This document discusses the doctor-patient relationship and communication. It covers: 1) Different models of the doctor-patient relationship including paternalistic, mutual, consumerist, and default. The mutual model with shared decision making is considered optimal. 2) Factors that influence the relationship like education levels, trust in doctors, and desire for patient autonomy. Relationships have shifted from paternalistic to mutual/consumerist. 3) Effective communication is key, requiring active listening, open-ended questions, and understanding the patient's perspective. This builds trust and leads to better health outcomes.

1. AETCOM
• Module 3

2. The
Doctor-Patient
Relationship

3. The
Doctor-Patient
Relationship

4. Objectives
• Understand why doctor-patient
communication is key to a successful
relationship
• Learn basic communication strategies for an
improved doctor-patient experience

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Social roles of doctors and patients ( parson’s model
of the sick role and doctor’s role
Traditional doctor-patient relationship
Different types of doctor-patient relationships
Explain the concepts of shared decision making and
concordance and their relevance to medical practice

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Introduction
It is an emotional association (clinical encounter)
between the doctor and a patient which arises when
the doctor in a professional capacity interact with the
patient
The relationship begins when a person who is ill or
believe that he is ill & consults a doctor.
The success or otherwise depend on various factors
including the nature of the relationship that exist
between the doctor and the patient.

7. The History of the Doctor-Patient
Relationship
20+ years ago... Over the last 20 years
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Lower rates of education
Less access to good medical
care
Doctors trusted completely
Doctor gave
advice/medication and
patient would take it Patients’
ideas, concerns &
expectations not asked about
Doctor treated- family cared
Doctor Centred Approach
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Higher rates of education
Medical advice on
internet/libraries
Better access and choice of
good medical care
High profile cases of doctors
not acting professionally-
general mistrust of doctors
Broken families- doctors
need to treat and care
Patients want to make own
decisions

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Four types of doctor- patient
relationship
Paternalistic
Mutual
Consumerist
Default

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Paternalistic relationship
Traditionally characterized medical consultation
Autocratic model
It is assumed that Dr knows best
High physician control and low patient control
The doctor is dominant and takes on role of
“parent”
Patient submissive
Shift towards Mutuality

10. Communication in Paternalistic
Between doctor and patient
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Foundation for diagnosis and treatment (elicit &
convey information)
Relationship has a therapeutic effect placebo effect
of drug
Doctor-centered consultation (Paternalistic style)
‘Closed’ nature questions e.g. “How long have you had
the pain? & is it sharp or dull?”
Diseased centered model talk

11. Paternalistic Relationship
If I’ve told you once
I told you 1,000
times, stop
smoking!!”

12. MUTUAL PARTICIPATION MODEL
Regarded as optimal DPR

13. MUTUAL PARTICIPATION MODEL
• Both parties share power and responsibility,
exchange of ideas & sharing of belief systems,
need each other and will work towards choices and
actions satisfying to them both
• Open questioning, interested in psycho-social
aspect of illness history & examination investigation
results in a diagnosis
• Hence there is integration

14. COMMUNICATION
Between doctor and patient
• ‘Patient-centered’ approach (Mutuality)
Encourage & facilitate their patients to
participate
Use of ‘open’ questions e.g. ‘tell me about your
pain’, ‘how do you feel? & ‘what do you think is
the cause of the problem?’
Active listening skills, requires more time
(participative style)
It’s serious isn’t it doctor?

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Patient’s role in mutual relationship
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

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Doctor’s role in mutual relationship
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

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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

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Disadvantages
Physicians do not know what certain degree
should they reach in communication
If the communication is fake, both physicians
and patients do not have mutual
understanding, making decision is
overwhelming to a patient

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consumerist relationship
The patient takes the active role and the doctor
plays passive role.
Trying to satisfy the patient need in term of referral to
the hospital, usage of medication and sick leave.

20. Consumerism
Patient controlled consultation
“You’re paid to do what
I tell you!!”

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Relationship of 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
Passive role by the patient and the doctor
Lack of sufficient direction in consultation
Ineffective in dealing with the illness.
Commonly occur in managing chronic illness
e.g. diabetes mellitus and hypertension,

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Doctor-patient relationship in the past
Paternalism
Because physicians in the past are 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

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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

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Social roles of doctors and patient
Occupying social role which facilitate
interaction as they define the expectations
and obligations of each participant.
Ensure that patients return to health and
normal role performance as soon as
possible.

25. PARSONS’ MODEL OF SICK
ROLE.

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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 a necessary,
occasional respite, providing a brief exemption
for patient from social responsibilities

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Patient’s role
When sick, a patient is allowed the privileges
of convalescence-he or she is not held
responsible for poor health and is excused
from everyday responsibilities
In order to enjoy these privileges, the patient
must seek technically competent help and
comply with medical advice
→passive and dependent

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Doctor’s role
Be guided by rules of professional practice
Applying a high degree of skill and
knowledge to the patients
The doctor legitimates the patient’s illness
and determines the course of treatment.
In doing so, the physician is compelled by
professional ethics to act only in his or her
sphere of expertise, to maintain an emotional
detachment and distance from the patient,
and to act in the patient’s best interest
→professionally dominant and autonomous

