doctor-patient psych iii

8/7/2019 DOCTOR-PATIENT PSYCH III

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DOCTOR-PATIENT

RELATIONSHIP

Hyacinth C. Manood, MD, FPPA


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ACTIVE LISTENING

Both what MD and patient are saying

Undercurrents of unspoken feelings between them

LEVELS OF COMMUNICATION:

What the person believes about himself

What he wants others to believe about him Who the person really is.


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RAPPORT: Spontaneous, conscious feeling of harmonious

responsiveness that promotes the development of aconstructive therapeutic alliance.

Understanding and trust

One of the essential qualities of the clinician is interest in

humanity, for the secret of the care of the patient is in caring for

the patient.


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6 Strategies in Establishing Rapport:

Putting patient at ease

Finding patients pain and expressing compassion

Evaluating patients insight and becoming an ally

Showing expertise

Establishing authority as physician and therapist

Balancing the roles of emphatic listener, expert andauthority


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EMPATHY Self-reflection and understanding

Putting yourself in patients shoes

BUT NOT TO THE POINT OF

ASSUMING THE PATIENTS

BURDEN OR FANTASIZINGTHAT THEY CAN BE THEIR

PATIENTS SAVIOR.


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TRANSFERENCE

Sets of expectations, beliefs, and emotional responsesthat a patient brings to the doctor-patient relationship.

Based on repeated experiences that patient had withother important authority figures throughout life.


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COUNTERTRANSFERENCE

When doctors unconsciouslyascribe motives or attributes topatients that come from thedoctors past relationships.

Can be ineffective

Emotions breeds counter-emotions.


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Difficult patients: Appear to defeat attempts to help themselves

Uncooperative

Request for second opinion

Fail to recover in response to treatment

Use physical and somatic complaints to mask

emotional problems

With chronic cognitive disorders Represent professional failure, threat to MDs

identity and self-esteem


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PHYSICIANS AS PATIENTS Notoriously poor patients

giving up control

Dependent Vulnerable and frightened

Burden

Ignorance and incompetence


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AMA PRINCIPLES:

Section 1 : A physician shall be dedicated to providingcompetent medical service with compassion and respect for human

dignity.

1.A psychiatrist shall not gratify his/her own needs by exploitinga patient. The psychiatrist shall be ever vigilant about the impactthat his/her conduct has upon the boundaries of the doctor-patient relationship and thus upon the well-being of the patient.

These requirements become particularly important because ofthe essentially private, highly personal, and sometimes intenselyemotional nature of the relationship with the psychiatrist.


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Section 2. A physician shall deal honestly with patients andcolleagues, and strive to expose those physicians deficient in

character or competence, or who engage in fraud or deception.

1. The requirement that the physician conduct himself/herself with

propriety in his/her profession and in all the actions of his/herlife is especially important for the psychiatrist because the patient

tends to model his/her behavior on that of his/her psychiatristby identification. Further, the necessary intensity of thetreatment relationship may tend to activate sexual and otherneeds and fantasies of both patient and psychiatrist, while

weakening the objectivity necessary for control. Additionally, theinherent inequality in the doctor-patient relationship may lead toexploitation of the patient. Sexual activity with a current or

former patient is unethical.


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What about sexual relationship between ex-patients and

therapists?

Once a patient, always apatient.

Transferential reaction thatalways exists between the

patient and the therapistprevents a rational decisionabout their emotional or

sexual union.

no sanctions should prohibitemotional or sexualinvolvements by ex-patients

and their psychiatrists.

a reasonable time shouldelapse before such a liaison.


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sexual activity with a patient's family

member is also unethical. This is most

important when the psychiatrist is treating a

child or adolescent.


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Sexual issues and Sexual History

A reluctance to do so may reflect the physician's own anxiety

about sexuality or even an unconscious attraction toward thepatient

the omission of those questions generally tells patients that

the doctor is uncomfortable with the subject, thus leading toan inhibition about discussing any number of other sensitivesubjects.


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NON-SEXUAL ISSUES

Dynamics of gift-giving and Transferential

meaning to the patient of rejecting or

accepting the gift

Crossing the boundaries

Boundary violation - exploitative


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MODELS OF INTERACTION BETWEEN

DOCTORS AND PATIENTS:

PATERNALISTIC MODEL

INFORMATIVE MODEL

INTERPRETIVE MODEL

DELIBERATIVE MODEL


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Paternalistic Model

Doctors knows best; patientexpected to comply withoutquestioning

Autocratic model

physician asks most of thequestions and generally dominatesthe interview

doctor may decide to withhold

information when it is believed tobe in the patient's best interests

emergency situations


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Informative Model

Doctor dispenses information freely

Patient left to decide

Appropriate in one-time consultation wherein there is noestablished doctor-patient relationship

places the patient in an unrealistically autonomous role and

leaves him or her feeling the doctor is cold and uncaring.


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Interpretive Model

doctor presents and discusses alternatives, with the patient's

participation, to find the one that is best for that particular

person. Doctor is flexible

Sense of shared decision-making

E.g. Family physician


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Deliberative Model

The physician acts as a friend or counselor to the patient, notjust by presenting information, but in actively advocating a

particular course of action.

modify injurious behavior


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ILLNESS BEHAVIOR

Patients reaction to the experienceof being sick.

SICK ROLE- role that societyascribes to people when they are ill.

excused from responsibility

Expectations of a sick person Influenced by culture, attitudes


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Assessment of Individual Illness Behavior

Prior illness episodes, especially illnesses of standard severity(childbirth, renal stones, surgery)

Cultural degree of stoicism

Cultural beliefs concerning the specific problem Personal meaning of or beliefs about the specific problem

Particular questions to ask to elicit the patient's explanatorymodel:


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What do you call your problem? What name does it have?

What do you think caused your problem?

Why do you think it started when it did?

What does your sickness do to you? What do you fear most about your sickness?

What are the chief problems that your sickness has caused you?

What are the most important results you hope to receive from

treatment? What have you done so far to treat your illness?


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doctor-patient psych iii

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