comes today without appt.

Demands to see you right away !

Role play

Difficult patient

What you expect

Anger

Grief

Sadness

Anxiety

Quilt feeling

A mixture of these

Address the patient

Invite the patient into your consultation roomAddress him with appropriate nameShow your concern ( eg. Facial expression)Quickly assess the non-verbal communication Active listening

Listen

Encourage the patient to sit down and then sit yourselfBetter than talk, don’t interruptsMaintain eye contactShow your concern by using appropriate non-verbal behaviourLet patient ventilate and tell the part of the story

Listen

Don’t argue

Don’t be defensive

Explore the reason for angering

Show empathy

Understanding the feelings of the patient

Tell him our understanding and check if he accepts your understanding

Apologize

Apologize for causing another’s feeling is different from apologizing for being wrong

Establishing rapport

Validate the person’s behaviour

Offer support non-judgmentally

Do

Listen

Be calm

Be comfortable

Show interest and concern

Be conciliatory

Be genuine

Allay any guilt

Do

Be sincere

Give time

Arrange follow up

Act as a catalyst and guide

Don’t

Touch the patient

Meet anger with anger

Reject the patient

Be a ‘wimp’

Evade the situation

Be overfamiliar

Talk too much

Don’t

Be judgemental

Be patronising

Improve DPR

Privilege Accessibility Personal care as a whole Family care Comprehensive Continuing care

Improve DPR

Empathy

Sympathy

Honesty

Respect both the patient and the assoicates

Erich Fromm’s ‘the art of loving’

Concern

Responsibility

Respect

Knowledge

Demanding patient

Eg. asks for SL

Demanding patientaltitude

Be calm

Non-judgmental

Show empathy

Acknowledge

Show willingness to help

Be ready to listen

Demanding patientaction

PhysicallySocially ( family, work, finance, social support ) Psychologically ( anger, demanding behaviour)Explore > low self esteem, poor coping skill, depression, secondary gain, idea of concern, misconceptionSet limit to the demand with reasonsCome to an agreementFollow up for progress

Psychosomatic patient(somatic symptoms with emotional stress )

Feeling understood

Full history and physical exam

Explore Emotional clues Social and family factors Health beliefs, concerns,

misconception, expectation, secondary gains, ticket of admission

Broaden the agenda

Feedback the results of assessment

Acknowledges the reality of symptoms

Link physical to psychological events ( re-attribution method )

Reframe the complaints with psychosocial life events

Link symptoms to psychological problems

Simple explanation ( low threshold for headache in anxious patient )

Demonstration ( painful when holding weigh with extending hand )

Projection of identification ( know persons who responded similarly )