Doctor Patient Relationship Yusuf Misau

Doctor-Patient Relationship/ Public Health Specialist –Community Relationship Dr. Yusuf Abdu Misau MBBS(ABU), MPH(UM), PhD Student(UM) Department of Social and Preventive Medicine, University of Malaya

Acknowledgement I wish to acknowledge A/P Nabilla Al-Sadat for permission to use her slides in this presentation 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Objectives Appreciate the social roles of doctors and patients Understand the Types and Models of Doctor-Patient Relationship (DPR) Understand the importance of effective Communication in DPR Appreciate the `the changing scenario in DPR 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Contents The nature of DPR Person’s model of the sick role and doctor’s role Factors influencing DPR Types of DPR Models DPR Szasz and Hollender Model Transactional Analysis Doctors’ Communication skills Changes in the Doctor-Patient Relationship 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Nature of Doctor-Patient Relationship 01/19/10 Yusuf Misau-Doctor-Patient Relationship It is an emotional association (clinical encounter) between the doctor and a patient which arises when the doctor in a professional capacity; interact with the patient It is usually related to clinical events, but it is important to realize the association beyond the clinical premise e.g in the community (non clinical situation) Such meetings are a frequent & regular occurrence Depends not only on Drs’ clinical knowledge & skills but also the nature of the social relationship that exists between the DR & Patient

Nature of Doctor-Patient Relationship 01/19/10 Yusuf Misau-Doctor-Patient Relationship The Doctor and The Patient are on two opposite ends The Doctor has a high level of knowledge on a problem the patient almost knows nothing about The Doctor is often concern with the disease diagnosis and treatment (find and fix approach) The patient is concern with illness (disruption of life) Its entirely different from mechanic-client relationship

DPR-Why is it relevant to us? 01/19/10 Yusuf Misau-Doctor-Patient Relationship Because of our understanding of: The Clinical Iceberg phenomena The decision making process in illness behavior The social triggers of decision to seek medical aid

PERCEPTIONS OF NEED THE CLINICAL ICEBERG (ICEBERG THEORY, LAST 1963) Refers to the gap between the need for medical care and the utilization of professional services. Health care professionals only see the tip of the iceberg with respect to the volume of illness in the community 01/19/10 Yusuf Misau-Doctor-Patient Relationship

01/19/10 Yusuf Misau-Doctor-Patient Relationship Public’s perceived need for care

01/19/10 Yusuf Misau-Doctor-Patient Relationship Public’s perceived need for care Note the difference between actual and perceived need Symptoms Do nothing No symptoms Self-med, Alternative med See GP

IMPLICATIONS Treated cases are not representative of sufferers as a whole and that knowledge of disorders obtained by the study of such cases is likely to be biased To reduce the gap Appropriate education of both groups Successful Doctor-Patient Consultation 01/19/10 Yusuf Misau-Doctor-Patient Relationship

THE DECISION-MAKING PROCESS 10 variables important in seeking of professional advice (Mechanic,1968) By illness behaviour we mean the way symptoms are perceived, evaluated and acted upon by a person who recognises some pain, discomfort or other signs of organic malfunction Social triggers (Zola,1973) A model of Health and Illness behaviour in a multi-ethnic society (Jaafar,1995 ) 01/19/10 Yusuf Misau-Doctor-Patient Relationship

THE DECISION-MAKING ROCESS Mechanic (1968) The visibility, recognizability & perceptual salience of the symptoms The perceived seriousness of the symptoms The extent to which symptoms disrupt work, family & other social activities The frequency of the appearance of symptoms & their persistence or recurrence The tolerance thresholds of others who are exposed to the symptoms The knowledge, cultural assumptions & understanding of the person and relevant others Other needs or practical matters competing with the illness response Competing possible interactions which can be assigned to symptoms once recognized Emotional barriers in the form of fear and anxiety which influence the choice of actions to deal with the problem The availability, physical proximity and the financial and/or emotional costs of taking various courses of action 01/19/10 Yusuf Misau-Doctor-Patient Relationship

