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Doctor Patient
relationship

Dr. Rizwan SA, M.D.,
“Men who are occupied in the restoration of health to other men
are above all the great of the earth, since to preserve and renew is
almost as noble as to create.” - Voltaire
Doctor Patient relationship
• The nature of the relationship
determines the success of the
treatment/intervention
• PARSONS was one of the earliest
sociologist to examine doctor
patient 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 & patients

2
Parsons Social roles of doctors &
patients

3
Other models
Szasz & hollender

• Seriously

ill

patient

–

activity passivity model
• Acute ( infectious diseases)
–

guidance

cooperation

model
• Chronic diseases – mutual
participation model

4
Conflicts in doctors role
• Doctors own values vs.
patients (abortion, AIDS,
homosexuality)
• Interest of the patient vs.
state (sick note, notification)
• Interest of individual patients
vs.
wider
population
(rationing of resources)
• Confidentiality

5
Outcomes
• Clinical
• Satisfaction
• Doctor

• Failure to elicit patients worries & interpretation of
symptoms lead to believe that patients have consulted
inappropriately & their time & skills are wasted
• Patient

• Perception of the doctors interpersonal & clinical skills
• Patients satisfaction with the initial consultation
• Information & advice given

6
Types of doctor patient relationship

7
Types of doctor patient relationship

Paternalistic
• The traditional D-P relationship

If I’ve told you once I told
you 1,000 times, stop
smoking!!”

• Doctor Takes on role of “parent”
• Patient submissive
• Shift towards Mutuality

8
Types of doctor patient relationship

Mutuality
• Equal partners
• Meeting between experts
• Joint venture
• Exchange of ideas

9
Types of doctor patient relationship
Consumerist
• Doctor: passive
• Patient : active role
• Second opinion, referral to
hospital, sick note

You’re paid to
do what I tell
you!!”

10
Types of doctor patient relationship

Default
• Patient adopts a passive role
• Doctor reduces his control
• If patient is not aware of
alternatives to passive patient
role/ timid in adopting a
participative relationship

11
Influences on doctor patient relationship
- Consultation style
Doctor centered
• Paternalistic - doctor is the expert
and patient expected to cooperate
• Tightly controlled interviewing style
aimed at reaching an organic
diagnosis.
• Closed questions
• ‘voice of medicine’- focus on
biomedical diagnosis and treatment
as quickly as possible

12
Influences on doctor patient relationship
- Consultation style
Patient centered
• Mutuality
• Less authoritarian - encourages patient to their own feelings and
concerns
• Open questioning, interested in psycho-social aspect of illness
• Voice of the patient- communication of patients beliefs feelings &
psychosocial context (bio psychosocial)

13
Influences on doctor patient relationship
- Time

• Average 6 minutes
• Pressures of time- doctor centered
consultation
• However, doctors own style &
approach influences than the time
available
• Patient centric approach needs more
time but overall reduces the number
of return visits & thus the total
consultation time

14
Influences on doctor patient relationship
- Patient
The patient’s ability to exercise and control depends
on a
number of factors:
• Age
• Social and educational level
• Sex
• Different languages
• Membership of an ethnic minority
15
Influences on doctor patient relationship
– structural context
• General practice
• Hospital situation
• Ward

16
Models of decision making

17
Shared decision making -impetus

• Increased medical knowledge among patients
• Prevailing social values- individual autonomy, responsibility
• Chronic illness
• To make choices and to balance risks & benefits
• Doctors make inaccurate guesses about patients concerns & their
preferences and treatment choices differ

18
Shared decision making –impetus
Compliance
• It is the extent to which a patient follows the clinical
instructions of the physician.
• Research confirms that the doctor-patient relationship is the
best predictor of whether the patient will follow the doctor’s
instructions and advice.
Examples of compliance include:
• Taking medications on schedule.
• Keeping appointments.
• Following directions for changes in behavior or diet.
• Approximately 1/3 of patients are compliant with treatment.
• 1/3 complies some of the time; and 1/3 don't comply with
treatment at all.
19
Shared decision making –impetus
Compliance
Factors associated with decreased patient's compliance:
• Perception of the physician as rejecting and unfriendly.
• Physician failure to explain the diagnosis or causes of
symptoms.
• Increased complexity of treatment regimen i.e. more
than three types of medication taken more than four
times a day
• Increased number of required behavioral changes.
• Verbal instructions for taking medication.
• Visual problems reading prescription labels (particularly
in the elderly).
20
Shared decision making –impetus
Compliance
Factors associated with increased patient's compliance
•

Good doctor-patient relationship.

•

Written instructions for taking medication.

•

Patient's subjective feelings of distress or illness.

•

Doctor's awareness of and sensitivity to the patient's belief system.

•

Physician enthusiasm, permissiveness, time spent talking with the
patient.

•

Physician experience and older physician age.

•

Short waiting room time.

•

Patient knowledge of the expected positive treatment outcome.

