Communication Skills for PatientPhysician Relationship Hakan Atalay Yeditepe

Communication Skills for Patient-Physician Relationship Hakan Atalay Yeditepe University Medical School Department of Psychiatry

Basic Concepts Psychic determinism Repression and resistance Primary and secondary processes Infantile sexuality Interpretation of dreams Transference Drives

TOPOGRAPHICAL MODEL OF THE MIND CONSCIOUS UNCONSCIOUS PRECONSCIOUS

Interpretation of Dreams Manifest and Latent Content ●Representability ●Symbolism ●Displacement ●Condensation ●Projection Secondary Revision

Two Principles of Mental Functioning Primary Process: Exist from the start ● Pleasure principle ● İmmediate satisfaction ● Timeless, dream, art, psychosis, etc. Secondary Process: Develops later ● Reality principle ● Delaying gratification ● Everyday life, grammatic structure, etc.

STRUCTURE OF PSYCHIC APPARATUS ID EGO SUPER-EGO

PSYCHOSEXUAL DEVELOPMENT Oral stage Anal stage Urethral stage Phallic stage Latency stage Genital stage

Defence mechanisms Denial, projection Acting out, projective identification, regression, somatization Displacement, rationalization, isolation, dissociation, reaction formation, repression Altruism, anticipation, humor, sublimation, suppression

Thanatos Eros

EGO PSYCHOLOGY EGO VS ID DEFENSE MECHANİSMS EGO AS AN ADAPTATION ORGAN CONFLICT-FREE EGO SPHERES

ERIKSON * Basic trust & Mistrust * Autonomy & Shame and doubt * Initiative & Guilt * Industry & Inferiority *Identity & Role confusion *Intimacy & Isolation * Generativity & Stagnation * Integrity & Despair

OBJECT RELATIONS THEORY (Kernberg) Attachment Theory Self and Other Integration of the Self

Empathy Interview provides considerable relief to patients: Puzzling and frightening symptoms are framed in the context of medical understanding. Of equal importance to an intellectual understanding is the capacity to undestand emotionally the experiences of patients. “Nonverbal cues” “How can you understand me if you haven’t gone through what I’m going through? ”

Interview provides considerable relief to patients: Puzzling and frightening symptoms are framed in the context of medical understanding. Of equal importance to an intelelctual understanding is the capacity to understand emotionally the experiences of patients. “Nonverbal cues” “How can you understand me if you haven’t gone through what I’m going through? ” 15

Change in Health Care System If the focus of the 21 st-century health care system is to be the patient, then the value of the doctor–patient relationship must be promoted. In this context doctor–patient communication is regaining interest because it is expected to lead to improved patient outcomes and fewer complaints from patients regarding medical practice. Lack of trust and agreement between patients and physicians contributes to frustrating visits from the physicians’ perspective and thus could hamper the quality of care they provide.

Different Perceptions Doctors perceived themselves to be more consistent from one patient to another patient than patients perceived doctors to be. Some doctors think that they are generally good at communicating with their patients and other doctors think that they are generally quite poor. Patients of the same doctor do not agree very much with each other about the level of communication skills of their physician. Doctors who think they are especially good at communicating with their patients are not necessarily seen that way by their patients.

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Services, not Quality of Treatment More complaints are related to the services of medical treatments rather than those against the quality of medical treatments, and the majority complaints are about inadequate communication between doctors and patients as well as poor services attitude of healthcare workers.

Excellent Doctor-Patient Communication * Effective relationship building * Information gathering * Understanding of patient’s perspective * Information giving * Good decision making 21

Medicalization of Medicine With the introduction of numerous medical treatment equipments, doctors become more dependent on those equipments rather than the traditional and basic methods of diagnosis including inspection, palpation, percussion, auscultation, listening, asking, and feeling. Doctors could understand the disease information without communicating with patients and the direct relationship between two people turns to be indirect due to the use of equipments. Consequently, the communication of feeling and thoughts becomes restricted.

