This document discusses the doctor-patient relationship and communication. It covers: 1) The core of medicine is the doctor-patient relationship, with patients expecting both a good relationship and cure. The relationship itself can be part of the therapeutic process. 2) Patients want to trust their doctor's competence, navigate the healthcare system effectively, be treated with dignity and respect, understand how illness/treatment affects their lives, discuss impacts on family/finances, and learn self-care. 3) Effective communication is unique due to the immediate trust and vulnerability patients have with doctors during examinations. Respect, empathy, objectivity, and understanding patient autonomy and values are important.

1. Chapter 4 Doctor-
Patient
Relationship

2. Good physician treats the disease;
the great physician treats the
patient who has the disease ~
William Osler (Canadian
Physician, 1849-1919)

3. The Patient-Doctor
Relationship
 Class exercise:
 Tell me about your most memorable positive experience
with a physician (when you were a patient)

4. The Patient-Doctor
Relationship
 Class exercise:
 Tell me your most negative experience

5. The Patient-Doctor
Relationship
 What does being a doctor mean to you?

6. The Doctor-Patient relationship
Is the core of the practice of medicine
The patient expects a good relationship
as much as a cure
Doctor -patient relationship itself
becomes part of the therapeutic process

7. Introduction
• These two people have just met, but within
seconds one has begun to tell the other intimate
personal details about his health.
• What is more, it is likely that, in a few minutes,
he will be prepared to remove some of his
clothes and submit to a physical examination.
• The interaction is shaped by their differing
social roles and their different needs.

8. Parsons’ “Ideal Patient”
Permitted to:
Give up some activities and
responsibilities, Regarded as being
in need of care
In Return :
Must want to get better quickly, Seek
help from and cooperate with a
doctor

9. Parsons’ “ Ideal Doctor”
 Apply a high degree of skill and knowledge
 Act for the good of the patient
 Remain objective and emotionally detached

10. What do patients want from
a physician?
 Patients want to be able to trust the competence
and efficacy of their caregivers.
 Patients want to be able to negotiate the health
care system effectively and to be treated with
dignity and respect.
 Patients want to understand how their sickness or
treatment will affect their lives, and they often fear
that their doctors are not telling them everything
they want to know.

11.  Patients want to discuss the effect their
illness will have on their family, friends, and
finances.
 Patients worry about the future.
 Patients worry about and want to learn how
to care for themselves away from the clinical
setting.

12. Why is Doctor-Patient Communication
Unique?
Trust
Within minutes of meeting, patients are
often required to remove their cloth for
a physical examination and are placed
in a vulnerable situation

13. Respect
 Introduce yourself (Patient, Family, caregiver)
 Explain your role and goal for the interaction
 If appropriate shake hands
 Always address the patient as: Mr., Mrs., Ms,
etc.

14. Empathy
 To understand a person’s experience
 Different than sympathy
 Requires
Active listening
Interest in patient’s experience

15. Objectivity
 Removing your own beliefs and values
 Avoid judgmental attitudes
Drug Abuse, Ageism
Education
Socioeconomic status
Language/Cultural differences

16. Person’s autonomy and value
What constitutes a person’s autonomy?
Three aspects of autonomy
1. Freedom of thought
2. Freedom of will
3. Freedom of action

17. UNDERSTANDING PATIENT VALUES
AND AUTONOMY
 The term value itself is generally defined as the beliefs or
principles of a person or group that are used to guide
decisions and way of life
 Collectively, values give weight and worth to ideas and
actions.
 A person’s values strongly influence how one feels about
many issues, including choice of occupation, the utility of
preserving life, and expenditure of resources on various
items.
 Health-related values specifically describe a person’s
values relating to the medical sphere,

18.  Health-related values include the extent to which a
person values life versus lifestyle, personal health
versus preservation of family assets, and unpleasant
physical symptoms versus potential health benefits
 Patient autonomy concerns the patient’s right to
involvement in the discussion and decision-making
process during consultation
 It can further be described as the patient’s ability to
make medical care decisions without being influenced
too strongly by care providers or others.

19.  Respect for patient autonomy is an important tenet of
ethical medical conduct and reflects a balance of the
physician’s practice style with the patient’s inclinations
 A common challenge to patient autonomy arises when
the patient’s expressed preferences contradict what the
physician perceives as being in the patient’s best
interest, such as when the patient refuses necessary
treatment or expresses desires drastically different from
those of family and friends

20.  Patient autonomy falls on a wide spectrum, ranging from
very high, where patients make all decisions, to very low,
where they have minimal decision-making involvement.
 Patient autonomy is often associated with the idea of
“locus of control,” which emerged from Julian Rotter’s
Social Learning Theory, where personality is described as
the product of individual and environment.
 Locus of control describes the extent to which one feels in
control of one’s environment and has been explicitly
extended to health care through such tools as the
Multidimensional Health Locus of Control Scales (MHLC).

