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Transcript
Doctor patient relationship
8th nov. 2015
Seeking medical care
Patients’ behavior when ill and their expectations of physicians are
influenced by their:
1. culture,
2. previous experiences with medical care,
3. physical and mental conditions,
4. personality styles (Table 21.1) and
5. coping skills.
Only about one-third of Americans with symptoms seek medical
care; most people contend with illnesses at home with over-thecounter medications and home management.
Seeking psychiatric care
In the US, there is a stigma to having a psychiatric
illness. Psychiatric symptoms are considered by many
Americans to indicate a moral weakness or a lack of
self-control. Because of this stigma, many patients fail
to seek help.
It is important for patients to seek help since there is a
strong correlation between psychological illness and
physical illness. Morbidity rates and mortality rates are
much higher in patients who need psychiatric attention.
The “sick role”
A person assumes a particular role in society and certain
behavioral patterns when he or she is ill (the “sick role,”
described by T. Parsons). The sick role includes:
1. exemption from usual responsibilities,
2. expectation of care by others, and
3. working toward becoming healthy and cooperating with
health care personnel in getting well.
Critics of the sick role theory argue that it applies only
to middle-class patients with acute physical illness,
emphasizes the power of the physician, and
undervalues the individual’s social support network in
getting well.
Telling patients the truth
In the US, adult patients generally are told the complete
truth about the diagnosis, the management and its side
effects, and the prognosis of their illness. Falsely
reassuring or patronizing statements in response to
patient questions (e.g., “Do not worry, we will take good
care of you” or “You still have one child” [after a
miscarriage]) are not appropriate.
Information about the illness must be given directly to
the adult patient and not relayed to the patient
through relatives. Parents decide if, how, and when
such information will be given to an ill child.
a. With the patient’s permission, the physician can tell
relatives this information in conjunction with, or after,
telling the patient.
b. Relieving the fears of close relatives of a seriously ill
patient can bolster the support system, and thus help the
patient.
Special situations
Patients may be afraid to ask questions about issues
that are embarrassing (e.g., sexual problems) or fearprovoking (e.g., laboratory results). A physician should
not try to guess what is troubling a patient; it is the
physician’s responsibility to ask about such issues in an
open-ended fashion and address them truthfully and fully
with the patient.
Physicians have the primary responsibility for dealing
with adherence issues (see II below), as well as with
angry, seductive, or complaining behavior by their
patients (Table 21.2).
Referrals to other physicians should be reserved only for
medical and psychiatric problems outside of the treating
physician’s range of expertise.
ADHERENCE
Patient characteristics associated with adherence
Adherence refers to the extent to which a patient follows the
recommendations of the physician, such as taking medications on
schedule, having a needed medical test or surgical procedure, and
following directions for changes in lifestyle, such as diet or exercise.
Patients’ unconscious transference reactions to their physicians,
which are based in childhood parent–child relationships, can increase
or decrease adherence.
Only about one-third of patients adhere fully to management
recommendations, one-third adhere some of the time, and one-third
do not adhere to such recommendations.
Factors that increase and decrease
adherence
Adherence is not related to patient intelligence, education,
sex, religion, race, socioeconomic status, or marital status.
Adherence is most closely related to how well the patient likes
the doctor. The strength of the doctor–patient relationship is also
the most important factor in whether or not patients sue their
doctors when an error or omission is made or when there is a
poor outcome.
THE CLINICAL INTERVIEW
Communication skills
Patient adherence with medical advice, detection of both physical
and psychological problems, and patient satisfaction with the
physician are improved by good physician–patient
communication.
a. Private… no desk or other obstacle …. eye level
b. ..first establish trust and rapport and then
gather information
c. educate and motivate to adhere to mx plan
d. Dangerous or threatening patients..
When interviewing young children the
physician should
a. First establish rapport by interacting with the child in a
nonmedical way, for example, drawing pictures.
b. Use direct rather than open-ended questions, for example,
“What is your sister’s name?” rather than “Tell me about your
family.”
c. Ask questions in the third person, for example, “Why do you
think that the little boy in this picture is sad?”
Direct questions are used to elicit specific information
quickly from a patient in an emergency situation (e.g.,
“Have you been shot?”) or when the patient is
seductive or overly talkative.
Open-ended questions are more likely to aid in
obtaining information about the patient, and to
encourage the patient to speak freely.
Interviewing techniques:
• Support and empathy……………….
• Validation …………………………………Rapport
• Facilitation
• Reflection
• Silence………………………………………Gather info.
• Confrontation
• Recapitalulaiton ……………………… Clarify