The Patient-Doctor Relationship

- One of the most crucial aspects in the practice of medicine and psychiatry
- Requires
o Solid appreciation of the complexities of human behavior
o A rigorous education in the techniques of talking and listening to people
Levels of communication
- A physician must have skills of active listening
o listening both to what they and the patient are saying and to the
undercurrents of the unspoken feelings between them
- A physician must understand that communication occurs at several levels at
once
o What the person believes about himself or herself
o What he or she wants others to believe about them
o Who the person really is
Rapport
- The spontaneous, conscious feeling of harmonious responsiveness that
promotes the development of a constructive therapeutic alliance
- A good relationship is established with good rapport
- Establishing good rapport process
o Defined by Ekkehard Othmer and Sieglinde Othmer
Empathy
- Way of increasing rapport
- Essential characteristic for psychiatrists but not a universal human capacity
- Incapacity for empathy is central to some personality disturbances
o Antisocial Personality Disorder
o Narcissistic Personality Disorder
- Can be focused and deepened through
o Training
o Observation
o Self-Reflection
- Often asked “How can you understand what I am going through if you haven’t
gone through it yourself?”
o Shared experience of being human
Transference
- The set of expectations, beliefs, and emotional responses that a patient brings to
the patient-doctor relationship
- Not necessarily based on who the doctor is or how he/she acts but on
experiences a patient has had with previous authority figures
- Attitude can range from one of basic trust and the belief that the physician has
the patient’s best interest in mind or mistrust and the belief that the physician will
be potentially abusive
Countertransference
- Doctors can often have countertransferential reactions towards their patients.
- Can take the form of negative feelings towards the patient but can also take the
form of disproportionately positive, idealizing, or even eroticized reactions to
patients
- Physicians, not only patients, often have unconscious or unspoken expectations
about their patients
- Countertransference feelings do not always have to be perceived in negative
terms. They also have the potential, if recognized and analyzed, to help the
doctor better understand the patient who has stimulated the feelings.
Disliking a Patient
- A physician who actively dislikes a patient is apt to be ineffective
- If a physician is able to rise above their emotions a relationship of mutual
antagonism can evolve into one of at least acceptance and grudging respect
- Doctors who have strong unconscious needs to be all-knowing and all-powerful
may have particular problems with certain types of patients. These types of
patients may be the most difficult to handle.
o Those who repeatedly appear to defeat attempts to help themselves
 (Patients with severe heart disease who continue to smoke or
drink)
o Those who are perceived as uncooperative
 (Patients who question or refuse treatment)
o Those who request a second opinion
o Those who fail to recover in response to treatment
o Those who use physical or somatic complaints to mask emotional
problems
 (Patients with somatization disorder, pain disorder,
hypochondriasis, or factitious disorders)
o Those with chronic cognitive disorders
 (Patients with dementia of the Alzheimer's type)
o Those who represent a professional failure and, thus, are a threat to the
physician's identity and self-esteem
Models of Interaction Between Physicians and Patients
- Paternalistic
o Also known as the autocratic model
o Assumed that the doctor knows what’s best for the patient
o The doctor will prescribe the patient medication and the patient will take it
without questioning. Moreover, the doctor may decide to withhold
information when it is believed to be in the patient's best interests
o Circumstances arise in which a paternalistic approach is desirable. In
emergency situations the doctor needs to take control and make
potentially life-saving decisions without long deliberation
- Informative
o The doctor in this model dispenses information. All available data are
freely given, but the choice is left wholly up to the patient.
o This model may be appropriate for certain one-time consultations where
no established relationship exists, and the patient will be returning to the
regular care of a known physician.
o May cause the patient to feel as though the doctor is uncaring or unwilling
to help
- Interpretive
o Involves the doctor understanding the patient more personally
o Doctors who have come to know their patients better and understand
something of the circumstances of their lives, their families, their values,
and their hopes and aspirations, are better able to make
recommendations that take into account the unique characteristics of an
individual patient
o A sense of shared decision-making is established as the doctor presents
and discusses alternatives, with the patient's participation, to find the one
that is best for that particular person.
o The doctor in this model is more flexible and willing to discuss alternatives
and suggestions
- Deliberative
o The physician in this model acts as a friend or counselor to the patient, not
just by presenting information, but in actively advocating a particular
course of action.
o Commonly used by doctors hoping to modify injurious behavior, for
example, in trying to get their patients to stop smoking or lose weight.
- No one model is superior to another and a doctor may or may not use all 4
approaches in a single visit.
- A problem will arise if the doctor is not able to switch between strategies and is
fixed on one approach
Illness behavior
- Aspects of the behavior have sometimes been termed as the “sick role”
- Describes the patient’s reactions to the experience of being sick.
