DOCTOR-PATIENT

RELATIONSHIP

Hyacinth C. Manood, MD, FPPA

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.

RAPPORT:
 Spontaneous, conscious feeling of harmonious
responsiveness that promotes the development of a
constructive 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.
6 Strategies in Establishing Rapport:

 Putting patient at ease

 Finding patient’s pain and expressing compassion
 Evaluating patient’s insight and becoming an ally
 Showing expertise
 Establishing authority as physician and therapist
 Balancing the roles of emphatic listener, expert and
authority
EMPATHY
 Self-reflection and understanding

 “Putting yourself in patient’s shoes”

 BUT NOT TO THE POINT OF

ASSUMING THE PATIENT’S
BURDEN OR FANTASIZING
THAT THEY CAN BE THEIR
PATIENT’S SAVIOR.
TRANSFERENCE
 Sets of expectations, beliefs, and emotional responses
that a patient brings to the doctor-patient relationship.

 Based on repeated experiences that patient had with

other important authority figures throughout life.
COUNTERTRANSFERENCE
 When doctors unconsciously
ascribe motives or attributes to
patients that come from the
doctor’s past relationships.

 Can be ineffective

 “Emotions breeds counter-

emotions.”
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 MD’s

identity and self-esteem

PHYSICIANS AS PATIENTS
 Notoriously poor patients
 giving up control

 Dependent

 Vulnerable and frightened

 Burden

 Ignorance and incompetence

SEXUALITY
 Romantic relationships with patients

 The doctor is a powerful figure in the United States culture

and may trigger many unconscious fantasies of being
rescued, taken care of, and loved.

 own unconscious fantasies of being and needing to be all-

powerful, rescuing, and loving

 stepping back and assessing the situation are essential.

AMA PRINCIPLES:

 Section 1 : A physician shall be dedicated to

providing competent medical service with
compassion and respect for human dignity.
1.A psychiatrist shall not gratify his/her own needs by
exploiting a patient. The psychiatrist shall be ever vigilant
about the impact that 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 of the essentially private, highly personal,
and sometimes intensely emotional nature of the relationship
with the psychiatrist.
Section 2. A physician shall deal honestly with patients and
colleagues, 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/her life is especially
important for the psychiatrist because the patient tends to model his/her
behavior on that of his/her psychiatrist by identification. Further, the
necessary intensity of the treatment relationship may tend to activate
sexual and other needs and fantasies of both patient and psychiatrist, while
weakening the objectivity necessary for control. Additionally, the inherent
inequality in the doctor-patient relationship may lead to exploitation of the
patient. Sexual activity with a current or former patient is unethical.
What about sexual relationship between ex-patients and
therapists?

 Once a patient, always a  no sanctions should prohibit

patient. emotional or sexual
involvements by ex-patients
 Transferential reaction that
and their psychiatrists.
always exists between the
patient and the therapist  a reasonable time should
prevents a rational decision elapse before such a liaison.
about their emotional or
sexual union.
 sexual activity with a patient's family
member is also unethical. This is most
important when the psychiatrist is treating
a child or adolescent.
 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 the patient

 the omission of those questions generally tells patients that

the doctor is uncomfortable with the subject, thus leading to
an inhibition about discussing any number of other sensitive
subjects.
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

MODELS OF INTERACTION BETWEEN
DOCTORS AND PATIENTS:

 PATERNALISTIC MODEL

 INFORMATIVE MODEL

 INTERPRETIVE MODEL

 DELIBERATIVE MODEL
Paternalistic Model
 Doctors knows best; patient
expected to comply without
questioning
 Autocratic model
 physician asks most of the
questions and generally
dominates the interview
 doctor may decide to withhold
information when it is believed
to be in the patient's best interests
 emergency situations
Informative Model

 Doctor dispenses information freely

 Patient left to decide

 Appropriate in one-time consultation wherein there is no

established doctor-patient relationship

 places the patient in an unrealistically autonomous role and

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

 The physician acts as a friend or counselor to the patient, not

just by presenting information, but in actively advocating a
particular course of action.

 modify injurious behavior

ILLNESS BEHAVIOR
 Patient’s reaction to the
experience of being sick.

 SICK ROLE- role that society

ascribes to people when they are
ill.
 excused from responsibility
 Expectations of a sick person
 Influenced by culture, attitudes
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 explanatory
model:
 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?