THE ROAD SO FAR

Psych 1: THE PHYSICIANS ROLE AND BEHAVIORNio Ismael S. Pastor, MD, PHSAE, DRDM, FPSMIDSCOPE AND SEQUENCEThe roles of a physicianCommunication and InterviewingClinical / health communicationConsultations

THE ROLE OF A PHYSICIANGeneral PerceptionsWe live in a time of unprecedented change.We live in a questioning society.Professions and medicine have lost status.We will not return to the golden period.The future will depend in part on how medicine responds.Professionalism is the key to public trust.Antiquity

Hippocrates

technologycuring

The PresentThe concept of the healer

The concept of the professional

Code of Ethics Middle agesLearned professionsclergy, law, medicine

1850: Legislation

1900: University linkageThe PresentScienceProfessionalism and Medicine

The Physician Has Two Roles Healer ProfessionalThe two rolesServed simultaneously.Analyzed separately.The Primary Role is that of the Healer8Medicines Values Are Derived From Both The Healer and the ProfessionalTo make whole or sound in bodily conditions; to free from disease or ailment, to restore to health or soundness.

Oxford English DictionaryTo Heal Definition: Profession An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and to the promotion of the public good within their domain. 11These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.Derived from the Oxford English Dictionary and the Literature on ProfessionalismIn Press, Teaching and Learning in MedicineProfessionalHealerAttributes

CompetenceCommitmentConfidentialityAltruismIntegrity and honestyMorality and ethicsResponsibility to the profession

Autonomy Self-regulationResponsibility to societyTeam work

Caring and compassionInsightOpennessRespect for the healing functionRespect patient dignity and autonomyPresence

13Society uses the concept of the professional as a means of organizing the delivery of complex services which it requires, including that of the healer.The Professional ModelROLESThe characteristic social behavior of a doctor in relation to the community.

Social expectationsPatients expectationsPhysicians expectationsProfessional development issues

Role competence: the ability to effectively and satisfactorily perform as expected within a doctors role.

YOU NEED TOPRACTISE SOCIAL EXPECTATIONSTechnical competence maintain a high level of knowledge of up-to-date technical skills of medical scienceUniversalism a doctors service is available for all and any individual, not just friends, relatives, regardless of RACE, RELIGION, RELATIONSHIP, ECONOMIC STATUS, etc.Specificity of competence: the doctor is expected to use only those skills and practice areas of medicine only in which he is competentSpecificity of scope of concern the physician uses his skill only for medical or public health care and should not exploit patientsAffective neutrality be objective in relating to patients, show professional concern and not become emotionally involved manifested as:Erotic arousalPersonal friendshipAggressionCollectivity orientation physician is expected to subordinate his personal gain to the patients welfareAvoidBargaining over feesAdvertisingRefusing poor-credit-risk patients

PATIENT EXPECTATIONSThese are clinical expectationsRelief from distress given the highest priority, patients expect doctors to attend to their symptomsUnhurried setting / atmosphere:patient can tell his / her storybe informed of findings, diagnosis, treatment options ask questionsMy doctor should always be there to treat, comfort or relieve painRIGHTS OF FILIPINO PATIENTSThe patient has the right to considerate & respectful care, irrespective of socio-economic statusThe patient has the right to obtain from his physician complete current information concerning his diagnosis, treatment and prognosis in terms the patient can reasonably be expected to understand.The patient has the right to receive from his physician information necessary to give informed consent prior to start of any procedure and or treatmentThe patient has the right to refuse treatment / life-giving measures, to the extent permitted by law and to be informed of the medical consequence of his actionThe patient has the right to every consideration of his privacy concerning his own medical care programThe patient has the right to expect that all communication and records pertaining to his care should be treated as confidentialThe patient has the right that within its capacity, a hospital must make reasonable response to the request of patient for servicesThe patient has the right to obtain information as to any relationship of the hospital to other health care and to other health care and educational institutions in so far as his care is concerned. The patient has the right to be advised if the hospital proposes to engage on or perform human experimentation affecting his care or treatmentThe patient has the right to expect reasonable continuity of care; he has the right to know in advance what appointment times the physicians are available and where

