patient doctor relationship
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Patient - Doctor relationship Dr KSR Prasad
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
Introduction
• Doctor – Patient relationships express the values of medical profession
• The relationship should not be the fish & fisherman
• It should be always like fish and water
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
01
Parsons’ “ Ideal Doctor”
Apply a high degree of – skill and knowledge
Act for the good of the patient
Remain objective and emotionally detached
Respect the position of privilege
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
02
Doctor’s role
• Health care providers• Technical consultant• To convince the necessity of
medical services• A tendency for the“consumer to be right”
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
03
Doctor Competencies
• Patient Care• Medical Knowledge• Practice-Based Learning (EBM) and
Improvement• Interpersonal Skills • Communication Skills• Professionalism• Systems-Based Practice
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
04
Patient’s role• Health shoppers Indications
of consumer behavior• Cost-consciousness• Information seeking• Exercising independent
judgment• Consumer knowledge
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
05
Parsons’ “Ideal Patient”Permitted to:Give up –• some activities • responsibilities• Regarded as being in need of care
In Return :Must want to get better quickly Seek help from and cooperate with a doctor
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
06
Consumerism
• The patients’ challenge to unilateral decision making by physicians in reaching closure on diagnoses and working out treatment plans
• Reversing the very basic nature of the power relationship
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
07
Conflict of Interest
• Interests of patient Vs society• Interests of patient Vs other patients• Problems of confidentiality
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
08
The Physician Charter
Principles include:
• Patient welfare • Patient autonomy
Commitments include:
• Honesty with patients• Patient confidentiality• Maintaining appropriate
relationships with patients
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
09
• - in Physician-Patient Communication1. Build the doctor-patient relationship2. Open the discussion3. Gather information4. Understand the patient’s perspective5. Share information6. Reach agreement on problems and plans7. Provide closure
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
10Seven Essential Elements
Etiquette Based MedicineChecklist for first meeting with a hospitalizedpatient:• Ask permission to enter the room /interrogation ;
wait for an answer• Introduce yourself, showing ID badge• Shake hands /greeting (wear gloves if needed)• Sit down, Smile if appropriate (relax your self and
make patient relaxed)• Briefly explain your role on the team• Ask the patient how he/she is feeling about being in
the hospital & about the treatments
Kahn MW, N Eng J Med, 2008
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
11
Length of Consultation
• Makes patient centred consultation styles more difficult.
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
12
Average 8 minutes
Consultation Styles
It’s serious isn’t it doctor?
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
• Sustained physician-patient partnerships with bonds of trust and knowledge of patients were correlates of three outcomes of care– Adherence– Satisfaction– Improved health
status
13
Doctor-Patient Relationship Linked to Outcomes of Care
Safran DG et al, J of Fam Practice, 1998
Rate from 0 to 100…
1. Communication
2. Compassion
3. Respectfulness
4. Responsibility
SCALE
100-Best Possible 90-Excellent 80-Very Good 70-Good 60-Above Average 50-Average 40-Below Average 30-Poor 20-Very Poor 10-Terrible 0-Worst Possible
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
14Evaluation key
(to be rated by patient)
Communication: • How well this doctor communicate with
you and your family• Did doctor answer your questions?Compassion: • Was the doctor is sensitive to you and
your family needs?Respectfulness:• Did the doctor ask and respect your
choices about your care Responsibility:• Did you feel the doctor acted
appropriative on your behalf?
Doctor-patient relationship in the past• Paternalism
– Because physicians in the past are people who have higher social status
– “doctor” is seen as a sacred occupation which saves people’s lives
• The advices given by doctors are seen as paramount mandate
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
15
Doctor-patient relationship at present
• Consumerism and mutuality
• Patients nowadays have higher education and better economic status
• The concept of patient’s autonomy
• The ability to question doctors
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
16
Patient influences on consultation
• The patient’s ability to exercise and control depends on a number of factors:– Social – Educational level– Sex– Membership of an ethnic
minority
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
17
Patient controlled consultation
“You’re paid to do what I tell you!!”
