How good a doctor will you be?

The doctor-patient relationship.

R.Fielding

Dept. of Community Medicine, HKU

© 1999

Learning objectives

By the end of this lecture, you should be able to:

• explain why the DPR is important

• analyse the ways the DPR might influence patients and their care

• predict problems arising in patient care from poor DPRs.

Why is the doctor-patient relationship important?

• All medical care is effected through the the dr.- pt. relationship (DPR)

• Nature of relationship determines degree of pt. participation

• DPR is the main determinant of patient satisfaction.

• Case outcome therefore dependant upon optimum DPR.

Types of DPR

1. Consensual models:• Parson’s (1951) “Sick role” model

– pt. gains exemption from role responsibilities– pt. not held responsible for own illness– pt. must want to get well– pt. should comply w. legitimate advice

• - Szasz & Hollender, (1956) 3 types of DPR– activity-passivity– cooperation-guidance

– mutual participation.

• Stewart & Roter, (1989) 4 types of DPR based on degree of control.– paternalistic– mutuality– default– consumerist

• Needs to acknowledge process and that relationships are not static but dynamic & reflect different needs at different stages.

2. Conflict models

• Conflict between what dr. & what pt. wanted to achieve.

– If Dr.s roles could include active, guiding, participative, then so too could pt.

– Friedson (1971) added: –guidance -cooperation (pt. guides

cooperative dr.)–passivity-activity (dr. passive, pt. active)

3. Negotiation models:• Newer perspective seen as pt.s have

negotiating rights (consumerist perspective).

• Pt.s better informed now. Expect their own concerns to be addressed.

• When pt. concerns not addressed, pt.evaluation of consultation poorer and satisfaction lower.

• Need to accomodate patients’ care acts (including non-adherence w. Rx).

Influences on DPR

• professional - lay differences

• stereotypes

• status differences

• expectations

• relationship between DPR & outcomes

“Problems” with patients

• Only about 50% of pts. adhere to Rx. (Ley, 1978)

• Doctor-shopping prevalence 40% in HK. (Lo et al, 1994).

• Dissatisfaction w. information given in HK.(Fielding & Hung, 1995).

• Link between satisfaction w. information giving, DPR, and Quality of Life (QoL) for pts. w. chronic illness. (Fielding et al, 1997)

Summary• DPR major determinant of Rx outcome

(except in passive or forced circumstances).• Therefore in order to be optimally effective

close attention needs to be given to meeting pt. needs during consults. This means;– assessing pts. preferences

– identifying their reasons for consulting

– checking if there are other issues than the presenting ones

– providing opportunities for pts. to participate in negotiating Rx.

• Purpose of each Rx needs to be negotiated, especially if;– Rx / follow-up meets drs. needs rather

than pts., assess potential costs to pt. in meeting FU.

– Rx has side-effects that may disrupt pts. activities or routines.

– Rx schedule is complex or prolonged, or requires major change in activities.

• Therefore, adequate information giving vital in context of mutual respect & responsibility for outcome.