22. Conflicting Values
 Paternalism:
 The doctor should act in a way that protects or
advances the patient’s best interests, even if it
is against the patient’s will.
 Patient autonomy:
 The doctor should help the patient to make
real choice, and provide intervention under the
constraints of (a) informed consent and (b)
confidentiality.

23.  In clinical practice, however, it has become evident that
many patients are not well represented by this single-axis
approach
 e.g. the patient with high autonomy but low formation of
health-related values.
 Consequently, the first step in the formation of the new
model is to allow autonomy and health care-related values
to vary independently of one another.
 This can be represented by plotting values and autonomy
on separate, perpendicular axes as illustrated below

25. A, the patient with high levels of autonomy and relatively unformed
health care-related values, e.g. a financial analyst
B, the patient from a very traditional culture where health care-
related values are clear but personal autonomy is low
An example of a situation in which values and autonomy are
uncoupled could be a stock analyst or high-ranking business
executive recently diagnosed with a rare disorder
From years of experience with executive responsibilities, this
patient has a high decision-making capacity and deeply involved
with all decisions and actions taken. However, this patient may
have no familiarity with the nature of illness or with health care as a
whole

26.  In previous models, the impact of patient medical knowledge
was not formally incorporated.
 The flow of medical information was assumed to move only
from physician to patient, but with information becoming
increasingly available to patients, such an assumption is no
longer reasonable.
 Patient familiarity with technical material has begun to
significantly influence the dynamic of patient–physician
interactions.
 As such, we complete our model of patient–physician
interaction with the addition of patient medical knowledge as a
third and final axis

28.  Patient values, patient autonomy, and patient knowledge are
the three axes in our model, emphasizing both their
independence and interaction
 A, the patient with high levels of autonomy and relatively
unformed health care-related values
 B, the patient from a very traditional culture where health
care-related values are clear but personal autonomy is low
 C: patients may be selectively well-informed about specific
diseases;
 D: Highly informed patient such as a physician

29. Medical
Information*
High Autonomy
Moderate
Autonomy
Low Autonomy No Autonomy
Very well-formed
health care values
Informative
Persons from
groups with
characteristically
low autonomy
Moderately well-
formed health care
values
Interpretive
Few well-formed
health care values
Technical
specialist, e.g.
financial analyst
Deliberative
No well-formed
health care values
Paternalistic,
trauma care

30. The four different stylesof Doctor patient
relations
Paternalistic: The paternalistic approach is typified
by a doctor centered style.
 It relies on closed questions designed to elicit yes
or no answers.
 The doctor will tend to use a disease centered
model and be focused on reaching a diagnosis,
rather than the patients unique experience of
illness.

31. The Paternalistic Approach
“If I’ve told you once I
told you 1,000 times,
stop smoking!!”

32. Patient controlled consultation
Consumeristic : Here the patient
knows exactly what
they want and forces the
doctor into a patient
centered approach
“You’re paid to do what I tell you!!”

33. Default :
This is where the patient centered style fails.
The doctor is trying to resign control but the patient is
unwilling to accept it, the result is an impasse/dead
Mutuality
The doctor uses open questions to encourage the
patient to talk about his complaint.
This approach relies on taking time to listen and trying
to understand the patients point of view

34. Mutual Styles
It’s serious isn’t it
doctor?

35. Evaluating Ethical models at
a glance
Paternalistic model
Informative model
Interpretive model
Deliberative model

36. Paternalistic model
1. Principle
2. Assumptions
3. Sources
4. Problems
 The doctor should make all the decisions
for a patient.
 People are not always rational/mature.
 Experts know better about the needs of
patients.
 Qualified doctors have good will.
 Hippocratic Oath; Plato.
 Are the needs of patients objective? How
can we be sure that doctors have good
will?

37. Informative model
1. Principle
2. Assumptions
3. Problems
 The doctor should provide all the relevant
information for the patient to make a
decision, and provide the selected
intervention on this basis.
 A fact/value division of labor yields the
best medical result.
 What is good for a patient depends on
what his/her personal values.
 Consumerism.
 What if the patient is unconscious,
incompetent, and making choices totally
unacceptable by our ethical standards?