Psychiatric versus Medical-Surgical Interviews
- Mack Lipkin Jr.
o Described the 3 functions of a medical interview
 To assess the nature of the problem and implement a treatment
plan
 To develop and maintain a therapeutic relationship
 To communicate information
o Same in Psychiatric and Surgical interviews
- Also universal are the predominant coping mechanisms used in illness, both
adaptive and maladaptive
o These mechanisms include such reactions as anxiety, depression,
regression, denial, anger, and dependency
- Psychiatric Interview have two main technical goals
o Recognition of the psychological determinants of behavior
o Symptom classification
- These two goals are reflected in two styles of interviewing
o Insight oriented or psychodynamic style
 This style of interviewing attempts to elicit unconscious conflicts,
anxieties, and defenses
o Symptom oriented or descriptive style
 Emphasizes the classification of patients' complaints and
dysfunctions as defined by specific diagnostic categories
- Psychiatric patients often contend with stresses and pressures that differ from
those of patients who do not have a psychiatric disorder. These stresses include
o Stigma attached to being a psychiatric patient (it is more acceptable to
have a medical or surgical problem than a mental problem)
o Communication difficulty because of disorders of thinking
o Oddities of behavior
o Impairments of insight and judgment that might make compliance with
treatment difficult
Biophysical Model
- Derived from the general systems theory and stressed an integrated systems
approach to human behavior and disease
- Composed of 4 different systems
o Biological System
 Emphasizes the anatomical, structural, and molecular substrate of
disease and its effects on the patient's biological functioning
o Psychological System
 Emphasizes the effects of psychodynamic factors, motivation, and
personality on the experience of illness and the reaction to it
o Social System
 Emphasizes cultural, environmental, and familial influences on the
expression and the experience of illness
- Engel's model does not assert that medical illness is a direct result of a person's
psychological or sociocultural makeup but, rather, encourages a comprehensive
understanding of disease and treatment
Interview
- Interviewing effectively is one of the most powerful tools available to the
physician
- Many factors can influence the content and process of an interview
- Patients' personalities and character styles significantly influence reactions as
well as the emotional context in which interviews unfold
Beginning an interview
- How a physician begins an interview provides a powerful first impression on a
patient, which can affect the remainder of the interview
- It is important to establish rapport quickly, put the patient at ease, and show
respect
- After introductions and initial assessments are over it is important to begin with
appropriate opening remarks.
Specific Techniques
- Open-Ended versus Close-Ended questions
o An ideal interview would be to begin with open-ended questions,
continuing by being more specific, then closing with detailed and direct
questioning
o Close ended question can be effective in getting quick and specific
responses about a topic
- Reflection
o In the technique of reflection, a doctor repeats to a patient, in a supportive
manner, something that the patient has said
o The goal of reflection is twofold:
 to assure the doctor that he or she has correctly understood what
the patient is trying to say
 To let the patient know that the doctor is perceiving what is being
said
o The response is meant to let the patient know that the doctor is both
listening to the patient's concerns and understanding them.
- Facilitation
o Doctors help patients continue in the interview by providing both verbal
and nonverbal cues that encourage patients to keep talking
- Silence
o Silence can be constructive and, in certain situations, allow patients to
contemplate, to cry, or just to sit in an accepting, supportive environment
in which the doctor makes it clear that not every moment must be filled
with talk.
- Confrontation
o The technique of confrontation is meant to point out to a patient something
to which the doctor thinks the patient is not paying attention, is missing, or
is in some way denying.
o Meant to help patients face whatever needs to be faced in a direct but
respectful way
- Clarification
o In this technique, doctors attempt to get details from patients about what
they have already said
- Interpretation
o The technique of interpretation is most often used when a doctor states
something about a patient's behavior or thinking of which the patient may
not be aware
o Interpretations usually help clarify interrelationships that the patient may
not see. It is a sophisticated technique and should generally be used only
after the doctor has established some rapport with the patient and has a
reasonably good idea of what some interrelationships are.
- Summation
o A doctor can take a moment and briefly summarize what a patient has
said thus far. Doing so assures both the patient and doctor that the doctor
has heard the same information that the patient has actually conveyed.
- Explanation
o Doctors explain treatment plans to patients in easily understandable
language and allow patients to respond and ask questions
- Transition
o The technique of transition allows doctors to convey the idea that sufficient
information has been obtained on one subject; the doctor's words
encourage patients to continue on to another subject.
