Building Effective Doctor-Patient Relationships

Patient - Doctor
relationship
Dr KSR Prasad
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda

Introduction
• Doctor – Patient
relationships express the
values of medical profession
• The relationship should not
be the fish & fisherman
• It should be always like fish
and water
Patient - Doctor relationship
01

Parsons’ “ Ideal Doctor”
 Apply a high degree of –
skill and
knowledge
 Act for the good of the
patient
 Remain objective and
emotionally detached
 Respect the position of
privilege
02

Doctor’s role
• Health care providers
• Technical consultant
• To convince the necessity of
medical services
• A tendency for the
“consumer to be right”
03

Doctor Competencies
• Patient Care
• Medical Knowledge
• Practice-Based Learning (EBM) and
Improvement
• Interpersonal Skills
• Communication Skills
• Professionalism
• Systems-Based Practice
04

Patient’s role
• Health shoppers Indications
of consumer behavior
• Cost-consciousness
• Information seeking
• Exercising independent
judgment
• Consumer knowledge
05

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
06

Consumerism
• The patients’ challenge to
unilateral decision making by
physicians in reaching closure
on diagnoses and working out
treatment plans
• Reversing the very basic nature
of the power relationship
07

Conflict of Interest
• Interests of patient Vs society
• Interests of patient Vs other patients
• Problems of confidentiality
08

The Physician Charter
Principles include:
• Patient welfare
• Patient autonomy
Commitments include:
• Honesty with patients
• Patient confidentiality
• Maintaining appropriate
relationships with patients
09

• - in Physician-Patient Communication
1. Build the doctor-patient relationship
2. Open the discussion
3. Gather information
4. Understand the patient’s perspective
5. Share information
6. Reach agreement on problems and plans
7. Provide closure
10
Seven Essential Elements

Etiquette Based Medicine
Checklist for first meeting with a hospitalized
patient:
• Ask permission to enter the room /interrogation ;
wait for an answer
• Introduce yourself, showing ID badge
• Shake hands /greeting (wear gloves if needed)
• Sit down, Smile if appropriate (relax your self and
make patient relaxed)
• Briefly explain your role on the team
• Ask the patient how he/she is feeling about being in
the hospital & about the treatments
Kahn MW, N Eng J Med, 2008
11

Length of Consultation
• Makes patient
centred
consultation
styles more
difficult.
12
Average 8 minutes

Consultation Styles
It’s serious isn’t it doctor?
• Sustained physician-
patient partnerships with
bonds of trust and
knowledge of patients
were correlates of three
outcomes of care
– Adherence
– Satisfaction
– Improved health
status
13

Doctor-Patient Relationship Linked to Outcomes of Care
Safran DG et al, J of Fam Practice, 1998
Rate from 0 to 100…
1. Communication
2. Compassion
3. Respectfulness
4. Responsibility
SCALE
100-Best Possible
90-Excellent
80-Very Good
70-Good
60-Above
Average
50-Average
40-Below
Average
30-Poor
20-Very Poor
10-Terrible
0-Worst Possible
14
Evaluation key
(to be rated by patient)
Communication:
• How well this doctor communicate with
you and your family
• Did doctor answer your questions?
Compassion:
• Was the doctor is sensitive to you and
your family needs?
Respectfulness:
• Did the doctor ask and respect your
choices about your care
Responsibility:
• Did you feel the doctor acted
appropriative on your behalf?

Doctor-patient relationship in the past
• Paternalism
– Because physicians in the past are 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
15

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
16

Patient influences on consultation
• The patient’s ability to
exercise and control
depends on a number of
factors:
– Social
– Educational level
– Sex
– Membership of an ethnic
minority
17

Patient controlled consultation
“You’re paid to do what I
tell you!!”
18

Patients beliefs and expectations
Influenced by:
1. Previous experience,
2. literature,
3. the media;
4. Family and friends;
5. Cultural influences;
6. Social significance.
These beliefs influence outcomes
19

Prototypes of doctor-patient relationship
Physician
control (Low)
Physician
control (High)
Patient control
(Low)
Default Paternalism
Patient control
(High)
Consumerism Mutuality
20

Ethical models at a glance
–Paternalistic model
–Informative model
–Interpretive model
–Deliberative model
21

Paternalistic model
• Principle
– The doctor should make all the decisions for a patient.
• Assumptions
– People are not always rational/mature.
– Experts know better about the needs of patients.
– Qualified doctors have good will.
• Sources
– Hippocratic Oath; Plato.
• Problems
– Are the needs of patients objective?
– How can we be sure that doctors have good will?
• Objection and modification
– John Stuart Mill’s liberal principle
22

The Paternalistic Approach
“If I’ve told you once I
told you 1,000 times,
stop smoking!!”
23

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 result.
– What is good for a patient depends on what his/her personal
values.
– Consumerism.
• Problems
– What if the patient is unconscious, incompetent, and making
choices totally unacceptable by our ethical standards?
24

The 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.
• Sources
– Sigmund Freud; hermeneutics.
• Limitation
– All that a doctor can do is to help the patient see his/her own
desires/values more clearly, but not to criticize them.
25

The deliberative model
• Principle
– The doctor should help the patient to deliberate well through dialogue
and discussion, and
– so develop values which are objective and truly worthy.
• Assumptions
– The objectivity of values.
– The patient’s good life consists not in the satisfaction of desires, but
maturity and rationality.
• Source
– Aristotelian ethics
• Problems
– Is the model different from the paternalistic model?
– What is the difference between dialogue and persuasion?
26

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
27

Mutuality - Patient’s role
• Patients need to define their problems in an
open and full manner
• The patient’s right to seek care elsewhere
when demands are not satisfactorily met
28

Mutuality - Doctor’s role
• 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
29

Mutuality - 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
30

Mutuality - Disadvantages
• Physicians do not know what certain degree
should they reach in communication
• If the communication is fake, -
– both physicians and patients do not have mutual
understanding,
– making decision is overwhelming to a patient
31

Mutuality - Discussion
• Is the patient capable of making the important
therapeutic decision even though they have
good communication of the physician?
32

Do – Don’ts
• Do not toss the treatments for
a patient
• Make always reliable advises
and practices
• Assuring the patient is first
choice of – placebo treatment
– But it should never be false
assurance
• Authentic tested managements
(EBM) are advised
33

Conclusion
• Relationship between patients
and doctors are often unstated,
and thy 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”
34

Thank you
• Dr KSR Prasad
35

Building Effective Doctor-Patient Relationships

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