The patient has the right to examine and receive an explanation of his bill regardless of source of payment. The patient has the right to know what hospital rules and regulations apply to his conduct as a patientPHYSICIANS EXPECTATIONSHow a patient should behavePatient is good when:Suffering legitimately rather than presenting with a minor or trivial complainPresents with objective signs and genuine symptomsCooperates in the treatment Grateful to doctor when cured or relieved When above is not fulfilled, the doctor tends to blame the patient. Highly associated with problemsProblems with patient begins withFailure to communicateDeficiency in technical skills, knowledge or judgement

PROFESSIONAL DEVELOPMENTBalancing objectivity with empathyNurturance and executive necessityOmnipotence and omniscience and tolerance for uncertaintyFormation of professional ego-idealMaturation of a professional operational identityPersonality factors in the development of the physicianThe Social Contract is Being Re-NegotiatedLegitimate worries and concerns on both sidesNegotiationsCan involve virtually all stakeholders with an interest in health, and take place in many settings.Influence on negotiations can be either direct or indirect and lead to minor or major changes.Medicine is no longer the dominant player - but it is at the table.Societys Needs and ExpectationsThe healer working as a professional using knowledge to heal and/or cure guaranteeing competenceworking in partnership with patients demonstrating morality and virtue being accountableAccountabilityTraditionalTo patients and colleaguesFor advice on public policySelf-regulation and discipline There have been high-profile failures in the area of self-regulation.These failures led to trust and a consequent inability to influence the newer levels of accountability now demanded. PROFESSIONS MUST SELF-REGULATEAccountability - NewEconomic (to payors)corporatestatePolitical (to wider society)impact on resourcespopulation healthThe Professions Needs and ExpectationsDeserve trust and respect despite some failings.Expertise should be recognized and used.Autonomy sufficient to act in best interests of patients and society.Regulatory procedures that are reasonable and validated.Adequate resources.A health care system which promotes (and does not subvert) those values which society wishes in its healers - caring, altruism, courtesy and competence.What Must Medicine Do?Fulfill the Role of HealerWhat Should Medicine Do?Address Principle Causes of Loss of Trustperception of decrease altruismfailure to self-regulatebehavior of some of medicines institutionslack of a single voice representing medicineWhat Should Medicine Do?Understand professionalism.teach and evaluate it at all levels Understand and meet the obligations needed to sustain the professional model. altruism integrity self-regulation accountabilityIndividual/Collective Responsibility

The most important problem for the future of professionalism is neither economic nor structural but cultural and ideological. The most important problem is its soulFreidsonCOMMUNICATION AND INTERVIEWINGEffects of physician communication on patientAdequacy of the clinical interviewAccuracy of detection of a psychological disturbancePatients understanding and compliance with doctors adviceImpact on patient of a distressing medical and surgical procedurePatient satisfactionINTERVIEWINGEffective interviewing the most important skill of physiciansEstablishes interaction between px & MDGathers data about pxDevelop px-MD relationshipPRIMARY GOALS OF INTERVIEWAt beginning of interview, establish rapportIntroduce himselfPut px at easeRespect pxDuring the interview, identify the problemAllow px to tell his storyUse language appropraite to px age, backgroundUse tact in framing questionsMove effectively from one QQ to another

Summarize periodicallyAllow px to express feelingConvey understanding and empathy to pxClarify inconsistencies and ambivalences in px statements & responsesObtain adequate & meaningful informationAt end of interviewInform px next stepsLet px ask QQMake closing statement to end interview comfortably

CONTENT & PROCESS CONTENT: verbal exchange between px MDPROCESS: what happens during the interview that shows th px and MD reaction to QQ and topics Sense & sensibilitiesBeneath the surfaceBetween the linesMENTAL GUIIDE FOR M.D.Why is the patient here to see me now?What are the patients feelings right now?What is the patients reaction(s) to what is happening between us right now?CHARACTERISTICS OF THE COMMUNICATION PROCESSA deeply held fear or apprehension may be expressed by momentary angerA px may talk about the present by recalling the pastImportant messages hide behind trivial passing remarks, asides and casual jokesShifts in conversation away or toward certain topics may occurSee body languageRepetition should alert MD about the importance of that topicRepeated requests for informationMD may become aware of his/her emotion reflections of the px emotionsTHE A.R.T. OF INTERVIEWINGAssessment open-ended QQ non-directed QQRanking occurs from beginning to end of interviewDecisions to pursue certain areas are madeConcern of px Urgency / gravity of symptoms / signTransition keeps the interview flowing

