THE PATIENT DOCTOR

RELATIONSHIP
Prof. Dr. Tuti Wahmurti, dr., SpKJ (K)
Reference :
Kaplan & Sadocks Synopsis of Psychiatry, Behavioral Sciences / Clinical
Psychiatry 10
th
ed., 2007, 1-

INTRODUCTION (1)
The quality of patient doctor relationship is crucial to the
practice of medicine.
The capacity to develop an effective relationship requires a
solid appreciation of the complexities of human behavior and
rigorous education in the techniques of talking and listening to
people
An effective relationship is characterized by good rapport.
Rapport is the spontaneous, conscious feeling of harmonious
responsiveness that promotes the development of a
constructive therapeutic alliance.


an understanding and trust between
the doctor and the patient.
INTRODUCTION (2)
Frequently, the doctor is the only person to whom the patient
can talk about things that they cannot tell anyone else.

Patient trust their doctor to keep secrets.

This confidence must not be betrayed
Patients who feel that someone :
knows them
understand them
accept them
INTRODUCTION (3)
}
find
a source of strength
ESTABLISHING RAPPORT
1. Putting patients and interviewers at ease.
2. Finding patients pain and expression compassion.
3. Evaluating patients insight and becoming an ally.
4. Showing expertise.
5. Establishing authority as physians.
6. Balancing the roles of emphatic listener, expert, and
authority.
EMPATHY
Is a way increasing rapport.
Normal understanding of what other people are feeling



the skills in establishing and maintaining rapport
TRANSFERENCE
As the set of expectations, beliefs, and emotional responses
that a patient brings to the patient doctor relationship.
They are based on repeated experiences the patient has had
with other important authority figures throughout life.
The patients attitude toward the physician is apt to be a
repetation of the attitude he or she has had toward authority
figures.
COUNTERTRANSFERENCE
Just the patient brings transferencial attitudes to the patient
doctor relationship, doctors themselves often have
countertransferential reactions to their patients.
It can take the form of negative feelings that are disruptive to
the patient doctor relationship.
It can also encompass disproportionately positive, reaction to
patients.
MODELS OF INTERACTION BETWEEN
DOCTOR AND PATIENT
1. The paternalistic model.
2. The informative model.
3. The interpretive model.
4. The deliberative model.
The paternalistic model
= the autocratic model.
It is assumed that the doctor. knows best.
The doctor will prescribe treatment, and the patient is expected
to comply without questioning.
The physician ask most of the questions and generally
dominates the interview.
Circumstances arises in which a paternalistic approach is
desirable :
Emergency situations life saving decisions without
long deliberations.
Some patients who feel overwhelmed by their illness
and are comforted by a doctor who can take charge.
The informative model
The doctor dispenses information.
All available data are freely given, but the choice is left wholly
up to the patient.

expect the patients to make up their
own minds without suggestion or
interference from them.
This model may be appropriate for certain onetime
consultations where no established relationship exist regular
care of a known physician.
The interpretive model
A sense of shared decision-making is established as the doctor
presents and discusses alternatives, with the patients
participation to find the one.
That is best for the particular person.
The doctor does not abrogate the responsibility for making
decisions, but is flexible, and is willing consider question and
alternative suggestions.
The deliberative model
The physician acts as a friend or counselor to the patient, in
actively advocating a particular course of acion.
The deliberative approach is commonly used by doctors
hoping to modify injurious behavior,
e.g. to stop smoking.
to lose weight
THREE FUNCTION OF THE MEDICAL
INTERVIEW
1. Determining the nature of problem.
Knowledge base of disease, disorders, problems, and
clinical hypothesis from multiple conceptual domains :
biomedical, sociocultural, psychodynamic,and behavioral.
Ability to elicit data.

2. Developing and maintaining a therapeutic relationship.
3. Communicating information and implementing a treatment
plan.
INTERVIEWING EFFECTIVELY (1)
1. Beginning the interview :
Provides a powerful first impression to patients.
Establish rapport quickly, put the patient at case,
show respect.

A productive exchange of information.

Making a correct diagnosis
Establishing treatment goal
2. The interview proper :
Physician discover in detail what is troubling patients.
Do in a systematic way that facilities the identification
of relevan problems in the contex of an ongoing
emphatic working alliance with patients.

INTERVIEWING EFFECTIVELY (2)
COMMON INTERVIEW TECHNIQUES (1)
1. Establish rapport as early as possible.
2. Determine the patients chief complaint.
3. Use the chief complaint to develop a provisional differential
diagnosis.
4. Rule the various diagnostic possibilities out or in by using
focused and detailed questions.
5. Follow up on vague or obscure replies with enough persistence
to acurately determine the answer to the question.
6. Let the patient talk freely enough to observe how tightly the
thoughts are connected.
7. Use a mixture to open ended and closed-ended questions
8. Give the patient a chance to ask questions at the end of the
interview.
9. Conclude the initial interview by conveying a sense of
confidence and, if possible, of hope.
COMMON INTERVIEW TECHNIQUES (2)
Checklist for Clinicians
1. I put the patient at ease.
2. I recognized the patients state of mind.
3. I help the patient warm up
4. I help the patient suspiciousness
5. I stimulated the patients verbal production.
6. I understood the patients suffering
7. I tuned in the patients effect.
8. I became aware of the patients revel of insight.
9. I assumed the patients view of the disorder.
10. I had a clear perception of the overt and therapeutic goals of
treatment.
11. I stated the overt goal of treatment to the patient.
12. I let the patient know that he or she is not alone with the
illness.
13. The patient thank me and made another appointment.
Checklist for Clinicians