Presentation on Doctor-Patient Relationship

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Presenter: Dr Girish J
AIIMS, New Delhi
The Doctor - Patient Relationship

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Outline
• Introduction
• Parson’s model of sick role and Doctor’s role
• Types of Doctor patient Relationship
• Influences On The Doctor–patient Relationship
• Improving Doctor Patient Relationship
• Communication skills
• Doctor- Patient relationship: Present and past
• Conclusion

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Introduction
• This is a unique social relationship where bonding is planned with the
ultimate objective of assisting the patient to achieve treatment goals.
• This approach requires the doctor to take on the responsibility of
directing , effecting and maintaining the therapeutic relationship,
exhibiting a professional and ethical approach
• Parsons (1951) was one of the earliest sociologists to examine the
relationship between doctors and patients
• Parsons regarded illness= social deviance (impairs normal role
performance, affects smooth functioning of thesociety)

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Parsons’ analysis of the roles of
patients and doctors

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Conflicts in the doctor’s role
• Doctors serve the state as agents of social control in
their role as gatekeepers with authority to
determine who is ‘healthy’ and who is ‘sick’
• Interest of a patient vs state (Medical leave certificate,
notification)
• Doctors own values vs patients
• Individual patient’s vs community (CAB surgery to non
smokers than smokers i.e. rationaling the resources)
• Confidentiality vs disclosing (HIV status, Epilepsy)

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Psychosocial and clinical
outcomes
• social interaction = Success of consultation
• Patients’ satisfaction with the consultation depends
on their perception of the doctors’ interpersonal
and clinical skills, and might in itself have a positive
effect on the pain and other symptoms experienced
(placebo’ effect)
• The social interaction between doctor and patient
can also influence doctors’ own feelings of
satisfaction.

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Types of doctor patient
relationship
• The doctor brings his or her clinical skills and knowledge to the
consultation in terms of diagnostic techniques, knowledge of the causes
disease, prognosis, treatment options and preventive strategies
• Patients bring their own expertise in terms of their experiences and
explanations of their illness, and knowledge of their particular social
circumstances, attitudes to risk, values and preferences

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Default
•When patient and physician
expectation are at odds, or
when the need for change in
the relationship can not be
negotiated, the relationship
may come to a dysfunction
standstill
•Both doctor and patient in
passive role
8

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Paternalistic
• Is widely regarded as the traditional form of doctor-
patient relationship.
• Doctor Takeson role of “parent”
• A passive patient and a dominant doctor.
• The supportive nature of paternalism appears to be
more important when patient are very sick
• Disadvantage: Manipulation and exploitation of the
vulnerable and ill

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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
• The patient’s right to seek care
elsewhere when demands are
not satisfactorily met

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Consumerist
• Reverse of the very basic nature of
the power relationship
• Doctor: Passive role and patient:
Active role
• Second opinion, referral to hospital,
sick note
• When things seem to go wrong,
when satisfaction is low, or when a
patient suspect less than optimal care
or outcome, patients are more likely
to question physician authority
You’repaid to do
what Itell you!!”

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Influences on the doctor–patient
relationship
Doctor’s clinical practice style (Consultation styles)
• ‘Doctor-centred’
• ‘Patient-centred’
• A doctor-centred consultation is characterized by
the traditional Parsonian model and paternalistic
approach
• Doctors classified as having a patient-centred style
tend to be the most flexible, showing the greatest
ability to respond to differences in patients’ needs
or the circumstances of the consultation

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Influences on the doctor–patient
relationship
• These differences in communication style reflect not only
doctors’ communication skills but also differences in their
attitudes and orientations to the medical task
• ‘voice of medicine’- focus on biomedical diagnosis and
treatment as quickly as possible vs ‘Voice of a patient’

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Influence of Time
• General practice consultations average about 6
minutes (2-20 minutes)
• Pressuresof time- doctorcentered consultation
• Pressures of time encourage a more tightly
controlled doctor-centred (or ‘paternalistic’)
consultation with less attention paid to the social
and psychological aspects of a patient’s illness
• Patient centric approach needsmore time but overall
reduces thenumber of return visits & thus the total
consultation time

