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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 cant win them all


You cant 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 Phase


IOpening
II - 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 Phase


V - Doctor (and/or patient) propose
solution(s) to patients problem(s)
VI - Doctor (and/or patient) examine the
solution(s)
VII - Doctor (and/or patient) agree a
solution
VIII - Closing

1.

2.
3.

4.

Define the reason for the patients


attendance
Consider other problems
With the patient, choose an appropriate
action for each problem
Achieve a shared understanding of the
problem with the patient
(ideas, concerns and expectations)

5.

6.
7.

To involve the patient in the


management and encourage her to
accept appropriate responsibility
Use time and resources
appropriately
To establish and maintain a
relationship with the patient which
helps achieve other tasks

1.
2.

3.

Gathering data - to understand


the patients problem(s)
Rapport building - and
responding to patients
emotions
Patient education and
motivation

1.

2.
3.

4.
5.

Connecting (establishing rapport; curtain


raisers and opening gambits)
Summarizing (listening and eliciting)
Handover (negotiating, influencing and
gift-wrapping)
Safety Netting(what to expect; how will
you know if youre wrong;what will you do )
Housekeeping (looking after yourself)

1.

2.
3.
4.

5.
6.

Exploring the disease and the illness


experience
Understanding the whole person
Finding common ground
Integrating prevention and health
promotion
Enhancing the doctor-patient relationship
Being realistic

Clarify the goals of the consultation


Understand the patients part in the
consultation
Recognise the patients views in the
consultation
Explore patients theories
Provide reactive explanations

1.
2.
3.

4.

Diagnosis acute or chronic illness


Cure disease whenever possible
Maximize functioning and minimize pain in
both acute and chronic conditions
Provide solace and palliative treatment in
terminal cases

1.

2.

3.

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
Illness Behavior : action of people
who see themselves as ill, for purpose
of defining their health state and
finding a remedy.
Sick Role Behavior activity by
individuals who consider themselves
as ill for the purpose of getting well.

The given name to the patients


responsibility
Element of the sick role :
1.Allowed off normal duties
2.seen as deserving of special care
3.should seek help
4.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 Confidence


2. Instillation of hope and minimize of fear and
doubt.
3. Empathy.
4. A Personal relationship associate with concern.
a. disease
b. illness
c. treatment
5. Communication

1.
2.
3.
4.

Activity Passivity or
Paternalistic Model
Guidance Cooperation or
Informative Model
Mutual Participation or
Interpretive Model
Friendship or Deliberative Model

1.

2.

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

1.

2.

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

1.

2.
3.

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.
This model shared decision making
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 patients 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 patients 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 consciousness
b. Impaired cognition due to dementing disorder
c. 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.
2.
3.

Transference
Counter transference
Resistensis

Refer to the displacement of feeling and attitude


from important relationship in the patients 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 availability
2.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 patients place to such
a degree that he able to experience
the meaning of the patients feelings,
wishes, and thoughts.

General practice
first contact
brief (5-10mins)
intervals short but
close review rare
long term
more social content
more intimate
more mutuality

Hospital
usually via filter
varies - may be
extended to hours
intervals very short or
very long
episodic
less social content
more paternalistic

All possibilities allowed


more 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 coordinating care
Translation service
Protection from overzealous hospital people
Being there