The Patient -Doctor Relationship

DR MOHAMMAD A.S. KAMIL

7
• An effective relationship is characterized by
good rapport.
• Rapport is the spontaneous, conscious feeling
of harmonious responsiveness that promotes
the development of a constructive therapeutic
alliance.
 Establishing Rapport
the development of rapport as encompassing six
strategies:
Ø putting patients and interviewers at ease
Ø finding patients' pain and expressing compassion
Ø evaluating patients' insight and becoming an ally
Ø showing expertise
Ø establishing authority as physicians and
therapists
Ø balancing the roles of empathic listener, expert,
and authority.
 Empathy

• understanding a person from his or her frame of reference

rather than one’s own, or vicariously experiencing that
person’s feelings, perceptions, and thoughts.
• Empathy does not, of itself, entail motivation to be of
assistance, although it may turn into sympathy or personal
distress, which may result in action.
• Empathy is a way of increasing rapport.
• Although empathy probably cannot be created, it can be
focused and deepened through training, observation, and
self-reflection.
• In psychotherapy, therapist empathy for the client can be a
path to comprehension of the client’s cognitions, affects,
motivations, or behaviors.
 Transference
• Transference is generally defined as the set of expectations, beliefs,
and emotional responses that a patient brings to the patient-doctor
relationship.
• a patient’s displacement or projection onto the analyst of those
unconscious feelings and wishes originally directed toward
important individuals, such as parents, in the patient’s childhood.
• It is posited that this process brings repressed material to the
surface where it can be reexperienced, studied, and worked
through to discover the sources of a patient’s current neurotic
difficulties and to alleviate their harmful effects.
• The term’s broader meaning—an unconscious repetition of earlier
behaviors and their projection onto new subjects—is acknowledged
as applying to all human interactions.
 Countertransference
• Countertransference can take the form of negative feelings that are
disruptive to the patient-doctor relationship, but it can also
encompass disproportionately positive, idealizing, or even
eroticized reactions to patients.
• The therapist’s unconscious (and often conscious) reactions to the
patient and to the patient’s transference.
• In classical psychoanalysis, countertransference was viewed as a
hindrance to the analyst’s understanding of the patient, but to
modern analysts and therapists, it may serve as a source of insight
into the patient’s effect on other people.
• In either case, the analyst or therapist must be aware of, and
analyze, countertransference so that it can be used productively
within the therapeutic process.
 Models of Interaction Between Doctor and
Patient

1-The paternalistic model: He or she will

prescribe treatment, and the patient is expected
to comply without questioning.
• In emergency situations the doctor needs to
take control and make potentially life-saving
decisions without long deliberation.
2-The informative model: The doctor in this
model dispenses information ,all available data
are freely given, but the choice is left wholly up
to the patient.
• For example, doctors may quote 5-year
survival statistics for various treatments of
breast cancer and expect women to make up
their own minds without suggestion or
interference from them.
3-The interpretive model: Doctors who have
come to know their patients better and
understand something of the circumstances of
their lives, their families, their values, and their
hopes and aspirations, are better able to make
recommendations that take into account the
unique characteristics of an individual patient.
• The doctor in this model is flexible, willing to
consider question and alternative suggestions.
4-The deliberative model : The physician in this
model acts as a friend or counselor to the
patient, not just by presenting information, but
in actively advocating a particular course of
action.
The deliberative approach is commonly used by
doctors hoping to modify injurious behavior, for
example, in trying to get their patients to stop
smoking or lose weight.
 Interviewing Effectively
• One of the physician's most important tools is the ability to interview
effectively
• Through a skilled interview, physicians can gather the data necessary to
understand and treat patients
• Many factors influence both the content and the process of interviews
1. Patients' personalities
2. character styles
3. Technical factors such as telephone interruptions, the use of an
interpreter, note taking, and the patient's illness itself "whether in an
acute stage or in remission "influence the content and process of the
interview.
4. Interviewers' styles, experiences, and theoretical orientations also have a
significant impact
5. Even the timing of interjections such as( uh huh) can influence when
patients speak.
 Beginning the Interview
• physician begins an interview provides a powerful first impression to patients
• Patients are often anxious on first encounters with physicians and feel both
vulnerable and intimidated.
• A physician who can establish rapport quickly, put the patient at ease
• Physicians should initially make sure that they know a patient's name and that
the patient knows the physician's name.
• Physicians should introduce themselves to other people who have come with
the patient and should find out if the patient wants another person present
during the initial interview.
• the physician should also attempt to speak with patients privately to
determine if there is anything that they want the doctor to know but would be
reluctant to say in front of someone else.
• Patients have a right to know the position and professional status of persons
involved in their care. Most patients do not speak freely unless they have
privacy and are sure that their conversations cannot be overheard.
 The Interview Proper
• The content of an interview is literally what is said between
doctor and patient: the topics discussed, the subjects
mentioned
• The process of the interview is what occurs nonverbally
between doctor and patient, that is, what is happening in the
interview beneath the surface. Process involves feelings and
reactions that are unacknowledged or unconscious.
• Patients may use body language to express feelings they
cannot express verbally, for example, a clenched fist
• Patients may shift the interview away from an anxiety-
provoking subject onto a neutral topic without realizing that
they are doing so
Specific Interview Technique
 1-Clinical Interview
The ability to establish rapport and an
atmosphere of trust is basic to taking a thorough
psychiatric history and mental state
examination.
 2-Open ended question
Useful in starting the interview & patients may be
more comfortable telling their story with out
interruption.
e.g. can you tell me more about that.
e.g. tell me about your hospital stay.
e.g. tell me about your home life.
 3-Closed- ended question
• Closed-ended questions can be effective in
generating specific and quick responses about a
clearly defined topic.
• Example: are you thinking about killing yourself?
• Have you ever consulted a mental health
professional before?
 4-Reflection
• The doctor repeats to the patient in a
supportive manner something that the patient
has said.
• Example: an elderly patient is speaking about
fears of dying. The doctor may say,(aging
causes many people to think about death)
 5-Silence
• can be constructive and, in certain situations, allow
patients to contemplate, to cry, or just to sit in an
accepting, supportive environment, in which the
doctor makes it clear that not every moment must
be filled with talk.
 6-Confrontation
• Is meant to point out to a patient something to which the
doctor thinks the patient is not paying attention, is
missing, or is in some way denying.
• Meant to help patients face whatever needs to be faced
in a direct but respectful way.