Patient Centered Communication Individual patient have different perceptions of how the ideal doctor-patient interaction should unfold. A patient may prefer descriptive talk versus numeric or graphics talk as the ideal method of information presentation. Patients’ opinios may differ as to what topics they want to discuss or address during a visit and/or the role they wish to play in the decision-making process. 23

Confidentiality and Trust Patients with successful doctor-patient interactions trust their doctors and are more inclined to delaying expensive diagnostic exams and accepting watchful waiting. Physicians can enhance patients’ trust through careful listening. Patients may be suspicious in reference to the objectives of the health care system and the role of physicians overall. 24

Holistic Approach The specialty system of modern medical science is based on physiological thoughts of reductionism and mind-body dualism, which believe that all diseases could present as illness in parts, could be detected by advanced test equipments and machines and described using figures or specific forms. In a doctor’s eyes, a patient is simply a part of his or her body, presented as cells, tissues, and gene segments instead of a human being as a whole. The patient, a human being with thoughts and feelings, becomes merely a disease carrier to doctors and medical science researchers, which would inevitably remove the doctor’s affection towards the patient.

Under the specialty system, the doctor cares only the disease but ignores what is needed most by the patient.

Be “Patient” Outpatients expecting doctors’ attention would act cautiously and give extremely detailed information about the experience of their illness. They would pay great attention to healthcare workers’ words and facial expressions, in the hope that doctors could be patient and inspect them thoroughly to give correct diagnosis. Once the doctor appears impatient, the patient would feel guilty and restless: dare not say more than enough words, just in case saying the wrong thing which would offend the doctor or miss out the opportunity of treatment.

Listening, Listening On the other hand, healthcare workers have little time to communicate with the patients, not to mention any encouragement or comfort, but asking closed questions based on their specialty knowledge. They are not interested in what patients say and often interrupt rudely or act impatiently. They would not talk about, listen to or ask anything irrelevant to the disease, but only focus on finishing the check list and diagnosis notes, and then urge patients to leave before letting them finishing the talk.

As a result, patients feel being ignored and develop doubts about the diagnosis and treatment.

Different Point of Views The doctor uses science and scientific experiment method to read a disease while the patient uses the influences on his/her daily life and body functions to define or read a disease. The differences of doctor-patient in understanding the disease caused two problems: one is the doctor would not pay enough attention to the patient’s pain of suffering during the diagnosis and treatment, the other one is the doctor could provide little help to those patients who suffer from a disease which is not clearly diagnosis under the classification in medical science.

As the patient feel he or she is not understood by the doctor, or because the pain is not lessened after repeat visits to the hospital, the patient develops passive emotion and becomes sensitive to diseaserelated information, negative ones in particular. The patient reads the doctor’s messages in a negative way, misunderstands the doctor, and even attacks the doctor by language or body violence.

The term of “informed consent” involves “sufficient information” and “consent”. “Sufficient information” means disclosure of information and understanding of disclosed information. “Consent” should be voluntarily make decision and give authorization to carry out the suggested action. Informed Consent

Giving “Sufficient” Information Giving sufficient information to the patient would help the patient to have a better understanding of the progress and health status; besides, it would make the patient more willing to cooperate with the doctor and follow the doctor’s requirements about inspection and treatment. To every outpatient, the treatment is about his or her own body, not about a machine, so it is natural that the patient would like to know the details of the diagnosis and each step of the treatment, also with the hope that the treatment would be rational, necessary, appropriate and possibly economy.

Giving “Sufficient” Time However, ineffective and asymmetric information transfer is common in medical service market. The doctor and the patient are not equally knowledgeable about the medical science, and have different understanding about pathology, diagnostic techniques, treatment methods, as well as the content, quality, effect and price of medical service. And doctors have very limited time and energy, and due to the restriction on communication ability and skills, they could not ensure clear explanation for patients even with their professional knowledge and judgment.

Respect for Patient (and Their Families) With this kind of bias, doctors do not pay attention to explain patients and their relatives about the full details of the disease, the purpose of the inspection, the treatment plan and price, risks of medical treatment, and prognosis, etc. This kind of communication barrier is that doctors lack of the respect for patients’ rights of informed consent, feeling that patients would not be able to understand even if are told.

