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Doctor Patient Relationship

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doctor patient relationship

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Doctor Patient Relationship

  1. 1. The Doctor-Patient Relationship Presenters : Dr. Priyadarshani Dr. Chibi Rushitha V Moderator : Dr. Shantibala K Associate Professor Date : 20/11/2015
  2. 2. OUTLINE  Introduction  Parsons’ Model Of the Sick Role And Doctor’s Role  Types Of Doctor-patient Relationship  Influences On The Doctor–patient Relationship  Partnerships In Treatment Decision Making  Communication Skills  Barriers In Communication  Doctor-patient Relationship In The Past  Doctor-patient Relationship In The Present  Improving Doctor Patient Relationship  Consumer Protection Act ,1986  Conclusion
  3. 3. 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 (care provider) to take on the responsibility of directing , effecting and maintaining the therapeutic relationship, exhibiting a professional and ethical approach.
  4. 4. Why does it matter ?  The patient-physician relationship is fundamental for providing 1. excellent care 2. to the healing process 3. to improved outcomes Therefore, it is important to understand what elements comprise the relationship and identify those that make it "good."
  5. 5. Parsons’ model (1951)  Parsons’ “Ideal Patient” (Sick Role) Rights (Permitted) to: Give up some activities and responsibilities. Regarded as being in need of care . Obligations (In Return) : Must want to get better quickly . Seek help and cooperate with a doctor.
  6. 6.  Parsons’ “Doctor” (Doctors’ Role)  Apply a high degree of skill & knowledge to the problems of illness.  Act for welfare of patient and community rather then for own self interest, desire for money, advancement etc.  Be objective and emotionally detached.  Be guided by rules of professional practice.
  7. 7.  Doctor’s Right  Granted right to examine patients physically & to enquire into intimate areas of physical & personal life.  Granted considerable autonomy in professional practice.  Occupies position of authority in relation to the patient.
  8. 8. Types of doctor-patient relationship Types Physician control (Low) Physician control (High) Patient control (Low) Default Paternalism Patient control (High) Consumerism Mutuality
  9. 9. Pateranalism  Is widely regarded as the traditional form of doctor-patient relationship.  A passive patient and a dominant doctor.
  10. 10. Advantages  The supportive nature of paternalism appears to be more important when patient are very sick .  Relief from the burden of worry is curative in itself, and the trust and confidence implied by this model allow doctor to perform “medical magic” →placebo effect
  11. 11. Disadvantages  Manipulation and exploitation of the vulnerable and ill .
  12. 12. 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.
  13. 13. Patient’s role  Patients need to define their problems in an open and full manner.  The patient’s right to seek care elsewhere when demands are not satisfactorily met.
  14. 14. Doctor’s role  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.
  15. 15. 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.
  16. 16. Disadvantages  If the communication is fake, both physicians and patients do not have mutual understanding, making decision is overwhelming to a patient.
  17. 17. Consumerism  Reverse of the very basic nature of the power relationship.  Patient taking active role and doctor adopting a fairly passive role.
  18. 18. Patient’s role  Health shoppers Indications of consumer behavior:  Cost-consciousness  Information seeking  Exercising independent judgement
  19. 19. Doctor’s role  Health care providers  Technical consultant  To convince the necessity of medical services
  20. 20. Advantages  Patients can have their own choices. Disadvantages  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.
  21. 21. 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.
  22. 22. Consultation styles 1. 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
  23. 23. 2. Patient centered  Mutuality  Less authoritarian - encourages patient to their own feelings and concerns  Open questions  ‘Voice of the patient’ - communication of patients beliefs, feelings & psychosocial context (bio psychosocial)
  24. 24. Key aspects of a of patient-centred consultation  Biopsychosocial perspective  Patient-as-a-person  Sharing power and responsibility  Therapeutic alliance  Doctor-as-a-person
  25. 25. Influences On The Doctor–patient Relationship 1. Influence of time –  Average 6 minutes (avg 2-20 min)  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 .
  26. 26. 2. Patient characteristics and behaviours The patient’s ability to exercise and control depends on a number of factors:  Age  Social and educational level  Sex  Different languages
  27. 27. 3. Influence of structural context  Hospital situation/ Ward  Fee-for service
  28. 28. Health literacy  Definition-- the ability to obtain, process, and understand basic information and services needed to make appropriate health decisions.  Low health literacy reduces the success of treatment and increases the risk of medical error.  Health literacy is of continued and increasing concern for health professionals, as it is a primary factor behind health disparities.
  29. 29. Tests to identify health literacy--  Medical Term Recognition Test (METER)  Rapid Estimate of Adult Literacy in Medicine (REALM) test  The Short Assessment of Health Literacy in Spanish and English populations (SAHL-S&E)  The Critical Health Competence Test (CHC-Test)
