Psychiatry

Lecture 23: The Physician-Patient Relationship

MEDICAL PRACTICE

Seeking medical care

Patients' behavior when ill and their expectations of physicians are influenced by:
 their culture
 previous experiences with medical care
 physical and mental conditions
 personality styles (not necessarily personality disorders) (see table below)
 coping skills

Patient Personality Style and Behavioral Characteristics During Illness

Personality Style Behavioral Characteristics During Illness
Dependent Has a need to be cared for by others, resulting in the
desire for excessive attention from the physician during an illness
Fears loss of control and may in turn become controlling
during illness
Obsessive-compulsive and Characterized by time pressure (e.g., feels rushed most
type A of the time) and competitiveness
May also show hostility, which is associated specifically with the
development of coronary artery disease
Histrionic May be dramatic, emotionally changeable, and approach the
physician in an inappropriate sexual fashion during illness
Narcissistic Has a perfect self-image, which is threatened by illness
Often feels superior to others and therefore may request that only
the "top" physicians be involved in treatment
Paranoid Often blames the physician for the illness
Is overly sensitive to a perceived lack of attention or caring from the
physician
Passive-aggressive Asks for help but then does not comply with the physician's advice
Schizoid Becomes even more withdrawn during illness

Seeking psychiatric care

 There are still attitudes within most societies that view symptoms of psychopathology as
threatening and uncomfortable, and these attitudes frequently foster stigma
and discrimination towards people with mental health problems.

 It is important for patients to seek help since there is a strong correlation between
psychological illness and physical illness. Morbidity rates and mortality rates are much
higher in patients who need psychiatric attention.
The "sick role"

 A person assumes a particular role in society and certain behavioral patterns when he
or she is ill (the "sick role," described by T. Parsons).
 The sick role includes exemption from usual responsibilities and expectation of care by
others, as well as working toward becoming healthy and cooperating with health care
personnel in getting well.

Telling patients the truth

 All adult patients should be told the complete truth about the diagnosis, the treatment
and its side effects, and the prognosis of their illness. Falsely reassuring or patronizing
statements in response to patient questions (e.g., "Do not worry, we will take good care
of you" or "You still have one child" [after a miscarriage]) are not appropriate.
 Information about the illness must be given directly to the adult patient and not relayed
to the patient through relatives. Parents decide if, how, and when such information will
be given to an ill child.
 With the patient's permission, the physician can tell relatives this information in
conjunction with, or after, telling the patient. Relieving the fears of close relatives of a
seriously ill patient can bolster the support system, and thus help the patient.

Special situations

 Patients may be afraid to ask questions about issues that are embarrassing (e.g., sexual
problems) or fear-provoking (e.g., laboratory results).
 A physician should not try to guess what is troubling a patient; it is the physician's
responsibility to ask about such issues in an open-ended fashion and address them
truthfully and fully with the patient.

 Physicians have the primary responsibility for dealing with compliance issues, as well as
with angry , seductive , or complaining behavior by their patients (see Table below).
Referrals to other physicians should be reserved only for medical and psychiatric
problems outside of the treating physician's range of expertise.

COMPLIANCE (ADHERENCE)

Patient characteristics associated with compliance

 Compliance or adherence refers to the extent to which a patient follows the instructions
of the physician, such as taking medications on schedule , having a ne e de d medical test
or surgical procedure, and following directions for change s in lifesty le , such as diet or
exercise.
 Patients' unconscious transference reactions to their physicians, which are based in
childhood parent-child relationships, can increase or decrease compliance.

 Only about one third of patients comply fully with treatment, one third comply some of
the time, and one third do not comply with treatment.
‫ لالطالع‬Common Problems in the Physician-Patient Relationship

