Doctor – patient communication

Doctor – patient communicationد.وليد عزيز العميدي

The theme behind all doctor-patient communication is eliciting or giving information in a way that fosters the relationship with the patient . in terms of giving information the key is in listening to what your patient already know , want to know , and are able to hear.
The physician must then communicate important information in a way that the patient can absorb . lecturing the patient on what you want him to know is often counterproductive and makes it harder for him to hear your message. e.g. telling the patient that he is 40 pounds overweight and needs to lose weight without talking to him about his concerns about weight and life style , and finding out what he has tried and what he wants to do about his weight will probably alienate him.

* Medical Practice
A. Seeking medical care
1. Patients behavior when ill and their expectations of doctors are influenced by their culture , their previous experiences with medical care, their physical and mental condition, and their personality styles (not necessarily personality disorders) .
2. Only about one third of individuals with symptoms seek medical care; most people contend with illnesses at home with over-the-counter medications and home treatment.
B. Seeking psychiatric care
1. In the United States, there is a stigma to having a psychiatric illness. Psychiatric symptoms are considered by many Americans to indicate "moral weakness" or a lack of self control. Because of this stigma, many patients fail to seek help.
2. It is important for patients to seek help since there is a strong correlation between psychological illness and physical illness. Morbidity rates and mortality rates are much higher in patients who need psychiatric attention.
Patient Personality Style and Behavioral Characteristics during Illness
Personality style Behavioral Characteristics During Illness
- Dependent - Has a need to be cared for by others, resulting in the desire for excessive attention from the physician during an illness.
- Obsessive-compulsive and Type A - Fear loss of control and may in turn become controlling during illness.
- Characterized by time pressure (i.e., feels rushed most of the time) and competitiveness.
- May also show hostility which is associated specifically with the development of coronary artery disease.
- Histrionic - May be dramatic, emotionally changeable, and approach the physician in an inappropriate sexual fashion during illness.
- Narcissistic - Has a perfect self-image which is threatened by illness.
- Often feels superior to others and therefore may request that only the "top" physicians be involved in treatment.
- Paranoid - Often blames the physician for the illness.
- Is overly sensitive to a perceived lack of attention or caring from the physician.
- Passive-aggressive - Asks for help but then does not comply with the physician s advice
- Schizoid - Becomes even more withdrawn during illness

C. the sick role :
1. A person assumes a particular role in society and certain behavioral patterns when he is ill (the "sick role," described by T. Parsons). The sick role includes exemption from usual responsibilities and expectation of care by others as well as working towards becoming healthy, and cooperating with health care personnel in getting well.
2. Critics of the sick role theory argue that it applies only to middle-class patients with acute physical illness, and that it emphasizes the power of the doctor and undervalues the individual s social support network in getting well.
D. Telling patients the truth
1. In the United States, adult patients generally are told the complete truth about the diagnosis, the treatment and its side effects and the prognosis of their illness. Falsely reassuring or patronizing statements in response to patient questions, (e.g., "do not worry about anything, we will take good care of you") are not appropriate.
2. Information about the illness must be given directly to the patient and not relayed to the patient through relatives.
a. With the patient s permission, the physician can tell relatives this information in conjunction with or after telling the patient.
b. Relieving the fears of close relatives of a seriously ill patient can bolster the support system and thus help the patient.
E. Special situations
1. Patients may be afraid to ask questions about issues that are embarrassing (e.g., sexual problems) or fear-provoking (e.g., laboratory results). A doctor should not try to guess what is troubling a patient; it is the doctor s responsibility to ask about such issues in an open-ended fashion and address them truthfully and fully with the patient.
2. Doctors have the primary responsibility for dealing with compliance issues as well as with angry, seductive, or complaining behavior by their patients. Referrals to other doctors should be reserved only for medical and psychiatric problems outside of the range of the expertise of the treating physician.





-Common Problems in the Doctor-Patient Relationship :
Problem do Do not
Angry patient Do acknowledge the patient s anger Do not take the patient s anger personally (the patient is probably fearful about becoming dependent as well as of being ill)
Seductive patient • Do call in a chaperon when you are with the patient

• Do gather information
using direct rather than open-ended questions

• Do set limits on the behavior that you will tolerate • Do not refuse to see the patient

• Do not refer the patient to another doctor
Non-compliant
Patient • Do examine the patient s
willingness to change his
health-threatening behavior
(e.g., smoking); if he is not willing, you must address that issue.

• Do identify the real reason for the patient s refusal to comply or to consent to a needed intervention . • Do not attempt to scare the patient into complying (e.g.,
showing frightening photographs
of untreated illness)

• Do not refer the patient to another doctor.

Suicidal patient Do assess the seriousness of the threat.