  30. 30. Intervention---  Teach back method.  Ask Me 3" is designed to bring public and physician attention to this issue, by letting patients know that they should ask three questions each time they talk to a doctor, nurse, or pharmacist: 1) What is my main problem? 2) What do I need to do? 3) Why is it important for me to do this?
  31. 31. PARTNERSHIPS IN TREATMENT DECISION MAKING  Models of decision making 3 models - paternalist - shared - informed  Paternalist model - the doctor, as medical expert, as solely responsible for treatment decisions with the patient expected merely to cooperate with advice and treatment.
  32. 32. Shared decision-making 1. Both doctor and patient are involved in the decision- making process 2. Both parties share information 3. Both parties take steps to build a consensus about the preferred treatment 4. An agreement (consensus) is reached on the treatment to implement
  33. 33. Informed model 1. partnership between doctor and patient - division of labour 2. doctor - information on all relevant options 3. decision-making- patient
  34. 34.  Shared decision making -impetus 1. Increased medical knowledge among patients 2. Prevailing social values- individual autonomy and responsibility 3. Chronic illness 4. To make choices between the treatment options and to balance risks & benefits –medical uncertainity 5. Doctors make inaccurate guesses about patients concerns & their preferences and treatment choices differ
  35. 35.  Patients’ preferences for participation  Patient’s state of health Patients in crisis situations Patients feel weak or distressed Differences in the desire for involvement
  36. 36. Consent Definition-- When two or more persons agree upon the same thing in the same sense they are said to consent ( section 13 of Indian Contract Act, 1872) Who can given consent? 1. any person who is conscious, 2. mentally sound and 3. ≥ twelve years of age
  37. 37. When a consent is not valid ? 1. under fear 2. fraud 3. misrepresentation of facts 4. by a person who is ignorant of the implications of the consent 5. who is under 12 years of age is invalid
  38. 38. Depending upon the circumstances in each case consent may be a) implied b) express – verbal / written c) informed
  39. 39. Doctors 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  The content of communication is influenced by a number of practical and situational factors (time available, initial or subsequent visit, private patient)
  40. 40.  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
  41. 41.  Communication skills and steps to be achieved in consultation 1. Initiating the session (establishing the initial rapport and identifying the reason(s) for theconsultation). 2. Gathering information (exploring the problem, understanding the patients’ perspective,providing structure to the consultation). 3. Building the relationship (developing rapport and involving the patient).
  42. 42. 4. Explanation and planning (providing the appropriate amount and type of information, aiding accurate recall and understanding, achieving a shared understanding and planning) 5. Closing the session.
  43. 43. BARRIERS IN COMMUNICATION A) Doctor’s barrier to effective communication  Lack of specific knowledge  Lack of counseling skills  Lack of time  Lack of appropriate resources
  44. 44. B) Patient’s barrier to effective communication  Sex  Social and educational level  Different languages  Membership of an ethnic minority
  45. 45. 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
  46. 46. DOCTOR-PATIENT RELATIONSHIPAT PRESENT Consumerism and mutuality Patients nowadays have higher education and better economic status The concept of patient’s autonomy The ability to question doctors
  47. 47. IMPROVING DOCTOR PATIENT RELATIONSHIP  Active Listening  Nonverbal Communication  Agendas  Empathize  Educating Patients
  48. 48. Reassurance Agreeing on a treatment plan Taking responsibility Avoid overreacting Establishing boundaries
  49. 49. Consumer Protection Act, 1986  In 1995 ,Medical profession was included under this act.  Empowers the consumer with the Right to :  Safety  Information  Choose  Heard  Redressal  Consumer education
  50. 50.  Relationship between patients and medical professionals as contractual and not a master-servant relationship .  A complaint filed in the Consumer Forum/Commission shall be decided within a period of 90 days from the date of notice by opposite party and within 150 days if it requires analysis or testing of commodities.  There are no court fees to be paid to file a complaint in a Consumer Forum / Commission.
  51. 51. Lodging A Complaint FORMAT: Written PERSON : Complainant / Representative PLACE : Consumer Dispute Redressal Forum FEE : Nominal TIME LIMIT : ≤ 2 yrs FATE : Accepted Dismissed Sec 12 CPA 1986
  52. 52. The structure of the consumer forums/ commission: It depends upon the amount of compensation and decided by the government from time to time 1. 1. District consumer redressal forum (Upto Rs. 20 lakhs) 2. 2. State consumer redressal forum (20 lakhs Up to 1Crore ) 3. 3. National consumer redressal forum (> Rs. 1 Crore) 4. 4. Supreme court: final appeal (unlimited)
  53. 53. Proof of Negligence The essentials of negligence are four "D"s: 1. There was a Duty towards patients 2. There was Deficiency in duty 3. This Directly resulted in the problem 4. Damage which may be physical, mental or financial loss to patient or relatives
  54. 54. 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.
  55. 55. THANK YOU

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