“Vicious Circle” Those who have no clear understanding of his/her own disease and could not participate in the treatment plan decision would only be able to passively use the medical service. Once the treatment is not effective as expected, or the price exceeds the patient’s expectation, or the patient believe that he or she was mislead by the doctor to pay for unnecessary medicines or medical services, then the patient would lose trust in the doctor. This is a vicious circle of Doctor-Patient communication barriers.

Vicious Circle Doctor’s misleading Information Patient’s misleading response Patient’s incorrect response Doctor’s emotional reaction

Patient or Client? Under the free healthcare system before the reform, doctors do not need to consider profit making, they usually wholeheartedly focus on curing patients, while patients have no reason to doubt doctors and accept all kinds of results. Nowadays, hospitals rely on medicine to generate revenue, and “big prescription”, “kickback”, “red envelope” become an phenomenon, doctors’ objectivity and authority have been challenged.

With the advocation by public opinions, patients begin to be aware of their own rights, and the complaints against healthcare workers are increasing year after year, and Doctor. Patient disputes involving violence continue to unfold. Within this kind of trust crisis, both doctors and patients have developed self-defense mechanism. From the moment when patients would be cautious of possible cheating. And doctors see patients as potential complaint makers, and worry about possibly being sued or attacked.

Google Medical Faculty On one hand, outpatients would try to get more medical knowledge through various channels like Google search, forums of various diseases, and will choose some more hospitals. Even though a lot of time and effort are wasted, the patient has got some confidence in his/her knowledge and would tend to challenge the authority of the doctor, keep asking questions about treatment plans, and the patient’s adherence to treatment gets worse.

Self-defence On the other hand, as doctors take precautions against patients and their families. In order to avoid the medical risks, they tend to adopt the following strategies: use treatment of conservative therapy, which eliminate all risks; before surgery or large disposal, present in a completely objective stance, without any subjective guide, and give patients the absolute freedom of choice in order to avoid any liability; exaggerate the uncertainty of the outcome of treatment or medical risk to reduce patients’ expectations of treatment, but at the cost of increasing the patient’s psychological burden.

Once Upon A Time Doctors Were. . . This kind of communication not only make the hospital lose the trust and respect of the public, but also lead to the disapproval of the personality of medical staff because of the “halo effect”, and damage the authority of their profession and social status.

Bio-Psycho-Social Model To improve doctor-patient communication, it is a must for “consulting a doctor” or “medical treatment” of the original “biomedical model” to evolve up to “seeing the patient” or “treating the patients” of the modern “biopsycho-social medical model”. It requires health workers to understand the psychological demand of outpatients, and to increase humane care in medical communication, truly practicing theme of “people-oriented” and show “respect, understand, serve people, care for people” in all outpatient medical activities.

Respect the Patient (i. e. , Yourself) In the outpatient doctor-patient communication process, the prerequisite is to respect the patient and his or her independent personality, and to regard the patient as a human being, not just the carrier of the disease. In addition to understanding the disease, doctors should encourage patients to tell their thoughts, ideas and emotion, and give them empathy and support, which forms a two-way, interactive communication process.

Have a Good Life Even With the Disease The goal of medical treatment is not limited to the “curing” of disease, but also includes helping patients recover as a person of dignity, regain control over his or her own life (even if limited), overcome the sense of powerlessness and regain physical freedom, and could have a good life even with the disease.

Therefore, doctors should pay attention to patients’ experience, not just to see the disease itself, and then doctors should, from the patients’ standing point, learn to understand to gain insight into the disease’s impact on their personal life.

Mutual Respect Comprehensive doctor-patient communication should ensure the patient fully informed and to be involved in the treatment process. Either diagnostic behavior or therapy behavior should be conducted on the basis of the doctor’s own expertise, combined with the patient and family’s wishes and values, repeatedly and interactively discussed, carefully selected, and finally decided by two parties.

Shared Decision Making Besides of disease information, the doctor should, from the patient perspective, pay equal attention to the patient’s feeling, financial ability, and the pressure he or she bears. And also the doctor should encourage the patient to raise questions and doubts, patiently explain relevant medical knowledge, disease development trends and potential risks. By respecting the patient’s ability to make appropriate decisions, this kind of practice could allow patients to participate in medical decision-making process, and establish a true trusting relationship between doctors and patients.