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Patient characteristics and
behaviours
• Mutual participation (more participative role)
• Age: Younger people > elderly people
• High SES> Low SES
• Differentlanguagesandculture
• There is some evidence that doctors volunteer
more explanations to some groups of patients,
including more educated patients and male
patients, even when the explanation is not
explicitly requested by the patient
• Structural context: Hospital situation, fee structure

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Models of treatment decision-
making

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Shared Decision making
• Both doctor and patient are involved in the
decision-making process
• Both parties share information
• Both parties take steps to build a consensus about
the preferred treatment
• An agreement (consensus) is reached on the
treatment to implement

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Shared Decision making
• Studies have identified that about 50% of patients with
chronic conditions do not take their treatment as
prescribed (they do not share the doctors’ view of the
appropriateness of the drugs prescribed)
• Other side demand for antibiotics to treat viral
infections
• Both parties participate in communicating their views,
concerns and preferences and share responsibility for
the final decision
• Main aim: to achieve the best use of medicines
compatible with what the patient desires and is
capable of achieving

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Factors associated with increased
patient's compliance
• Gooddoctor-patient relationship.
• Written instructions for takingmedication.
• Patient's subjective feelings of distress orillness.
• Doctor's awarenessof and sensitivity tothe patient's belief system.
• Physicianenthusiasm, permissiveness, time spent talking with the
patient.
• Physicianexperience andolder physicianage. Short waiting room
time.
• Patient knowledge of the expected positive treatment outcome.
• Patient knowledge of the namesand effects of prescribed drugs.

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Factors associated with decreased
patient's compliance:
• Perceptionof the physicianasrejectingandunfriendly
• Physicianfailure to explainthe diagnosisorcausesof symptoms
• Increasedcomplexity of treatment regimeni.e. more
thanthreetypesof medicationtakenmorethanfour times aday
• Increasednumber of required behavioral changes.
• Verbalinstructions for takingmedication.
• Visualproblemsreadingprescription labels(particularly in theelderly)

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Changes in doctor patient relationship
• The increasing size of general practices, together with the
greater involvement of nurses, health visitors, counsellors and
other health professionals in the provision of primary care-
challenge of achieving good interprofessional communication
• Telemedicine: new challenges in establishing a relationship
between individual patients and healthcare providers, and
facilitating their communication

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Communication skills
• Doctors frequently overestimate the amount of
information they have provided to patients, and
also believe that patients are satisfied with the
communication they received
• A recent qualitative study based on 35 patients
aged 18 years and over consulting 20 general
practitioners, found that only four of the 35
patients voiced all their concerns during the
consultation (Barry et al 2000)

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Communication skills
Patients perception of inadequaciesof communication arisefrom
• Content skills –what doctors say, e.g.,the substanceof the
questionsasked, the answersreceived, the information given,
the differential diagnosislist, andthe doctorsmedical
knowledgebase
• Process skills – how doctors say it, e.g., how the doctor asks
questions, how well he listens, how he setsup explanation and
planning with the patient, how he structures his interaction
andmakesthat structure visible to the patient through sign
postingor transitions &how he build relationships with
patients

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Communication Skills and Steps to
be Achieved in the Consultation
• Initiating the session (establishing the initial rapport and
identifying the reason(s) for the consultation)
• Gathering information (exploring the problem, understanding the
patients’ perspective, providing structure to the consultation)
• Building the relationship (developing rapport and involving the
patient)
• Explanation and planning (providing the appropriate amount and
type of information, aiding accurate recall and understanding,
achieving a shared understanding and planning)
• Closing the session

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DOCTOR-PATIENT RELATIONSHIP
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
supreme orders
Present
• Consumerism and
mutuality: Patients
nowadays have higher
education and better
economic status
• The concept of patient’s
autonomy
• The ability to question
doctors

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Conclusion
• The doctor-patient relationship is at the core of the
practice of healthcare
• Essential for the delivery of high-quality health care
in the diagnosis and treatment of disease
• The Doctor-Patient Relationship itself is part of the
therapeutic process
• Many issues may complicate or negatively affect
the doctor-patient relationship if not taken
properly into consideration

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THANK YOU