Doctor - Patient
Relationship
Dr. Iwan Arijanto, SpKJ, MKes
.
Medical Situation
Situation Related to the effort and process of
treating a disease
Rapport, the Relationship of the Doctor and
the Patient:
Core of Medical Practice
Influence the effort and process of treatment
Doctor
A Sick person
Not just
a diagnostic number
Good rapport :
Spontaneous team work
Conscious
Compatible
Constructive
Mutual Understanding & Trust
George Engel
Integrated Biopsychosocial approach to Human Behavior and
disease
Biological :
Anatomical, Structural, Molecular substrate of disease & its effects
on the Patient Biological Functioning
Psychological
Effects of psycho dynamic factors, Motivations & Personality on the
Experience of illness & The Reaction to it
Social :
Emphasize cultural, Environmental & Familial influences on the
Expression & The Expression & The Experience of illness
Comprehensive Understanding of disease and treatment
Illness Behavior & Sick Role
Affected by previous experience with illness,
psychological factors & cultural background .
5 Stages ( Edward Suchman )
1. Symptom Experience
something is wrong
2.
Assumption of the Sick role
one is sick & needs professional care
3.
Medical care contact
seek professional care
4.
Dependent - Patient role
transfer control to the doctor, follow prescribed treatment
5. Recovery , Rehabilitation
give up the patient role
Sick role ( peran sakit )
The Role that society ascribes to
the Sick person
( excused from certain responsibilities ,
expected to obtain help to get well ).
Models of Doctor - Patient
relationship .
Influence by Personalities, Expectations & needs of
the Doctor & the Patient
Unspoken difference
Miscommunication & disappointment.
Flexible Needs of patient
& treatment Requirements
1, Active - Passive
The patient fully passive ( unconscious, immobilized, delirious )
& The Doctor taking Over totally the patient care &
treatment
2. Teacher - Student
Doctor : dominant paternalistic , controlling.
Patient : dependence, acceptance ( recovery from surgery )
3. Mutual Participation
Both Doctor & Patient require and depend on each others
input . Active participation of the Patient is needed
( chronic illness.)
4. Friendship / Socially intimate
Dysfunctional , Unethical.
Underlying psychological problem in the physician
Relation with the Patient is a substite for another
broken Relationship.
Some characteristics of good Doctor - Patient
relationship.
Some Obstacles
- Acceptance
- honesty
- empathy
- trust
- sympathy
- transference
- Counter transference
Interview ( anamnesis )
To obtain psychological background and symptoms
classification
proper diagnosis & treatment .
Psychiatric Examination - interview / anamnesis
Steps :
1. Establishing Rapport
Doctor - Patient at ease : Empathy to patient complaints, Express
compassion, Evaluating the Patients insight and becoming an ally,
showing expertise, establishing authority as physician and therapist;
Balancing the roles of Emphatic listener, expert and authority.
2.
Specify the chief complaint
3.
Based on the chief complaint develop A provisional DD/
4.
Probe DD/ by using focused and detailed Qs.
5.
Clarify vague / obscure replies to get the right answer.
6.
Let the patient talk freely enough to observe the coherency of his /
her thoughts.
7.
Use a mixture of open & closed ended Qs
8.
Dont be afraid / hesitate to ask difficult / embarrassing topics.
9.
Ask about suicidal thoughts
10. Give the patient a chance to ask Qs at the end of the interview
11. Conclude the initial interview by confidence, and if possible, of
hope.
Content vs process
Content, what is verbally expressed between the
doctor and the patient
Process, what is occurring non verbally between
the doctor and the patient
( feelings, reactions body language )
Technique :
Open ended - closed ended Qs
Reflection
Confrontation;
Interpretation;
Self - Revelation
Reassurance;
Facilitation;
Silence;
Clarification
Summation;
Explanation;
Transition;
Positive Reinforcement ;
Advice.
Special Cases
Some types of patient requre particular skill (patiency) of
the physician to understand the covert emotions, fears,
conflicts that the patients overt behavior represents.
Histrionic
Seductive behavior emerge from an unconscious need for
reassurance that she is still attractive even ill and from
fear that she will not be taken seriously , unless she
appear (sexually) attractive (actually she never want to seduce the doctor)
The Physician needs to be calm, reassuring , firm and
non flirtations.
Demanding and Dependent
Often become angry or frightened if the doctor seems not
taking their concern seriously.
Set necessary limits within the context of an expressed
willingness to listen and to care for the patient.
Demanding and Impulsive
Difficult to delay gratification, demand that discomforts be
eliminated immediately
Easily frustrated petulant, angry, aggressive, self
destructive to get what they need must act in that
inappropriate way . Firm not -angry limits from the
outset, defining clearly acceptable and unacceptable
behavior, while still treated with respect & care, He / She
must be held responsible for their actions
Narcissistic
Thought that He / She is superior to other, have a
tremendous need to appear perfect arrogant, rude,
abrupt, demeaning mask for a feeling of inadequacy ,
helplessness and emptiness .
Do not influence by the attitude of the patients even when
he / she disdain the doctor is only an ordinary human being
.
Obsessive
orderly, punctual, over concerned
with detail, strong need to be in control of everything in the
environment .
Strengthen the patient s sense of control include as
much as possible in their own care & treatment , give detail
explanation about what is going on & what is being planned
Paranoid
critical, suspicious, evasive, formal,
explain in detail every decision and treatment procedure
& react non defensively to the patients suspicion. Warmth
and empathy are often viewed with suspicion
Isolated , Solitary
detached, reclusive, do
not need / want much contact with others.
Treat with as much respect for privacy as possible.
Complaining , Passive - aggressive
complaints, disappointment, blaming others.
Give as much tolerance as possible & especially important
involved with & support the (already very tired) family
members.
Sociopathic & Malingering
Intelligent, charming, socially adept, never consciously aware
of what is mean to be guilty.
Still treat he / she with respect but with heightened sense of
vigilance, set firm limits on behavior, patient is held responsible
for his / her action , doctors should not hesitate to ask for
assistance.
Depressed & Potentially suicidal
unable to
give an adequate explanation about their illness.
Give specific, direct question about history and symptoms
related to depression, including suicidal ideation. (suicide note,
previous suicidal attempt, family history of suicide etc. ).
If not hospitalized the patient must be able to contact the doctor
anytime, in general do not give premature reassurement, but
that help and hope is certainly possible
Violent .
With / without restraints patient should not be
interviewed alone .
Asked specific Qs pertaining to the previous
acts of violence and to violence experienced
as a child.
Under what conditions the patients resorts to
violence , to detect possible precipitating
factors, .
If reality testing is so impaired medication
could be given before started the interview.
Delusional
delusion is patients
defensive & self - protective , Albeit maladaptive ,
strategy against overwhelming anxiety , lowered
self esteem, and confusion.
Do not challenge directly , do not agree , just
understand it.
Interviewing relatives
Important , ESP. If auto anamnesis is not possible
(psychotic, severely depressed , suicidal ideation )
keep patients privacy ( secrets)
