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
May 06, 2015
Doctor-Patient Relationship/Public Health Specialist –Community Relationship
Dr. Yusuf Abdu MisauMBBS(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
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Objectives
Appreciate the social roles of doctors and patientsUnderstand the Types and Models of Doctor-
Patient Relationship (DPR)Understand the importance of effective
Communication in DPRAppreciate the `the changing scenario in DPR
Contents1. The nature of DPR
2. Person’s model of the sick role and doctor’s role
3. Factors influencing DPR
4. Types of DPR
5. Models DPR
1. Szasz and Hollender Model
2. Transactional Analysis
6. Doctors’ Communication skills
7. Changes in the Doctor-Patient Relationship
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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
Nature of Doctor-Patient Relationship
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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?
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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
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PERCEPTIONS OF NEEDPERCEPTIONS OF NEEDTHE 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
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Public’s perceived need for care
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Public’s perceived need for care
Note the difference between actual and perceived need
Symptoms Do
nothingNo
symptom
s
Self-med,
Alternative med
SeeGP
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IMPLICATIONSIMPLICATIONS 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
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THE DECISION-MAKING PROCESS 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)
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THE DECISION-MAKING ROCESS Mechanic (1968)THE DECISION-MAKING ROCESS Mechanic (1968)
1. The visibility, recognizability & perceptual salience of the symptoms
2. The perceived seriousness of the symptoms
3. The extent to which symptoms disrupt work, family & other social activities
4. The frequency of the appearance of symptoms & their persistence or recurrence
5. The tolerance thresholds of others who are exposed to the symptoms
6. The knowledge, cultural assumptions & understanding of the person and relevant others
7. Other needs or practical matters competing with the illness response
8. Competing possible interactions which can be assigned to symptoms once recognized
9. Emotional barriers in the form of fear and anxiety which influence the choice of actions to deal with the problem
10. The availability, physical proximity and the financial and/or emotional costs of taking various courses of action
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SOCIAL TRIGGERS (ZOLA, 1973)SOCIAL TRIGGERS (ZOLA, 1973)Non physiological ‘triggers’ to the decision to seek
medical aid:1. An interpersonal crisis 2. Perceived interference with personal relationships3. ‘Sanctioning’; that is, one individual taking primary
responsibility for the decision to seek medical aid for someone else (the patient)
4. Perceived interference with work or physical functioning
5. The setting of external time criteria (‘If it isn’t better in 3 days…..then I’ll take care of it’)
PARSONS’ MODEL OF SICK ROLE.
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Parsons’ “Ideal Patient” (Sick Role)Rights (Permitted) to:Give up some activities and responsibilitiesRegarded 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
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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)
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Doctor’s RightDoctor’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
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
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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
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Factors influencing DPR
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Factors influencing DPR
Conflict of Interest Interests of patient vs. society Interests of patient vs. other patients Problems of confidentiality
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Factors influencing DPRDifferences in perspectives
social classethnicitygenderclinical-practice styleTypes and models of doctor-patient
relationships
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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?
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TYPES OF DOCTOR-PATIENT RELATIONSHIP
TYPES OF DOCTOR-PATIENT RELATIONSHIP
Types of doctor-patient relationships
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1. Default
2. Paternalism (Doctor-centred, Disease model)
3. Consumerism (typical in private practice)
4. Mutuality (Patient-centred, illness model)
5. conflict
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Types of doctor-patient relationshipsTypes of doctor-patient relationships
PATIENT CONTROL
DOCTOR CONTROL
LOW HIGH
LOW DEFAULT PATERNALISM
HIGH CONSUMERISM MUTUALITY
CONFLICT
MODELS OF DPR
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Szasz and Hollender 1956 - Parson’s concept
Transactional Analysis- Eric Berne
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MODELS OF DPR MODELS OF DPR
Szasz and Hollender 1956 - Parson’sconcept
Activity-passivity ModelGuidance-cooperation ModelMutual Participation Model
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MODELS OF DPR MODELS OF DPR
Szasz and Hollender 1956 - Parson’s concept
Activity-passivity Model
Doctor assumes complete responsibilityfor the pt’s treatment (Pt on the operating table )
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MODELS OF DPRMODELS OF DPRSzasz and Hollender 1956 - Parson’s conceptGUIDANCE-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
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MODELS OF DPRMODELS OF DPR
Szasz and Hollender 1956 - Parson’s ConceptMUTUAL 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
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MODELS OF DPRTransactional Analysis or TA (Eric Berne 1986)
Describes and explains how we relate to each
other by looking at 3 ego states.
Ego states: ParentAdultChild
Transactional Analysis
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Parent
Adult
Child
Parent
Adult
Child
Doctor Patientreciprocal
crossed
Duplex/covert
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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
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A MODEL OF THE COMMUNICATION PROCESS
SENDER RECEIVERENCODING DECODINGCHANNELCHANNEL
Transmit Message ReceiveMessage
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COMMUNICATIONBetween 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
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COMMUNICATIONBetween 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)
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COMMUNICATION STUDIESCOMMUNICATION STUDIESStudies 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:1. 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%
3. Schouten et al (2002)• Pts’ satisfaction is
positively related to the communicative behaviour of dentists
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COMMUNICATION STUDIESCOMMUNICATION STUDIESInfluence on time:1. Howey et al (1992)
Pressure on time result in fewer psychological problem are identified & more prescriptions are issued (2-20 min, average 6 minutes)
2. 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 context1. Hospital situation discourage
personal continuity of care compared to general practice
2. Financing of health care• Fee-for-service encourage
longer consultation and increase pt satisfaction compared to per capita or salaried basis
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Why is there poor communication?Why is there poor communication?
The influence of class and status
Cognitive failure
Professional attitudes and interviewing styles
Professional power
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Good Communication Skills In ConsultationGood Communication Skills In Consultation
1. Initiating the session ( initial rapport ) 2. Gathering information (exploring the problem,
understanding the patients views)3. Building the relationship (involving the patient) 4. Explanation and planning (providing the appropriate
amount & type of information, aiding accurate recall and understanding, achieving a shared understanding and planning)
5. Closing the sessionSilverman et al, 1998
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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
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Advantages of improved communicationAdvantages of improved communication1. 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
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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
Changes in the DPR
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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
Changes in the DPR
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Strategies for improvement of 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
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Strategies for improvement of DPR 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 practices6. Assessing role of context (social, economic,
environmental factors - focus on who?)Helman, 2000
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The proposed conceptual model: Patients preferences in dentist communication
skills in the Malaysian Army
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
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CONCLUSIONCONCLUSION
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
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REFERENCESREFERENCES
1. Cecil G Helman. Culture, Health and Illness. Wright 20002. David Armstrong. Outline of Sociology as Applied to Medicine.
Butterworth Heinemann. 1994.3. Graham Scambler (ed). Sociology as Applied to Medicine.
Saunders 2003.4. David Tuckett (ed). An introduction to Medical Sociology.
Tavistock Publications. 1976.5. 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.
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