38. The interpretive model
1. Principle
2. Assumptions
3. Limitation
 The doctor should help the patient to
articulate his/her values through
interpretation, and provide intervention
which is truly wanted.
 Patients have unconscious and inconsistent
desires.
 Their conscious decisions may not reflect
their deepest values.
 All that a doctor can do is to help the patient
see his/her own desires/values more clearly,
but not to criticize them.

39. The deliberative model
1. Principle
2. Assumptions
3. Source
4. Problems
 The doctor should help the patient to deliberate well
through dialogue and discussion, and so develop
values which are objective and truly worthy.
 The objectivity of values.
 The patient’s good life consists not in the satisfaction
of desires, but maturity and rationality.
 Aristotelian ethics
 Is the model different from the paternalistic model?
What is the difference between dialogue and
persuasion?

40. Factors which influence
Dr-Patient Communication
 Patient-related factors
 Dr-related factors
 The interview setting

41. Patient-related factors
 Physical symptoms
 Psychological factors
 Previous experience
 Current experience

42. Dr-related factors
 Training in communication skills
 Self-confidence in ability to communicate
 Personality
 Physical factors
 Psychological factors

43. The interview setting
 Privacy
 Comfortable surroundings
 An appropriate seating arrangement

44. Discussion
 Give an example which indicates the
tension between doctors and patients
in Addis Ababa.
 Which ethical model of doctor-patient
relationship can give help resolving
this tension? And how?
 Does your favorite model suggest that
we give more rights to patients? Or
less?

45. What makes communication effective?
 Communication between two people is most likely to be
successful when two conditions are present:
 One person is not more powerful than the other
 Both people have the same objective
 The doctor is likely to be in a more powerful position than
the patient; having professional knowledge social status,
and gate-keepers such as receptionists and secretaries.
 The patient is the supplicant, may have waited a long time
for the appointment, may feel humiliated by embarrassing
confessions or undress and may be heavily out-numbered
eg. during a ward round

46. Continued--
 The patient will be concerned mainly with their own
symptoms; and their perspective will be coloured by
the material, cultural and inter-personal context
 The doctor will be concerned with their whole work
load i.e. the present patient plus all the other patients
waiting to be seen; and their perspective will be
coloured by their professional training and
socialisation.
 In consequence, successful communication during a
consultation can be difficult to achieve. Doctors
need to understand these problems, because
successful communication can influence their
clinical effectiveness

47. Clinical Effectiveness
The following can affect the doctor's clinical
effectiveness.
A. Information exchange:
 Accuracy and completeness of the diagnosis
 Physiological response to therapy, e.g. recovery
after surgery
 Practicality of the treatment regime
B. Patient Satisfaction
 Effectiveness of therapy, e.g. placebo effect
 Compliance with medical advice e.g. 30% of
prescribed drugs are either not taken or taken
incorrectly;

48. Continued---
C. Balance of power
 Historically power has shifted between doctor and
patient; as medicine becomes more specialised, shift
of power towards doctor.
 However medical paternalism clashes with patient
autonomy, therefore the power shifts back towards
patient. The balance of power between doctor and
patient depends up on: Patient’s clinical status :
 unconscious, acutely ill
 managing a chronic disease
 healthy patient requesting assistance

49. Continued----
D. Setting of the consultation
 number of staff present
 whether patient undressed or in bed
 patient alone
 Depends on whether the person is GP, Hospital, surgeon etc
 symbols of authority- white coat, stethoscope etc

50. Continued---
E. Social distance between doctor and patient
 Doctors are members of social class and the majority
of consultations are with working class patients.
 Inverse Care Law: the lower class you are, the less
time you get with GP
F. Private consultations
 fee-paying patients often feel more confident; and
doctors may be more concerned to remain of service
to these patients.

51. Continued---
G. Negotiation
 Doctors have tended to prefer guidance-cooperation,
paternalistic style doctor-centred
 Patients prefer mutual participation
 Both doctors and patients have strategies for shifting
the balance of power in the direction they desire.
 The doctor can indicate lack of time and emphasise
greater knowledge.
 The patient may display emotion e.g. sob or cry; and
make unfavourable comparisons with other doctors

52. Suggestions for further
reading
1. Parker, Michael & Dickenson, Donna (2010),
The Cambridge Medical Ethics Workbook:
Case Studies, Commentaries, and Activities,
Cambridge; New York: Cambridge University
Press, Chapter 9.
2. Emanuel, Ezekiel J., & Emanuel, Linda L.
(1992), “Four Models of the Physician-Patient
Relationship”, Journal of the American
Medical Association, vol.267, no.16, pp.2221-
2226.