- Self-Revelation
o Limited, discreet self-disclosure by physicians may be useful in certain
situations if physicians feel at ease and can communicate a sense of self-
comfort
o A doctor who practices self-revelation excessively, however, is using a
patient to gratify unfulfilled needs in his or her own life and is abusing the
role of physician
o If a doctor thinks that a piece of information will help a particular patient be
more comfortable, the doctor can decide to be self-revealing.
o The decision depends on whether the information will further a patient's
care or if it will provide nothing useful. Even if the doctor decides that self-
revelation is not warranted, he or she should be careful not to make the
patient feel embarrassed for asking a question
- Positive Reinforcement
o The technique of positive reinforcement allows patients to feel comfortable
telling a doctor anything, even about such things as noncompliance with
treatment
o Encouraging a patient to feel that the doctor is not upset by whatever the
patient has to say facilitates an open exchange
- Reassurance
o Truthful reassurance of a patient can lead to increased trust and
compliance and can be experienced as an empathic response of a
concerned physician.
o False reassurance, however, is essentially lying to a patient and can badly
impair the patient's trust and compliance
 False reassurance is often given from a desire to make a patient
feel better, but once a patient knows that a doctor has not told the
truth, the patient is unlikely to accept or believe truthful reassurance
- Advice
o In many situations it is not only acceptable but desirable for doctors to give
patients advice.
o To be effective and to be perceived as empathic rather than inappropriate
or intrusive, the advice should be given only after patients are allowed to
talk freely about their problems so that physicians have an adequate
information base from which to make suggestions.
o At times, after a doctor has listened carefully to a patient, it becomes clear
that the patient does not, in fact, want advice as much as an objective,
caring, nonjudgmental ear
Ending an Interview
- Physicians want patients to leave an interview feeling understood and respected
and believing that all the pertinent and important information has been conveyed
to an informed, empathic listener
- To this end, doctors should give patients a chance to ask questions and should
let patients know as much as possible about future plans.
Specific Issues in Psychiatry
- Fees
o Before clinicians can establish an ongoing relationship with patients, they
must address certain issues. For instance, they must openly discuss
payment of fees. Discussing these issues and any other questions about
fees from the beginning of the relationship can minimize misunderstanding
later
- Confidentiality
o Psychiatrists and mental health professionals should discuss the extent
and limitations of confidentiality with patients, so that patients are clear
about what can and cannot remain confidential. As much as physicians
must legally and ethically respect patients' confidentiality, it may be wholly
or partially broken in some specific situations
- Supervision
o It is both commonplace and necessary for doctors in training to receive
supervision from experienced physicians. This practice is the norm in
large teaching hospitals, and most patients are aware of it.
- Missed Appointments and Length of Sessions
o Patients need to be informed about a doctor's policies for missed
appointments and length of sessions. Psychiatrists generally see patients
in regularly scheduled blocks of time ranging from 15 to 45 minutes. At the
end of this time, psychiatrists expect patients to accept the fact that the
session is over
o The same can be said about policies for missed appointments. Some
doctors ask patients to give 24 hours' notice to avoid being billed for a
missed session
- Availability of Doctor
o What are a doctor's obligations to be available between scheduled
appointments? Is it incumbent on physicians to be available 24 hours a
day? Once a patient enters into a contract to receive care from a particular
physician, the doctor is responsible for having a mechanism in place for
providing emergency service outside scheduled appointment times
 - Follow-Up
o Many events can disrupt the continuity of the patient-doctor relationship.
Some of these events are routine, such as residents ending their training
and moving on to another hospital; others are out of the ordinary and thus
unpredictable
o A complex situation arises when physicians become ill and are unable to
continue caring for patients. When they know in advance that they will
have to interrupt therapy, clear arrangements for referral to other doctors
can be made
Qualities of a Physician
- Physicians are drawn to the field of medicine for many reasons. These include a
desire to help people, to cure illness, to be part of a respected profession or to
hold a position of authority, and to exert some control over life and death
- Many who have chosen to be a physician are normally
o Perfectionistic
o Attentive to details
o Demanding of themselves
- Physicians need to also be balanced with
o Healthy doses of self-knowledge
o Humility
o Humor
o Kindness
- Characters and Qualities of Physicians
o Imperturbability
 The ability to maintain extreme calm and steadiness
o Presence of Mind
 Self-control in an emergency or embarrassing situation so that one
can say or do the right thin
o Clear Judgement
 The ability to make an informed opinion that is intelligible and free
of ambiguity
o Ability to Endure Frustration
 The capacity to remain firm and deal with insecurity and
dissatisfaction
o Infinite Patience
 The unlimited ability to hear pain or trial calmly
o Charity Towards Others
 To be generous and helpful, especially toward the needy and
suffering
o The Search for Absolute Truth
 To investigate facts and pursue reality
o Composure
 Calmness of mind, bearing, and appearance
o Bravery
 The capacity to face or endure events with courage
o Tenacity
 The capacity to face or endure events with courage
o Idealism
 Forming standards and ideals and living under their influence
o Equanimity
 The ability to handle stressful situations with an undisturbed, even
temper