GUIDE FOR INTERVIEWING / COMMUNICATINGGood interview: gets much information as possibleResult of verbal & non-verbal communicationOpen & productive communicationPx interview is a professional not personal communicationInterview style: between friendly conversation and interrogationPERSONALITY OF MD & PxMD must examine own feelings,,thoughts and reactions during the interviewPx responses and objective evidence of px feelings should be notedEmotional behavior (laughing / crying)Motor behaviorFacial expressions and gesturesSpeech patterns: rate, volume, modulation & mumblingBody gestures (cloenching fist, fidgeting, shaking)Clinical / health communication

BREADTH OF CLINICAL COMMUNICATIONDoctor-patient communicationDoctor-patient's family/caregiversDoctor-doctorDoctor-other health professionalWithin a teamWriting medical recordsWorking with media, authorities, other organizations and complaintsDoctor-patient communicationConsultation by telephoneLetters and email to patients

Doctor-patient's family/caregiversFace to face with or without patient presentTelephone, letters, and email

Doctor-doctorProfessionalSeeking or giving adviceAppraisal and mentoringDoctor as patient

Doctor-other health professionalReferral and delegationSeeking or giving adviceCase discussion

Within a teamAwareness of difference in professionals' languageAssume the roles and responsibilities of a team member and leader

Writing medical recordsLegalCourt appearancesReports

Media, authorities, other organizations and complaints

Against oneself including admitting error and apologizingAbout colleagues

OTHERSWhistle blowingRunning meetingsTeaching

60COMMUNICATION TIPSBody languageListening techniquesKeep It SimpleFamilyProfessional image

Body languageSitting - sit off-center, not directly in front of patient, about three feet awaYArms - watch gestures, may be distracting and offensive in certain culturesFace - smile often and watch expressionsEyes - eye contact is usually good, some cultures eye contact is not a priorityHead - nodding helps patient to know you are listening

Listening techniquesActive - respond to what the patient is sayingReflective - you repeat what the patient said - good to use to check for understandingEmpathetic - you are interested, encouraging; don't interruptKeep It SimpleTake time to explain thoroughly Make sure patient understands information about his/her illnessTalk about what patient wants to know about illnessPractice shared decision-makingUse handouts and draw pictures to illustrate processesUse medical jargon and abbreviations minimallyFamilyDon't ignore the role that family plays in patient's lifeAcknowledge their presenceMake them your allies - enlist support of family especially if you have bad newsBe able to "handle" the person who tries to speak for patientProfessional imageWhite coats are good to wear - make sure they are cleanInformal physicians - negatively perceivedDress modest and conservativeScrubs may be okay if you are a surgeon - not necessarily for cliniciansBe healthy - a doctor in good health is more believable

Jewelry - keep to a minimum, don't let it get in the wayCartoon characters on clothing - good if you are a pediatricianShoes- comfortable, not loud if hard-surface floor. Tennis shoes - may be acceptable.Hairstyles should also be conservative, you should not have to fix it while talking to patientsMake-up, perfume, nails - minimal

CONSULTATIONSCONSULTATION SKILLS. Doctors were ill-prepared for general practice consultations even though such consultations were commonplace in medical practice. There was a need to define and improve skills more appropriate for general practice. Such skills were neither taught nor learned in medical schools or teaching hospitals. What is the consultationthe transaction between doctor and patients and central to the relationship between doctors and patients.[2]

MODELS OF CONSULTATIONS2000: The Calgary Cambridge method'narrative-based' model of the consultation2000: The Calgary Cambridge method

an evidence-based approach to integration of the 'tasks' of the consultation and improving skills for effective communicationThe consultation is divided into:Initiating the session (rapport, reasons for consulting, establishing shared agenda).Gathering information (patient's story, open and closed questions, identifying verbal and non-verbal cues).Building the relationship (developing rapport, recording notes, accepting patient's views/ feelings and demonstrating empathy and support).Explanation and planning (giving digestible information and explanations).Closing the session (summarising and clarifying the agreed plan).

A 'narrative-based' model of the consultationJohn LaunerCircular questioning or picking up patients' words to form open questions and help patients to focus on meaning.A focus on listening (for example avoiding note-making during the consultation).Exploring the context of the problem (may lie outside medical presentation in family, work or community)..Developing a joint story with the patient (emphasises equality of relationship with the patient).Shifting the balance of power to the patient.Using genograms and constructing a family tree to help understand the context of a patient's problems