Problem Do Do not
Angry patient Do acknowledge the patient's Do not take the patient's anger
anger Personally (the patient is probably
fearful about becoming dependent as
well as of being ill)
Seductive patient Do call in a chaperone when Do not refuse to see the
you are with the patient patient
Do gather information using Do not refer the patient to
direct rather than open-ended another physician
questions
Do set limits on the behavior
that you will tolerate
Non-compliant patient Do examine the patient's Do not attempt to scare the
Willingness to change his or her patient into
health threatening behavior (e.g., complying (e.g., showing
smoking); if he or she is not willing, frightening photographs of untreated
you must address that issue illness)
Do identify the real reason for Do not refer the patient to
The patient's refusal to comply Another physician
or to consent to a needed
intervention and address it (e.g., fear)
Suicidal patient Do assess the seriousness of Do not release a hospitalized
the threat patient who is a threat to himself or
Do suggest that the patient herself (patients who are a threat to
remain in the hospital voluntarily if self or others can be
the threat is serious held involuntarily
Complaining patient Do encourage the patient to Do not intervene in the patient's
speak to the other physician directly if relationship with another physician
the patient complains about a unless there is a medical reason to do
relationship with another physician so
Do speak to your own office staff if Do not blame the patient for
the patient has a complaint problems with office staff
about one of them

Factors that increase and decrease compliance

 Compliance is not related to patient intelligence , education, sex, religion, race,

socioeconomic status, or marital status.

 Compliance is most closely related to how well the patient likes the doctor. The strength
of the doctor-patient relationship is also the most important factor in whether or not
patients sue their doctors when an error or omission is made or when there is a poor
outcome.
 Some factors associated with compliance are listed in Table below.

THE CLINICAL INTERVIEW

Communication skills
 Patient compliance with medical advice, detection of both physical and psychological
problems, and patient satisfaction with the physician are improved by good physician-
patient communication.
  One of the most important skills for a physician to have is how to interview patients.
The physical setting for the interview should be as private as possible. Ideally, there
should be no desk or other obstacle between the physician and patient, and the
participants should interact at eye level (e.g., both seated).

 During the interview, the physician must first establish trust in and rapport with the
patient and then gather physical, psychological, and social information to identify the
patient's problem.
 The physician should obtain backup (e.g., hospital security) as soon as it appears that a
patient is dangerous or threatening.
 The interview serves to obtain the patient's psychiatric history , including information
about prior mental problems, drug and alcohol use, sexual activity, current living
situation, and sources of stress.

Specific interviewing techniques

Direct questions: Direct questions are used to elicit specific information quickly from a patient
in an emergency situation (e.g., "Have you been shot?") or when the patient is seductive or
overly talkative.
Open-ended questions
Although direct questions can elicit information quickly, open-ended types of questions are
more likely to aid in obtaining information about the patient, and not close off potential
areas of pertinent information.
Using open-ended questions (e.g., "What brings you in today?"), the interviewer gives little
structure to the patient and encourages the patient to speak freely.

Factors Associated with Compliance with Medical Advice

Factors Associated Factors Associated with Comments
with Increased Decreased Compliance
Compliance
Good physician-patient Poor physician-patient Liking the physician is the most important
relationship relationship factor in compliance; it is even more
important than the physician's technical
skill
Physicians perceived as unapproachable
have low compliance from patients
Patient feels ill and usual Patient experiences few In asymptomatic illnesses, such
activities are disrupted Symptoms and little as hypertension, only about half
by the illness disruption of usual activities of patients initially comply with treatment
Many asymptomatic patients who
initially complied have stopped complying
within 1 year of diagnosis
Short time spent in the Long time spent in the Patients kept waiting get
waiting room waiting room angry and then fail to comply
Belief that the benefits of Belief that financial and The "Health Belief Model"
care outweigh its financial time costs of care outweigh of health care
and time costs its benefits
Written diagnosis and Verbal diagnosis and Patients often forget what is said during a
Instructions for treatment Instructions for treatment visit to the physician because they are
 anxious
asking the patient to repeat your verbal
instructions can improve understanding and
thus increase compliance
Acute illness Chronic illness Chronically ill people see physicians more
often but are more critical of them than
acutely ill people
Recommending only one Recommending multiple To increase compliance, instruct the patient
behavioral change at a behavioral to make one change (e.g., stop smoking)
time changes at once this month, and make another
Change (e.g., go on a diet) next month
Recommending too many changes
at once will reduce the likelihood
that the patient will make any changes
Simple treatment Complex treatment Compliance is higher with medications that
schedule schedule require once daily dosing, preferably
With a meal
Patients are more likely to forget to
take medications requiring frequent or
between-meal dosing
Older physician Younger physician Usually young physician age is only
an issue for patients in the initial
stages of treatment
Peer support Little peer support Membership in a group of People with a
similar problem (e.g.,smoking) can
increase compliance

The End