•

Patient knowledge of the names and effects of prescribed drugs.
21
Communication skills
Patients perception of inadequacies of
communication arise from
• Content skills – what doctors say, e.g., the
substance of the questions asked, the
answers received, the information given, the
differential diagnosis list, and the doctors
medical knowledge base
• Process skills – how doctors say it, e.g., how
the doctor asks questions, how well he
listens, how he sets up explanation and
planning with the patient, how he structures
his interaction and makes that structure
visible to the patient through signposting or
transitions &how he build relationships with
patients
22
Communication skills

23
Communication and Treatment

Advice, reassurance and support
from the doctor can have a
significant effect on recovery

The placebo effect

24
Thank you
“We have not lost faith, but we have transferred it from God
to the medical profession.” - George Bernard Shaw

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Doctor patient relationship

  • 1. Doctor Patient relationship Dr. Rizwan SA, M.D., “Men who are occupied in the restoration of health to other men are above all the great of the earth, since to preserve and renew is almost as noble as to create.” - Voltaire
  • 2. Doctor Patient relationship • The nature of the relationship determines the success of the treatment/intervention • PARSONS was one of the earliest sociologist to examine doctor patient 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 & patients 2
  • 3. Parsons Social roles of doctors & patients 3
  • 4. Other models Szasz & hollender • Seriously ill patient – activity passivity model • Acute ( infectious diseases) – guidance cooperation model • Chronic diseases – mutual participation model 4
  • 5. Conflicts in doctors role • Doctors own values vs. patients (abortion, AIDS, homosexuality) • Interest of the patient vs. state (sick note, notification) • Interest of individual patients vs. wider population (rationing of resources) • Confidentiality 5
  • 6. Outcomes • Clinical • Satisfaction • Doctor • Failure to elicit patients worries & interpretation of symptoms lead to believe that patients have consulted inappropriately & their time & skills are wasted • Patient • Perception of the doctors interpersonal & clinical skills • Patients satisfaction with the initial consultation • Information & advice given 6
  • 7. Types of doctor patient relationship 7
  • 8. Types of doctor patient relationship Paternalistic • The traditional D-P relationship If I’ve told you once I told you 1,000 times, stop smoking!!” • Doctor Takes on role of “parent” • Patient submissive • Shift towards Mutuality 8
  • 9. Types of doctor patient relationship Mutuality • Equal partners • Meeting between experts • Joint venture • Exchange of ideas 9
  • 10. Types of doctor patient relationship Consumerist • Doctor: passive • Patient : active role • Second opinion, referral to hospital, sick note You’re paid to do what I tell you!!” 10
  • 11. Types of doctor patient relationship Default • Patient adopts a passive role • Doctor reduces his control • If patient is not aware of alternatives to passive patient role/ timid in adopting a participative relationship 11
  • 12. Influences on doctor patient relationship - Consultation style Doctor centered • Paternalistic - doctor is the expert and patient expected to cooperate • Tightly controlled interviewing style aimed at reaching an organic diagnosis. • Closed questions • ‘voice of medicine’- focus on biomedical diagnosis and treatment as quickly as possible 12
  • 13. Influences on doctor patient relationship - Consultation style Patient centered • Mutuality • Less authoritarian - encourages patient to their own feelings and concerns • Open questioning, interested in psycho-social aspect of illness • Voice of the patient- communication of patients beliefs feelings & psychosocial context (bio psychosocial) 13
  • 14. Influences on doctor patient relationship - Time • Average 6 minutes • Pressures of time- doctor centered consultation • However, doctors own style & approach influences than the time available • Patient centric approach needs more time but overall reduces the number of return visits & thus the total consultation time 14
  • 15. Influences on doctor patient relationship - Patient The patient’s ability to exercise and control depends on a number of factors: • Age • Social and educational level • Sex • Different languages • Membership of an ethnic minority 15
  • 16. Influences on doctor patient relationship – structural context • General practice • Hospital situation • Ward 16
  • 17. Models of decision making 17
  • 18. Shared decision making -impetus • Increased medical knowledge among patients • Prevailing social values- individual autonomy, responsibility • Chronic illness • To make choices and to balance risks & benefits • Doctors make inaccurate guesses about patients concerns & their preferences and treatment choices differ 18
  • 19. Shared decision making –impetus Compliance • It is the extent to which a patient follows the clinical instructions of the physician. • Research confirms that the doctor-patient relationship is the best predictor of whether the patient will follow the doctor’s instructions and advice. Examples of compliance include: • Taking medications on schedule. • Keeping appointments. • Following directions for changes in behavior or diet. • Approximately 1/3 of patients are compliant with treatment. • 1/3 complies some of the time; and 1/3 don't comply with treatment at all. 19
  • 20. Shared decision making –impetus Compliance Factors associated with decreased patient's compliance: • Perception of the physician as rejecting and unfriendly. • Physician failure to explain the diagnosis or causes of symptoms. • Increased complexity of treatment regimen i.e. more than three types of medication taken more than four times a day • Increased number of required behavioral changes. • Verbal instructions for taking medication. • Visual problems reading prescription labels (particularly in the elderly). 20
  • 21. Shared decision making –impetus Compliance Factors associated with increased patient's compliance • Good doctor-patient relationship. • Written instructions for taking medication. • Patient's subjective feelings of distress or illness. • Doctor's awareness of and sensitivity to the patient's belief system. • Physician enthusiasm, permissiveness, time spent talking with the patient. • Physician experience and older physician age. • Short waiting room time. • Patient knowledge of the expected positive treatment outcome. • Patient knowledge of the names and effects of prescribed drugs. 21
  • 22. Communication skills Patients perception of inadequacies of communication arise from • Content skills – what doctors say, e.g., the substance of the questions asked, the answers received, the information given, the differential diagnosis list, and the doctors medical knowledge base • Process skills – how doctors say it, e.g., how the doctor asks questions, how well he listens, how he sets up explanation and planning with the patient, how he structures his interaction and makes that structure visible to the patient through signposting or transitions &how he build relationships with patients 22
  • 24. Communication and Treatment Advice, reassurance and support from the doctor can have a significant effect on recovery The placebo effect 24
  • 25. Thank you “We have not lost faith, but we have transferred it from God to the medical profession.” - George Bernard Shaw