Doctor - Patient

Relationship
Dr.
Dr. Lynna
Lynna Lidyana
Lidyana SpKJ
SpKJ
 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 other’s
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. - Acceptance - honesty
- empathy - trust
 Some Obstacles - 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 Patient’s 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. Don’t 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 Facilitation; Silence;
Confrontation; Clarification Summation;
Interpretation; Explanation; Transition;
Self - Revelation Positive Reinforcement ;
Reassurance; Advice.
Special Cases
Some types of patient requre particular skill (patiency) of
the physician to understand the covert emotions, fears,
conflicts that the patient’s 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 patient’s 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 patient’s
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 patient’s privacy ( secrets)