Physician Patient Relationship

Physician-Patient Relationship
AB.RAJAR.
ASSISTANT PROFESSOR.
COMMUNITY HEALTH SCIENCES.

Learning Objectives.
• Introduction.
• Why does it matter?
• Types of relationships.
• What is the ideal patient-physician relationships ?
• Ethical Models of Physician-Patient Relationship.
• Relationship of the 21st century
• Conclusion.

INTRODUCTION
• Doctor-Patient relationships
express the values of medical
profession.
• The relationship should not be
fish and fisherman.
• It should always be like fish and
water.

Hippocrates viewed the physician as 'captain of the ship' and
the patient as someone to take orders

Why Does It Matter
• The patient-physician relationship is fundamental for
providing and receiving,
– Excellent care
– To the healing process
– To improved outcomes
• Therefore, it is important to understand what
elements comprise the relationship and identify
those that make it "good."
AB.RAJAR/drabrajar@gmail.com

Why Does It Matter
• Because of the rapidly changing environment
that characterizes health care today,
• We need to understand what physicians and
patients must do to protect and nurture the
relationship.

The Patient
• Patients are individual human beings with problems that all to
often transcend their physical complaints.
• The patient are not „cases” or „admissions” or „diseases”

Parsons’ model
• The nature of relationships determines
the success of the
treatment/intervention.
• PARSON was one of the earliest
sociologist to examine the patient
doctor 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
and patients.

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 necessary,
providing a brief exemption for patient from
social responsibilities

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

Parsons’ “ Ideal Doctor”
 Apply a high degree of-
 skill and
 knowledge
 Acts for the good of the patient
 Remain objective and
emotionally detached
 Respect the position of privilege

DOCTOR’S ROLE.
• Health care provider.
• Technical consultant.
• To convince the necessity of
medical services.
• A tendency for the “Consumer to
be right.”

DOCTOR COMPETENCIES
• Patient care.
• Medical knowledge.
• Practice-based learning (PBL) and
improvement.
• Interpersonal skills.
• Communication skills.
• Professionalism.
• System-based practice.

Patient’s role.
• Health shoppers indicators of
consumer behavior
• Cost consciousness.
• Information seeking.
• Exercising independent
judgment.
• Consumer knowledge.

CONFLICT OF INTEREST
• Interests of patient Vs society.
• Interests of patient Vs other patients.
• Problems of confidentiality.

The Physician Charter.
Principle includes:
– Patient welfare.
– Patient autonomy.
Commencements Includes:
– Honesty with Patients.
– Patient confidentiality.
– Maintaining appropriate
relationships with patients.

PATIENTS BELIEFS & EXPECTATIONS
• Influenced by:
1. Previous experience.
2. Literature.
3. The media.
4. Family and friends.
5. Cultural influences.
6. Social significance.
These beliefs influence in outcome.

TYPES OF RELATIONSHIPS
1) Paternalism (Doctor centered, Disease Model).
2) Mutuality (Patient centered, Illness model).
3) Consumerism (Typical in private practice)
4) Default.
5) Conflict.

1.Paternalism
• Traditional form of doctor-patient relationship
• Doctor takes on role of parent
• Doctor is the expert and patient expected to cooperate
• Tightly controlled interviewing style aimed at reaching an
organic diagnosis
• Passive patient and a dominant doctor
• Focus is on care, rather than autonomy

PATERNALISM
• Making of decisions by professionals on behalf of patients.
• Dirty word-OUT-AUTONOMY- is IN.
– Liberty,diginity,individuality,independence,accepting responsibility, self assertion,
knowledge of one’s own interests,privacy,voluntarieness,freedom from
deception.

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

Advantages
• The supportive nature of paternalism appears to be
important when patients are very sick at their most
vulnerable
• Relief from the burden of worry is curative in itself, and the
trust and confident implied by this model allows doctor to
perform “medical magic”

2.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

2.Mutuality Cont...
• Patients need to define their problems in an open and full manner
• The patient has right to seek care elsewhere when demands are not satisfactorily
met.
• 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

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

Disadvantages
• Physicians do not know what certain degree should they
reach in communication
• Is the patient capable of making the important
therapeutic .

