doctor-patient relationship and initial patient interview michael blumenfield, m.d. professor of...
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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
The Interview Process The Interview Process INE HRAA-VF- WAY5 To MAV WE mvF- WAY5TOMA14F- ~ WE RA.VF-
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