:Need and rational
Dr. Md. Nazmul Hossain
Department of Surgery
Medical College for Women and Hospital,
By the end of this session audience should
be able to:
Describe the different types of doctor-
Social factors influencing this consultation;
Outline some of the sociological
perspectives on the doctor-patient
Types of D-P relationship
Barrier of good communication
Art of interview
Take home massage
Stop and think!
In what ways are relationships
between doctors and their
patients different from other
social relationships (e.g. between
student and librarian or between
passenger and bus driver?
Perhaps patient has just met her
doctor, but within seconds s/he tells
the doctor very intimate personal
details about his/her health.
within a minutes, s/he is prepared
to remove his/her clothes and
submit to a physical examination.
This is a one-way process, it would
be highly inappropriate if the doctor
started to discuss his/her own
bowel movements or if the patient
asked his/her personal questions.
The doctor-patient interaction is
shaped by their differing social roles
and their different needs.
Current practice of “ ConsultationConsultation”
Patients are likely to rely on the doctors because ofPatients are likely to rely on the doctors because of
their lower education and social status and theirtheir lower education and social status and their
high dependency on medical deliberation, andhigh dependency on medical deliberation, and
obedience to authority;obedience to authority;
while doctors dominate the consultation processwhile doctors dominate the consultation process
and the decision-making because they are theand the decision-making because they are the
legalized profession, i.e. supported by our sociallegalized profession, i.e. supported by our social
The status and power of physicians may encourage patient’s dependencyThe status and power of physicians may encourage patient’s dependency
and, influence how they perceive their healthand, influence how they perceive their health.
Disadvantages of the currentDisadvantages of the current
1.1. Restricts the patient’s inclination to help themselves.Restricts the patient’s inclination to help themselves.
2.2. Restricts the patients in giving their own opinion.Restricts the patients in giving their own opinion.
3.3. Reinforces the patient’s sick role.Reinforces the patient’s sick role.
4.4. Reinforces the hierarchical relationship betweenReinforces the hierarchical relationship between
doctor and patient.doctor and patient.
5.5. Assumes the doctor knows everything about the patientsAssumes the doctor knows everything about the patients
rather than the patient knowing his or her own conditionrather than the patient knowing his or her own condition
better (e.g. pain)better (e.g. pain)
Types Doctor-Patient Relationship
Patient Control Low High
Low Default Paternalist
High Consumerist Mutuality
The traditional D-P relationship
Doctor Takes on role of “parent”
But currently shift towards Mutuality
The Paternalistic Approach
“If I’ve told you once I
told you 1,000 times,
“You’re paid to do what
I tell you!!”
Doctors’ barriers to effective
• lack of specific knowledge;
• lack of counselling skills;
• lack of time;
• lack of appropriate resources.
Patient barriers to effective
Membership of an ethnic minority
Developing a REAL relationship
Have an „open” attitude: whatever is going on
between us in interaction is important and intimate,
no matter what is being discussed.
Develop in the interviewee a feeling that he/she is
Concentrate all your attention on the interviewee
Help the interviewee to express those contents which
are important for the diagnosis
• Create a calm and unhurried atmosphere
• Listen kindly with empathy
• Do not express surprise
Try not to be late…
Concentrate fully and only at the patient
Take care of the patients comfort
Organize the environment
Pay attention to the physical distance
The Art of asking questions
The first question: general, open, refer to
the interviewee’s general life situation or
the presenting problem
• What brings you here?
• What can I do for you?
• What is your problem?
• Why are you here? (in the hospital)
• Could you tell me a bit more about …
The Art of asking questions
Narrowing down the questions (general to
Progression (relatively benign to personal)
Leading questions (indirect)
Postponed questions (change of context,
Projective questions („some people…”,
description of interpersonal situation)
The language must be matched to:
• interviewee’s intelectual level
• verbal skills
• personal experience
Avoid the proffesional language and
When the interview comes to a
Check whether all problems have been discussed and
leave some time for their discussion
When time is up – communicate it directly instead of
constantly checking the time or „suggesting” that you have
to go (e.g.. By gathering the notes impatiently)
Try to summarize the interview
Finish the conversation stressing your interest in the
interviewee and in what has been said
You can ask the patient to evaluate the conversation
Say good-bye, get up and thank the interviewee for
How to maintain the rapport?
• „Yes”, „I understand”, „Yhym”
• „Could you tell me more about this?”
• Body posture
• Tilt of the head
• Facial expression
• Eye expression
Communication and Diagnosis
Patients who feel at ease and who are
encouraged to talk freely are more likely
to disclose the real reason for consulting
Communication and Treatment
Advice reassurance and support from the
doctor can have a significant effect on
The placebo effect
1.1. Both patient and doctor could participate inBoth patient and doctor could participate in
discussion and planning for treatments.discussion and planning for treatments.
2. Increase health knowledge and understanding2. Increase health knowledge and understanding
among patients.among patients.
3. Treat patients in a humanistic and adult manner3. Treat patients in a humanistic and adult manner
Empowerment of the ptsEmpowerment of the pts
Take home message