3.Consumerism
• We can simplify the complicated relationship with “buyer and seller”
relationship, is it good or bad? What is your opinion?
• The patient can challenge to unilateral decision making by physicians in
reaching diagnosis and working out treatment plans
• Reversing the very basic nature of the power relationship.

4.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.

Patient Centred consultation style
• Dr is less authoritarian , encourages patients to express their own
feelings and concerns , empathic , listen more than talk .
• Dr use open end questioning , show interest in psycho-social aspect of
patient’s illness .

Length of Consultation
 Average 8 minutes
makes...
– Patient centred
consultation styles
more difficult.

Consultation style.
It’s serious, isn’t it doctor ?
• Sustained physician patient
partnerships with bonds of trust
and knowledge of patients were
correlate of three outcomes of
care…
– Adherence.
– Satisfaction.
– Improved health status.

Types of Dr-Pt relationship
 Doctor controlled
 Patient controlled

Prototypes of doctor-patient relationship
Physician
control (Low)
Physician
control (High)
Patient control
(Low)
Default Paternalism
Patient control
(High)
Consumerism Mutuality

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

ETHICAL MODELS AT GLANCE.
–PATERNALISTIC MODEL.
–INFORMATIVE MODEL.
–INTERPRETIVE MODEL.
–DELIBERATIVE MODEL.

PETERNALISTIC MODEL
• Principle.
– The doctor should make all the decisions for the patient.
• Assumptions.
– People are not always rational/mature.
– Experts knows better about the needs of patients.
– Qualified doctors have good will.
• Sources:
– Hippocratic oath.
• Problems:
– Are the needs of patients objective?
– How can we be sure that doctors have good will?

INFORMATIVE MODEL
• Principle.
– The doctor should provide all the relevant information for the
patient to make a decision, and provide the selected
intervention on this basis.
• Assumptions.
– A fact/value division of labor yields the best medical results.
– What is good for a patient depends on what his/her personal
values.
– Consumerism.
• Problems.
– What if patient is unconcious,incompetent and making choices
totally unacceptable by our ethical standards?

INTERPRETIVE MODEL
• Principle.
– The doctor should help the patient to articulate his/her values through
interpretation, and provide intervention which is truly wanted.
• Assumptions.
– Patients have unconscious and inconsistent desires.
– Their conscious decisions may not reflect their deepest values.
• Limitations.
– All that a doctor can do is to help the patient see his/her own
desires/values more clearly, but not to criticize them.

DELIBERATIVE MODEL
• Principle.
– The doctor should help the patient to deliberate well through dialog and
discussion, and ,
– So develop values which are objective and truly worthy.
• Assumptions.
– The objectivity of values.
– The patient’s good life consist not in the satisfaction of desires, but
maturity and rationality.
• Problems.
– Is the model different from the paternalistic model?
– What is the difference b/w dialog and persuasions?

The Patient
"nothing about me without me."

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

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.

Principal elements that are essential to the relationship
1) Communication.
2) Office Experience.
3) Hospital Experience.
4) Education.
5) Integration.
6) Decision-Making.
7) Outcome.

Communication and Treatment
• Advice reassurance and support
from the doctor can have a
significant effect on recovery.
• The placebo effect

Communication with pt includes
 An integrated approach to information gathering.
 Seeking to identify physical psychological and social factors
 Will likely to produce a better outcome of health care.

Elements of Communication
• Seven Essential Elements in Physician-Patient Communication
– Build the doctor-patient relationship
– Open the discussion
– Gather information
– Understand the patient’s perspective
– Share information
– Reach agreement on problems and plans
– Provide closure

Gathering data to understand the patient
• Nonverbal skills
– Attentive and interested body
posture
– Facial expression
– Appropriate eye contact
– Touch

Who are “difficult” patients?
What characteristics make a patient “difficult”?
– Mental health disorders
– Multiple symptoms
– Chronic pain
– Functional impairment
– Unmet expectations
– Lower satisfaction with care
– High users of health care services
Dr. Tom O’Dowd coined the term “heartsink patient”
BMJ, 1988

Conclusion
• Relationship between patients and doctors are often
unstated, and they are dynamic.
• As conditions change, the kind of relationship that
works best for a patient may change.
• Doctors and patients should choose a “relationship
fit”.
• effectiveness of the patient-physician relationship
directly relates to health outcomes.

Physician Patient Relationship

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