Doctor-Patient relationships express the values of medical profession.
The relationship should not be fish and fisherman.
It should always be like fish and water.
2. Learning Objectives.
• Introduction.
• Why does it matter?
• Types of relationships.
• What is the ideal patient-physician relationships ?
• Ethical Models of Physician-Patient Relationship.
• Relationship of the 21st century
• Conclusion.
Physician-Patient Relationship
3. INTRODUCTION
• Doctor-Patient relationships
express the values of medical
profession.
• The relationship should not be
fish and fisherman.
• It should always be like fish and
water.
Physician-Patient Relationship
4. Hippocrates viewed the physician as 'captain of the ship' and
the patient as someone to take orders
Physician-Patient Relationship
5. Why Does It Matter
• The patient-physician relationship is fundamental for
providing and receiving,
– Excellent care
– To the healing process
– To improved outcomes
• Therefore, it is important to understand what
elements comprise the relationship and identify
those that make it "good."
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
6. Why Does It Matter
• Because of the rapidly changing environment
that characterizes health care today,
• We need to understand what physicians and
patients must do to protect and nurture the
relationship.
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
7. The Patient
• Patients are individual human beings with problems that all to
often transcend their physical complaints.
• The patient are not „cases” or „admissions” or „diseases”
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
8. Parsons’ model
• The nature of relationships determines
the success of the
treatment/intervention.
• PARSON was one of the earliest
sociologist to examine the patient
doctor relationship.
• He regarded illness as a form of social
deviance (impairs normal role
performance, affects smooth
functioning of the society).
• The amount of illness is controlled by
socially prescribed roles for doctors
and patients.
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
9. Parsons’ model
• Parson saw the doctor and patient as fulfilling
necessary functions in a well balanced and
maintained social structure
• Sickness is considered to be necessary,
providing a brief exemption for patient from
social responsibilities
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
10. 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
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
11. Parsons’ “ Ideal Doctor”
Apply a high degree of-
skill and
knowledge
Acts for the good of the patient
Remain objective and
emotionally detached
Respect the position of privilege
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
12. DOCTOR’S ROLE.
• Health care provider.
• Technical consultant.
• To convince the necessity of
medical services.
• A tendency for the “Consumer to
be right.”
Physician-Patient Relationship
AB.RAJAR/drabrajar@gmail.com
13. DOCTOR COMPETENCIES
• Patient care.
• Medical knowledge.
• Practice-based learning (PBL) and
improvement.
• Interpersonal skills.
• Communication skills.
• Professionalism.
• System-based practice.
Physician-Patient Relationship
AB.RAJAR/drabrajar@gmail.com
14. Patient’s role.
• Health shoppers indicators of
consumer behavior
• Cost consciousness.
• Information seeking.
• Exercising independent
judgment.
• Consumer knowledge.
Physician-Patient Relationship
AB.RAJAR/drabrajar@gmail.com
15. CONFLICT OF INTEREST
• Interests of patient Vs society.
• Interests of patient Vs other patients.
• Problems of confidentiality.
Physician-Patient Relationship
AB.RAJAR/drabrajar@gmail.com
16. The Physician Charter.
Principle includes:
– Patient welfare.
– Patient autonomy.
Commencements Includes:
– Honesty with Patients.
– Patient confidentiality.
– Maintaining appropriate
relationships with patients.
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
17. PATIENTS BELIEFS & EXPECTATIONS
• Influenced by:
1. Previous experience.
2. Literature.
3. The media.
4. Family and friends.
5. Cultural influences.
6. Social significance.
These beliefs influence in outcome.
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
19. 1.Paternalism
• Traditional form of doctor-patient relationship
• Doctor takes on role of parent
• Doctor is the expert and patient expected to cooperate
• Tightly controlled interviewing style aimed at reaching an
organic diagnosis
• Passive patient and a dominant doctor
• Focus is on care, rather than autonomy
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
20. PATERNALISM
• Making of decisions by professionals on behalf of patients.
• Dirty word-OUT-AUTONOMY- is IN.
– Liberty,diginity,individuality,independence,accepting responsibility, self assertion,
knowledge of one’s own interests,privacy,voluntarieness,freedom from
deception.
Physician-Patient Relationship
AB.RAJAR/drabrajar@gmail.com
21. The Paternalistic Approach
“If I’ve told you once I told you
1,000 times, stop smoking!!”
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
22. Advantages
• The supportive nature of paternalism appears to be
important when patients are very sick at their most
vulnerable
• Relief from the burden of worry is curative in itself, and the
trust and confident implied by this model allows doctor to
perform “medical magic”
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
23. 2.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
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
24. 2.Mutuality Cont...