SOCIAL TRIGGERS (ZOLA, 1973) Non physiological ‘triggers’ to the decision to seek medical aid: An interpersonal crisis Perceived interference with personal relationships ‘ Sanctioning’; that is, one individual taking primary responsibility for the decision to seek medical aid for someone else (the patient) Perceived interference with work or physical functioning The setting of external time criteria (‘If it isn’t better in 3 days…..then I’ll take care of it’) 01/19/10 Yusuf Misau-Doctor-Patient Relationship

PARSONS’ MODEL OF SICK ROLE. 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Parsons’ “Ideal Patient” (Sick Role) Rights (Permitted) to: Give up some activities and responsibilities Regarded as being in need of care and unable to get well by his own decision & will Obligations (In Return) : Must want to get better quickly Seek help from and cooperate with a doctor Parsons, 1951 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Apply a high degree of skill & knowledge to the problems of illness Act for welfare of patient and community rather then for own self interest, desire for money, advancement etc Be objective and emotionally detached Be guided by rules of professional practice Parsons, 1951 Parsons’ “Doctor” (Doctors’ Role) 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Doctor’s Right Granted right to examine patients physically & to enquire into intimate areas of physical & personal life Granted considerable autonomy in professional practice Occupies position of authority in relation to the patient Parsons, 1951 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Implications of Parsons’ theory Protection for the vulnerable From threatening symptoms From exploitation Doctor-patient relationship unequal Correction of societal deviance Being sick is ‘social threat’ Society may be exploited 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Problems with Persons’ model Address acute problems (ignores chronic dx) Clinically oriented Centered on individuals Rights do not always apply Ignores ‘lay referral system’ Ignores differential treatment of pt by Doctors 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Factors influencing DPR 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Factors influencing DPR Conflict of Interest Interests of patient vs. society Interests of patient vs. other patients Problems of confidentiality 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Factors influencing DPR Differences in perspectives social class ethnicity gender clinical-practice style Types and models of doctor-patient relationships 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Recap….. What do you understand by DPR? Why do you think it is important? What are the factors influencing DPR? What are the implications and flaws of Parsons’ Model of Sick role? 01/19/10 Yusuf Misau-Doctor-Patient Relationship

TYPES OF DOCTOR-PATIENT RELATIONSHIP 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Types of doctor-patient relationships 01/19/10 Yusuf Misau-Doctor-Patient Relationship Default Paternalism (Doctor-centred, Disease model) Consumerism (typical in private practice) Mutuality (Patient-centred, illness model) conflict

Types of doctor-patient relationships 01/19/10 Yusuf Misau-Doctor-Patient Relationship CONFLICT PATIENT CONTROL DOCTOR CONTROL LOW HIGH LOW DEFAULT PATERNALISM HIGH CONSUMERISM MUTUALITY

MODELS OF DPR 01/19/10 Yusuf Misau-Doctor-Patient Relationship Szasz and Hollender 1956 - Parson’s concept Transactional Analysis- Eric Berne

MODELS OF DPR Szasz and Hollender 1956 - Parson’s concept Activity-passivity Model Guidance-cooperation Model Mutual Participation Model 01/19/10 Yusuf Misau-Doctor-Patient Relationship

MODELS OF DPR Szasz and Hollender 1956 - Parson’s concept Activity-passivity Model Doctor assumes complete responsibility for the pt’s treatment ( Pt on the operating table ) 01/19/10 Yusuf Misau-Doctor-Patient Relationship

MODELS OF DPR Szasz and Hollender 1956 - Parson’s concept GUIDANCE-COOPERATION MODEL Paternalistic relationship (high physician control & low patient control) Dr is dominant & acts as a parent figure Decides for patient’s best interest Traditional medical consultation Reliance on doctors for decision making 01/19/10 Yusuf Misau-Doctor-Patient Relationship