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
18
Patients beliefs and expectationsInfluenced by:
1. Previous experience, 2. literature, 3. the media;4. Family and friends;5. Cultural influences;6. Social significance.
These beliefs influence outcomes
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
19
Prototypes of doctor-patient relationship
Physician control (Low)
Physician control (High)
Patient control (Low) Default Paternalism
Patient control (High) Consumerism Mutuality
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
20
Ethical models at a glance
–Paternalistic model–Informative model–Interpretive model–Deliberative model
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
21
Paternalistic model• Principle
– The doctor should make all the decisions for a patient.• Assumptions
– People are not always rational/mature.– Experts know better about the needs of patients.– Qualified doctors have good will.
• Sources– Hippocratic Oath; Plato.
• Problems – Are the needs of patients objective? – How can we be sure that doctors have good will?
• Objection and modification– John Stuart Mill’s liberal principle
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
22
The Paternalistic Approach
“If I’ve told you once I told you 1,000 times, stop smoking!!”
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
23
Informative model• Principle
– The doctor should provide all the relevant information for the patient to make a decision, and provide the selected intervention on this basis.
• Assumptions – A fact/value division of labor yields the best medical result.– What is good for a patient depends on what his/her personal
values. – Consumerism.
• Problems – What if the patient is unconscious, incompetent, and making
choices totally unacceptable by our ethical standards?
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
24
The interpretive model• Principle
– The doctor should help the patient to articulate his/her values through interpretation, and provide intervention which is truly wanted.
• Assumptions – Patients have unconscious and inconsistent desires.– Their conscious decisions may not reflect their deepest
values. • Sources
– Sigmund Freud; hermeneutics.• Limitation
– All that a doctor can do is to help the patient see his/her own desires/values more clearly, but not to criticize them.
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
25
The deliberative model• Principle
– The doctor should help the patient to deliberate well through dialogue and discussion, and
– so develop values which are objective and truly worthy. • Assumptions
– The objectivity of values.– The patient’s good life consists not in the satisfaction of desires, but
maturity and rationality.• Source
– Aristotelian ethics• Problems
– Is the model different from the paternalistic model? – What is the difference between dialogue and persuasion?
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
26
Mutuality• The optimal doctor-patient relationship model• This model views neither the patient nor the
physician as standing aside• Each of participants brings strengths and
resources to the relationship• Based on the communication between doctors
and patients
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
27
Mutuality - Patient’s role• Patients need to define their problems in an
open and full manner• The patient’s right to seek care elsewhere
when demands are not satisfactorily met
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
28
Mutuality - Doctor’s role• Physicians need to work with the patient to
articulate the problem and refine the request• The physician’s right to withdraw services
formally from a patient if he or she feels it is impossible to satisfy the patient’s demand
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
29
Mutuality - Advantages• Patients can fully understand what problem
they are coping with through physicians’ help• Physicians can entirely know patient’s value• Decisions can easily be made from a mutual
and collaborative relationship
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
30
Mutuality - Disadvantages• Physicians do not know what certain degree
should they reach in communication• If the communication is fake, -
– both physicians and patients do not have mutual understanding,
– making decision is overwhelming to a patient
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
31
Mutuality - Discussion
• Is the patient capable of making the important therapeutic decision even though they have good communication of the physician?
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
32
Do – Don’ts • Do not toss the treatments for
a patient• Make always reliable advises
and practices• Assuring the patient is first
choice of – placebo treatment – But it should never be false
assurance • Authentic tested managements
(EBM) are advised
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
33
Conclusion• Relationship between patients
and doctors are often unstated, and thy are dynamic
• As conditions change, the kind of relationship that works best for a patient may change
• Doctors and patients should choose a “relationship fit”
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
34
Thank you
• Dr KSR Prasad
Patient - Doctor relationship
Dr. K. Shiva Rama Prasad, see the ppt at http://www.slideshare.net/technoayurveda
35
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