M. Faisal Idrus

Relationship between doctor and patient is essential in all of medical specialization.

A good relationship, even more than a cure Physician work with sick people, not only with

disease syndromes. In psychiatric attention to this area can make

the difference between a succesfull and unsuccesfull outcome

The relationship may be the therapy Compromise and tolerance are required to

make it work Relationships may be the vehicle for change

You can’t win them all You can’t like/ love them all Role of games and rituals in relationships Change is not always possible or desirable There is always risk involved and its not

just patients who get hurt.

2/3 of psychosocial and psychiatric problems are missed (Goldberg & Blackwell, 1970)

54% of patients’ complaints are not elicited by physicians (Stewart et. al., 1979)

45% of patients’ concerns are not elicited 50% of consultations doctor and patient did

not agree on main presenting problem (Starfield et. al.,1981)

The Diagnostic PhaseI- OpeningII - Patient states his/her problem(s)III - Doctor explores the nature of the

problem(s)IV - Doctor and/or patient agree on nature

of the problem

The Management PhaseV - Doctor (and/or patient) propose

solution(s) to patient’s problem(s)VI - Doctor (and/or patient) examine the

solution(s)VII - Doctor (and/or patient) agree a

solutionVIII - Closing

1. Define the reason for the patient’s attendance

2. Consider other problems3. With the patient, choose an appropriate

action for each problem4. Achieve a shared understanding of the

problem with the patient (ideas, concerns and expectations)

5. To involve the patient in the management and encourage her to accept appropriate responsibility

6. Use time and resources appropriately

7. To establish and maintain a relationship with the patient which helps achieve other tasks

1. Gathering data - to understand the patient’s problem(s)

2. Rapport building - and responding to patients’ emotions

3. Patient education and motivation

1. Connecting (establishing rapport; curtain raisers and opening gambits)

2. Summarizing (listening and eliciting)3. Handover (negotiating, influencing and

gift-wrapping)4. Safety Netting(what to expect; how will

you know if you’re wrong;what will you do )5. Housekeeping (looking after yourself)

1. Exploring the disease and the illness experience

2. Understanding the whole person3. Finding common ground4. Integrating prevention and health

promotion5. Enhancing the doctor-patient relationship6. Being realistic

Clarify the goals of the consultation Understand the patient’s part in the

consultation Recognise the patient’s views in the

consultation Explore patient’s theories Provide ‘reactive’ explanations

1. Diagnosis acute or chronic illness2. Cure disease whenever possible3. Maximize functioning and minimize pain in

both acute and chronic conditions4. Provide solace and palliative treatment in

terminal cases

1. “Health Behavior” : action taken by people who see themselves as healthy in order to prevent disease or detect it while it is still a symptomatic

2. “Illness Behavior” : action of people who see themselves as ill, for purpose of defining their health state and finding a remedy.

3. “Sick Role Behavior” activity by individuals who consider themselves as ill for the purpose of getting well.

The given name to the patient’s responsibility Element of the sick role : 1.Allowed off normal duties2.seen as deserving of special care3.should seek help4.should want to get well

The physician must measure the impact of the various aspect of illnes to determine how to properly manage a patient 1.Impersonal Element, include physical limitation, medication, dietary.2.Intrapersonal Element, motivation, personality react to stress of an illness.3.Interpersonal Element, refer to effects on the patient relationship with family, friend, employer, and environment.

1. Trust and Confidence2. Instillation of hope and minimize of fear and

doubt.3. Empathy.4. A Personal relationship associate with concern.

a. diseaseb. illnessc. treatment

5. Communication

1. Activity – Passivity or Paternalistic Model

2. Guidance – Cooperation or Informative Model

3. Mutual Participation or Interpretive Model

4. Friendship or Deliberative Model

1. The model, base on the parent – infant relationship, the physician in the role of an powerful figure who renders who patient unable to contribute in a procedure.

2. This model may be seen when physicians idealize the sick role to suggest the patient comply totally with all recommendation for health care

1. The model, base on the parent – child relationship, emphasize the dominance, controlling role of the physician. Patient noncompliance may be base on pas struggle with such an authoritarian situation.

2. With increased consumer awareness and the availability of the various health strategies, patient may not blindly cooperate with or obey their physicians

1. This model, base on a dyadic relationship between two adults, allow the patient to help herself as she participates in a collaborative effort for health maintenance.

2. This model shared decision making3. The fact that, by possessing particular

knowledge and skill, the physicians is “one up on” the patient make this model more ideal than real.

The physician in this acts as a friend or counselor to patient, not just by presenting information, but in activity advocating a particular course of action.

Deliberative approach is commonly use by doctor hoping to modify injuriuos behavior, for examples, in trying to get their patient to stop smoking or lose weight.

At least two parties (doctor and patient) are involved

Both take steps to participate in the process

Information sharing is a prerequisite to shared decision making

A decision is made Both parties agree to the decision

(Concordance)

Refer to the patient’s right to choose among treatment options or diagnostic procedures for his disorder base on a thorough understanding of the potential benefit and risk. To asses the patient’s capacity to consent to treatment, the following element s should be considered.1. The treatment options must be explained by the physician in a manner understandable to a lay person. Such communication can be impeded by :

a. Fluctuating level of consciousnessb. Impaired cognition due to dementing disorderc. Ambivalence due to a psychiatric disorder or

anxiety

2. The patient must be understand the essential information regarding the treatment or procedure

3. The patient must be appreciate the situation within the context of the disease.

4. The patient must base his or her decision on a reasonable analysis of the information given

1. Transference 2. Counter – transference3. Resistensis

Refer to the displacement of feeling and attitude from important relationship in the patient’s past to the physician. Through transference, the physician may be regarded as a paternal or maternal figure, a teacher, or a rescuer. Such attitude can be positive or negative.1.A patient who views her physician as an all powerful or ever-caring parental figure will be dissapointed by any deviation from total availability2.Negative transference reaction (e.g., hostility, suspeciousness, competitiveness) may elicit inappropriately angry responses from physician

An emotional reaction to the patient base on the physician needs or conflicts

Refer to the complementary, albeit unconscious, attitude of physician toward her patient.

The physician identifies with the patient to a greater or lesser degree.

The attitude can be negative or positive Example, critical attitudes and erotic

fantasies

Capacity of the physician to put himself in the patient’s place to such a degree that he able to experience the meaning of the patient’s feelings, wishes, and thoughts.

General practice Hospital

◦ first contact◦ brief (5-10mins)◦ intervals short but

close review rare◦ long term◦ more social content◦ more intimate◦ more mutuality

◦ usually via filter◦ varies - may be

extended to hours◦ intervals very short or

very long◦ episodic◦ less social content◦ more paternalistic

All possibilities allowedmore scope for early exposure of psychosocial

illness More background knowledge - provides

diagnostic ‘cues’ and ‘clues’ More ready expression of anxieties Hidden agenda more likely to be revealed Sixth sense may operate

Reassurance more likely to be on target Compliance is aided by trust Observation more feasible Relieves patient of the burden of co-

ordinating care Translation service Protection from overzealous hospital people Being there