MODELS OF DPR Szasz and Hollender 1956 - Parson’s Concept MUTUAL PARTICIPATION MODEL Active involvement of patients as more equal partners (‘meeting of experts’) Both parties share power and responsibility, exchange of ideas & sharing of belief systems, need each other and will work towards choices and actions satisfying to them both 01/19/10 Yusuf Misau-Doctor-Patient Relationship

MODELS OF DPR Transactional Analysis or TA (Eric Berne 1986) Describes and explains how we relate to each other by looking at 3 ego states. Ego states: Parent Adult Child 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Transactional Analysis Adult 01/19/10 Yusuf Misau-Doctor-Patient Relationship Parent Child Parent Adult Child Doctor Patient reciprocal crossed Duplex/covert

SZASZ and HOLLENDER’S MODEL Vs. TRANSACTIONAL ANALYSIS ACTIVITY-PASSIVITY MODEL (Parent & child) Dr assumes complete responsibility for the pt’s treatment GUIDANCE-COOPERATION MODEL ( Parent & child) Instructions given by the doctors and patients cooperate by following this advice. Most common model used MUTUAL PARTICIPATION MODEL (Adult-Adult) Both parties share power and responsibility, need each other and will work towards choices and actions satisfying to them both 01/19/10 Yusuf Misau-Doctor-Patient Relationship

01/19/10 Yusuf Misau-Doctor-Patient Relationship COMMUNICATION SKILLS

A MODEL OF THE COMMUNICATION PROCESS 01/19/10 Yusuf Misau-Doctor-Patient Relationship SENDER RECEIVER E NCODI NG D ECODIN G CHANNEL Transmit Message Receive Message

COMMUNICATION Between doctor and patient Foundation for diagnosis and treatment (elicit & convey information) Relationship has a therapeutic effect placebo effect of drug Doctor-centred consultation (Paternalistic style) ‘ Closed’ nature questions e.g. “How long have you had the pain? & is it sharp or dull?” Diseased centred model talk 01/19/10 Yusuf Misau-Doctor-Patient Relationship

COMMUNICATION Between doctor and patient ‘ Patient-centered’ approach (Mutuality) Encourage & facilitate their patients to participate Use of ‘open’ questions e.g. ‘tell me about your pain’, ‘how do you feel? & ‘what do you think is the cause of the problem?’ Active listening skills, requires more time (participative style) 01/19/10 Yusuf Misau-Doctor-Patient Relationship

COMMUNICATION STUDIES Studies on medical practitioners: 1.Kincey et al (1975) In US only 56% felt that they had been fully informed of dx, aetiology, tt and prognosis of their condition 2. Cartwright & Anderson (1981) In UK 23% felt their Dr was not good at explaining things to them Studies on dentists: Collet (1969) About 25% of pts left a dental practice over a 5-yr period because of poor dentist-pt communication 2. Corah (1974) Reported loss of pts as high as 50% Schouten et al (2002) Pts’ satisfaction is positively related to the communicative behaviour of dentists 01/19/10 Yusuf Misau-Doctor-Patient Relationship