• For example, a patient who has just made a suicidal

gesture but is telling the doctor that it was not serious
may be confronted with the following statement: What
you have done may not have killed you, but it's telling me
that you are in serious trouble right now and that you
need help so that you don't try suicide again.
 7-Clarification
• doctors attempt to get details from patients about
what they have already said.
• For example, a doctor may say, You are feeling
depressed. When do you feel most depressed?
 8-Interpretation
• is most often used when a doctor states something about a
patient's behavior or thinking of which the patient may not be
aware.
• The technique requires the doctor's careful listening for
underlying themes and patterns in the patient's story.
• Interpretations usually help clarify interrelationships that the
patient may not see
• For example, a doctor may say, When you talk about how
angry you are that your family has not been supportive, I
think you're also telling me how worried you are that I won't
be there for you either. What do you think?
• It is a sophisticated technique and should generally be used
only after the doctor has established some rapport with the
patient
 9-Summation
• Briefly summarize what the patient has said.
For example, the doctor may say OK, I just want
to make sure that I've got everything right up to
this point
 10-Explanation
• Doctors explain treatment plans to patients in easily
understandable language and allow patients to
respond and ask questions
• For example: You will be given a small dose of
medication that will make you sleepy. The
medication is called Halcion, and the dose you will be
getting is 0.125 mg.
 11-Transition
• transition allows doctors to convey the idea
that sufficient information has been obtained
on one subject; the doctor's words encourage
patients to continue on to another subject
• For example, a doctor may say, You've given
me a good sense of that particular time in
your life. Perhaps now you could tell me a bit
more about an even earlier time in your life.
 12-Positive Reinforcement
• allows patients to feel comfortable telling a doctor
anything, even about such things as noncompliance
with treatment
• Encouraging a patient to feel that the doctor is not
upset by whatever the patient has to say facilitates
an open exchange.
• For example: my job is not to judge what you say but
to understand what you are experiencing.
 13-Advice
• should be given only after patients are allowed to
talk freely about their problems so that physicians
have an adequate information base from which to
make suggestions.
• Example: “until your anxiety subside, I don’t think
you should look for a new job.”
 14-Reassurance
• Can lead to increased trust & compliance&
can be experience as an empathic response of
a concerned physician.
• Example: “I know you are upset but I think I
can help you”.
 15-Facilitation
• Doctors help patients continue in the
interview by providing both verbal and
nonverbal cues that encourage patients
to keep talking. Nodding one's head,
leaning forward in the chair, and saying
Yes, and then or Uh-huh, go on, are all
examples of facilitation.
 Ending the Interview

• Physicians want patients to leave an interview feeling understood and

respected and believing that all the pertinent and important information
has been conveyed to an informed, empathic listener.
• doctors should give patients a chance to ask questions and should let
patients know as much as possible about future plans.
• Doctors should thank patients for sharing the necessary information and
let patients know that the information conveyed has been helpful in
clarifying the next steps.
• Any prescription of medication should be spelled out clearly and simply,
and doctors should ascertain whether patients understand the
prescription and how to take it.
• Doctors should make another appointment or give a referral and some
indication about how patients can reach help quickly if it is necessary
before the next appointment.
THANK YOU