29. Parsons’ “Ideal Patient” (Sick
Role)
Rights (Permitted) to:
Give up some activities and responsibilities
Regarded as being in need of care and unable
to get well by his own decision & will
Obligations (In Return) :
Must want to get better quickly
Seek professional medical advice and
cooperate with the doctor.
Parsons, 1951

30. Expectations
Patient expects from
doctor.... Why a patient goes to doctor..
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A cure
Medication
To be listened to
Sympathy
Advice- he understands
The ‘answer’
A sick note
What they want (agenda)
Comfort
A chat
No harm
Professionalism & Respect
To be told what to do To
feel better
The truth
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They feel ill physically
They feel ill mentally
They are lonely
They want time off work
Need advise
Don’t know who to turn to
Marital/family problems
Legal reasons

31. Expectations
Doctor expects from patient...
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Trust
Compliance to treatment
Agreement
The truth
Respect
They want to get better
To be listened to
To obey the ‘Rules’!

32. If Expectations are not met...
Patient may... Doctor may...
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Not take medication
Not follow advice
Choose another doctor
Lose trust
Complain
Not come back
Come back
Become more ill/die
Not tell doctor why they came
Become Distressed/Sad/Angry
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Become annoyed
Become ‘stressed’
Not be thorough
Dread seeing patient again
Refuse to see patient again
Refer pt to another doctor
(Balint calls this ‘the
collusion of anonymity’ )
Not listen

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Problems with Parsons’ model
Address acute problems (ignores chronic dx:
imagine a cancer patient on medical leave for
10 year!)
Clinically oriented
Centered on individuals
Rights do not always apply

34. Communication
• Patient-Doctor communication is important
– Improved satisfaction
– Improved compliance
– Improved decision making
– Better health outcomes
– Decreased malpractice claims

35. Communication
• Information gathered must be:
– Objective
– Accurate
– Precise

36. Communication
• Who will you be communicating with?
– Patients
– Families
– Colleagues
– Other health professionals

37. Communication Skills
• Essential for diagnosing and treating illness
• Essential in establishing a meaningful patient-
doctor relationship
• Facilitates educating and counseling patients

38. Patient Communication
• Patients who feel at ease are more likely to tell
you their reason for coming to the doctor’s
office
• Be yourself!
• Show true interest

39. The Physician’s Duties
• Respects the patient
• Ensures privacy and trust of confidential
information
• Demonstrates genuine concern for patient’s
health
• Limits distraction to provide patient undivided
attention

40. Respect
• If appropriate shake hands
• Always address the patient as: Mr., Mrs., Ms,
etc.

41. A model patient-doctor relationship
• Trust
• Compassion
• Open and honest communication
• Respect

42. Why is Doctor-Patient Communication
Unique?
• Trust
– Patients on the first visit share their most personal
information to someone they have never met
before
– They look to you for guidance when making
critical health care decisions
– Within minutes of meeting, patients are often
required to disrobe for a physical examination and
are placed in a vulnerable situation

43. Empathy
• To understand a person’s experience
• Different than sympathy
• Requires
– Active listening
– Interest in patient’s experience

44. Objectivity
• Removing your own beliefs and values
• Avoid judgmental attitudes
– IV Drug Abuse
– Education
– Socioeconomic status
– Language/Cultural differences
– Ageism

45. Active Listening Skills
• Respect the patient as a whole person, not a
diseased body
• Use confirmatory statements:
– “Yes”
– “Tell me more about that”
• Allow the person to tell their whole story
without unnecessary interruptions
• Don’t be afraid of silence

46. Body Language
• Examination room configuration
• Sitting/Standing
• Eye contact
– Note taking
• Posture
• Hurried speech

47. Body Language
• Patients notice more than you think
– 2/3 of communication is non-verbal
• Appropriate use of touch

48. Patient-Doctor Communication:
Key Points
• Ask about expectations, feelings and concerns
• Show concern for comfort and modesty
• Give an opportunity to express feelings and
concerns
• Encourage patients to ask questions

49. Communication skills can be developed
with practice, patience and a willingness
to learn .

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Influence of time
Shortage of time is a major constraint –
paternalistic approach
Less attention paid to social and
psychological aspect
Unnecessary prescription issued
Increase in the number of visits
Thus more time required for participative
patient centered consultation, listen to
patient’s worries and concern

51. The importance of a good
PATIENT DOCTOR RELATIONSHIP
lies in the :
• Confidence
• Trust
• K n o w l e d g e
• Shared k n o w l e d g e about
diseases and how they
are r e l a t e d

52. The success of a good Doctor
Patient Relationship is related to
• Amount of Information
• Quality of Information
• Accuracy of Diagnosis
• Effective Treatment
• Compliance

53. IN SUMMARY
Relationships based on openness, trust and good
communication will enable you to work in partnership with your
patients to address their individual needs.
To fulfil your role in the doctor-patient partnership you must:
a. be polite, considerate and honest
b. treat patients with dignity
c. treat each patient as an individual
d. respect patients' privacy and right to confidentiality
e. support patients in caring for themselves to improve and
maintain their health
f. encourage patients who have knowledge about their
condition to use this when they are making decisions about
their care.

54. HOW TO FIND OUT IF IT WAS A GOOD
DOCTOR PATIENT RELATIONSHIP
•PATIENT SATISFACTION
•CONTINUITY
•GOOD OUTCOMES