Do suggest that the
patient remain in the hospital voluntarily, if the threat is serious. • Do not release a hospitalized patient who is a threat to himself
[patients who are a threat to self
or others can be held
involuntarily
Complaining
Patient Do encourage the patient to speak to the other doctor directly if the patient complains about a relationship with another doctor.
Do speak to your own office staff if the patient has a complaint about one of them Do not intervene in the patient s relationship with another doctor
unless there is a medical reason
to do so.
Do not blame the patient for problems with office staff.
* Compliance:
A. Patient characteristics associated with compliance
1. Compliance is the extent to which a patient follows the instructions of the physician such as taking medications on schedule, having a needed medical test or surgical procedure and following directions for changes in life-style such as diet or exercise.
2. Patients unconscious transference reactions to their doctors, which are based in childhood parent-child relationships, can increase or decrease compliance .
3. Only about one-third of patients comply with treatment, one-third comply some of the time, and one-third do not comply with treatment.
B. Compliance is not related to patient intelligence, education, sex, religion, race, socioeconomic status, or marital status.

Compliance with Medical Advice
Factors Associated with
Increased Compliance Factors Associated with
Decreased Compliance Comments
Good physician-patient
Relationship Poor physician-patient
relationship Liking the doctor is the most
important factor in compliance;
it is even more important than
the doctor s technical skill
Physicians perceived as
unapproachable have low
compliance from patients
Patient feels ill and
usual activities are
disrupted by the illness Patient experiences
few symptoms
and little
disruption of usual
activities In asymptomatic illnesses such
as hypertension, only about half of patients initially comply with
treatment
Many asymptomatic patients who
initially complied have stopped
complying within 1 year of
diagnosis
Short time spent in
the waiting room Long time spent in
the waiting room • Patients kept waiting get angry
and then fail to comply
Belief that the benefits
of care outweigh its
financial and time costs Belief that financial
and time costs of care
outweigh its benefits The "Health Belief Model"
of health care
Written diagnosis and
instructions for
treatment Verbal diagnosis and
instructions for
treatment Patients often forget what is
said during a visit to the doctor
because they are anxious
Asking the patient to repeat your
verbal instructions can improve
understanding and thus increase
compliance
Acute illness Chronic illness Chronically ill people see doctors
more often but are more critical
of them than acutely ill people
Recommending only one
behavioral change
at a time Recommending multiple behavioral
at once To increase compliance, instruct the patient to make one change (e.g., stop smoking) this month, and make another change (e.g., go on a diet) next month.
Recommending too many changes at once will reduce the likelihood that the patient will make any changes
Simple treatment
Schedule Complex treatment
schedule Compliance is higher with medications that require once daily dosing, preferably with a meal
Patients are more likely to forget
to take medications requiring
frequent or between meal dosing
Older physician Younger physician Usually young physician age is
only an issue for patients in
the initial stages of treatment
Peer support Little peer support Membership in a group of people
with a similar problem [(e.g.,
smoking can increase compliance

* The Clinical Interview :
A. Communication skills
1. Patient compliance with medical advice, detection of both physical and psychological problems, and patient satisfaction with the physician are improved by good doctor-patient communication.
2. One of the most important skills for a physician to have is how to interview patients. In the interview, the physician must first establish trust in and rapport with the patient and then gather physical, psychological, and social information to identify the patient s problem.
3. The interview serves to obtain the patient s psychiatric history including information about prior mental problems, drug and alcohol use, sexual activity, current living situation, and sources of stress.
B. Specific interviewing techniques
1. Direct questions. Direct questions are used to elicit specific information quickly from a patient in an emergency situation (e.g., "Have you been shot?") or when the patient is seductive, or overly talkative.
2. Open-ended questions
a. Although direct questions can elicit information quickly, open-ended types of questions are more likely to aid in obtaining information about the patient, and not close off potential areas of pertinent information.
b. Using open-ended questions (e.g., "What brings you in today?"), the interviewer gives little structure to the patient and encourages the patient to speak freely.

Aims of the Clinical Interview and Interviewing Techniques
Aim Technique Specific use
To establish rapport -Support and empathy



-Validation -To express the physician s interest , understanding, and concern for the patient.

-To give value and credence to the
patient s feelings
To maximizing information gathering -Facilitation





-Reflection






-Silence

-To encourage the patient to elaborate on an answer; can be a verbal question or body language
such as a quizzical expression.


-To encourage elaboration of the increased after lifting answer by repeating the part of the patient s previous response.



-To increase the patient s
Responsiveness
To clarify
information -Confrontation



-Recapitulation -To call the patient attention to his or her responses or body language.


-To sum up all of the information obtained during the interview to ensure that the doctor understands
the information provided by the patient.