doctor-patient relationship c h chen. why bother important essential component of medical care...
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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 )