• Patients need to define their problems in an open and full manner
• The patient has right to seek care elsewhere when demands are not satisfactorily
met.
• 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
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
25. 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
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
26. Disadvantages
• Physicians do not know what certain degree should they
reach in communication
• Is the patient capable of making the important
therapeutic .
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
27. 3.Consumerism
• We can simplify the complicated relationship with “buyer and seller”
relationship, is it good or bad? What is your opinion?
• The patient can challenge to unilateral decision making by physicians in
reaching diagnosis and working out treatment plans
• Reversing the very basic nature of the power relationship.
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
28. 4.Default
• When patient and physician expectation are at odds, or when
the need for change in the relationship cannot be negotiated,
the relationship may come to a dysfunction standstill.
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
29. Patient Centred consultation style
• Dr is less authoritarian , encourages patients to express their own
feelings and concerns , empathic , listen more than talk .
• Dr use open end questioning , show interest in psycho-social aspect of
patient’s illness .
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
30. Length of Consultation
Average 8 minutes
makes...
– Patient centred
consultation styles
more difficult.
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
31. Consultation style.
It’s serious, isn’t it doctor ?
• Sustained physician patient
partnerships with bonds of trust
and knowledge of patients were
correlate of three outcomes of
care…
– Adherence.
– Satisfaction.
– Improved health status.
Physician-Patient Relationship
32. Types of Dr-Pt relationship
Doctor controlled
Patient controlled
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
33. Prototypes of doctor-patient relationship
Physician
control (Low)
Physician
control (High)
Patient control
(Low)
Default Paternalism
Patient control
(High)
Consumerism Mutuality
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
36. PETERNALISTIC MODEL
• Principle.
– The doctor should make all the decisions for the patient.
• Assumptions.
– People are not always rational/mature.
– Experts knows better about the needs of patients.
– Qualified doctors have good will.
• Sources:
– Hippocratic oath.
• Problems:
– Are the needs of patients objective?
– How can we be sure that doctors have good will?
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
37. 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 results.
– What is good for a patient depends on what his/her personal
values.
– Consumerism.
• Problems.
– What if patient is unconcious,incompetent and making choices
totally unacceptable by our ethical standards?
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
38. 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.
• Limitations.
– All that a doctor can do is to help the patient see his/her own
desires/values more clearly, but not to criticize them.
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
39. DELIBERATIVE MODEL
• Principle.
– The doctor should help the patient to deliberate well through dialog and
discussion, and ,
– So develop values which are objective and truly worthy.
• Assumptions.
– The objectivity of values.
– The patient’s good life consist not in the satisfaction of desires, but
maturity and rationality.
• Problems.
– Is the model different from the paternalistic model?
– What is the difference b/w dialog and persuasions?
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
41. Doctor-patient relationship in the past
• Paternalism
– Because physicians in the past were
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
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
42. 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.
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
43. Principal elements that are essential to the relationship
1) Communication.
2) Office Experience.
3) Hospital Experience.
4) Education.
5) Integration.
6) Decision-Making.
7) Outcome.
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
44. Communication and Treatment
• Advice reassurance and support
from the doctor can have a
significant effect on recovery.
• The placebo effect
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
45. Communication with pt includes
An integrated approach to information gathering.
Seeking to identify physical psychological and social factors
Will likely to produce a better outcome of health care.
Physician-Patient Relationship
AB.RAJAR/drabrajar@gmail.com
46. Elements of Communication
• Seven Essential Elements in Physician-Patient Communication
– Build the doctor-patient relationship
– Open the discussion
– Gather information
– Understand the patient’s perspective
– Share information
– Reach agreement on problems and plans
– Provide closure
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
47. Gathering data to understand the patient
• Nonverbal skills
– Attentive and interested body
posture
– Facial expression
– Appropriate eye contact
– Touch
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
49. Who are “difficult” patients?
What characteristics make a patient “difficult”?
– Mental health disorders
– Multiple symptoms
– Chronic pain
– Functional impairment
– Unmet expectations
– Lower satisfaction with care
– High users of health care services
Dr. Tom O’Dowd coined the term “heartsink patient”
BMJ, 1988
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship
50. Conclusion
• Relationship between patients and doctors are often
unstated, and they 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”.
• effectiveness of the patient-physician relationship
directly relates to health outcomes.
AB.RAJAR/drabrajar@gmail.com
Physician-Patient Relationship