COMMUNICATION STUDIES Influence on time : Howey et al (1992) Pressure on time result in fewer psychological problem are identified & more prescriptions are issued (2-20 min, average 6 minutes) Ridsdale et al, 1992 Increase to 10 minutes resulting in all Drs asking more questions. Patient characteristics & behaviours Mutual participation more among younger than elderly people Pts with high SES ask more Qs & explanation than pts from lower SES Social class difference 27% working class compared to 45% middle-class pts sought clarification (Tuckett, 1985) Drs offer more explanations to some groups eg educated pts nad male pts (Street, 1991) Influence of structural context Hospital situation discourage personal continuity of care compared to general practice Financing of health care Fee-for-service encourage longer consultation and increase pt satisfaction compared to per capita or salaried basis 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Why is there poor communication? The influence of class and status Cognitive failure Professional attitudes and interviewing styles Professional power 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Good Communication Skills In Consultation Initiating the session ( initial rapport ) Gathering information (exploring the problem, understanding the patients views) Building the relationship (involving the patient) Explanation and planning (providing the appropriate amount & type of information, aiding accurate recall and understanding, achieving a shared understanding and planning) Closing the session Silverman et al, 1998 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Non-verbal (Body language ) Verbal Greet patient, SMILE, polite and gentle - Social exchanges Forewarn patient of your next action - Address the patient accordingly Facial expression - Avoid compound question Listening - Open and focused questions Eye contact - Facilitate talking: “Go on…” Posture - Restating: repeat what patient say in your own words. Proximity Position - Simple words and speak clearly Body contact 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Advantages of improved communication Compliance with medical instructions and advice Low compliance Dr who do not seek pts’ active participation in the interview, are formal and distant in their mx of the pt by providing little in the way of feedback 2. Satisfaction with health care Goals of pt – dx and tt of any oral problems, relief of fear & anxiety 3. The social dimensions of healing Benefits of improved DPR – satisfactory recovery Significance of EMPOWERMENT 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Wersch & Eccles, 2001 (Development of clinical guidelines for practice) Philosophy of patient-centred care Shift towards shared treatment decisions Greater access to high quality medical information on the internet will increase the no. of ‘information-rich’ pts 01/19/10 Yusuf Misau-Doctor-Patient Relationship Changes in the DPR

Ridsdale & Hudd, 1994 The widespread use of computers in the consultation Position of pt from the screen Drs’ ability to maintain their personal touch through verbal skills and eye contact Confidentiality of data maintain TRUST The use of telemedicine as a means of delivering health care 01/19/10 Yusuf Misau-Doctor-Patient Relationship Changes in the DPR

Strategies for improvement of DPR 1. Understanding illness How pts and those around him view origin, significance & prognosis of the condition & how it affects other aspects of life Info about pts’ cultural, religious, social & economic background, his previous experience of ill-health, & if possible his view of misfortune in general 2. Improving communication “ Language of distress” - culturally specific folk illnesses (Mechanic) Helman, 2000 01/19/10 Yusuf Misau-Doctor-Patient Relationship

Strategies for improvement of DPR 3. Increasing reflexivity (self-awareness) 4. Treating ‘illness’ and ‘disease’ Do not deal with physical abnormalities/malfunctions The many dimensions of “ILLNESS” 5. Respecting diversity – health beliefs and practices 6. Assessing role of context (social, economic, environmental factors - focus on who?) Helman, 2000 01/19/10 Yusuf Misau-Doctor-Patient Relationship

The proposed conceptual model: Patients preferences in dentist communication skills in the Malaysian Army 01/19/10 Yusuf Misau-Doctor-Patient Relationship DPR SOCIOEMOTIONAL BEHAVIOUR TECHNICAL COMPETENCY INTERPERSONAL COMPETENCY GOOD TREATMENT FRIENDLY COMPETENT & SKILFUL CAREFUL & DON’T RUSH ++ Accurate ++ decision COGNITIVE & INFORMATION GIVING CONFLICT RESOLUTION & NEGOTIATION Ref: Zainal Abidin Z. MCD 1997

CONCLUSION Goal of consultation is not only to arrive at diagnosis and formulating a treatment plan But also, to develop common understanding between patient and doctor To help patients develop self control over their illness and its course 01/19/10 Yusuf Misau-Doctor-Patient Relationship

REFERENCES Cecil G Helman. Culture, Health and Illness. Wright 2000 David Armstrong. Outline of Sociology as Applied to Medicine. Butterworth Heinemann. 1994. Graham Scambler (ed). Sociology as Applied to Medicine. Saunders 2003. David Tuckett (ed). An introduction to Medical Sociology. Tavistock Publications. 1976. Fredric D. Wolinsky. The sociology of Health: Principles, Professions and Issues. Little, Brown and Company Ltd. 1980. n CG. Culture, Health and Illness. 4th ed. 2001; Butterworth Heinemann, London. Chapter, pp. 79-107. 01/19/10 Yusuf Misau-Doctor-Patient Relationship

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Doctor Patient Relationship Yusuf Misau

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