Doctor Patient Relationship Good physician treats the disease

Doctor Patient Relationship

Good physician treats the disease; The great physician treats the patient who has the disease William Osler (Canadian Physician, 1849 -1919)

People don’t care how much you know, until they know how much you care. Lewis Barnett, MD UVA Family Medicine 7

"The public tells us they want physicians who are good diagnosticians and also caring people. We start with students who are very caring but have no diagnostic skills and end up with physicians with great diagnostic skills but who don't care. ” Richard Frankel, MD, Prof of Medicine and Geriatrics at IU School of Medicine 8

The Doctor-Patient Relationship At the core of the practice of medicine ﻣﺤﻮﺭﻋﻤﻠکﺮﺩ پﺰﺷکی The patient expects a good relationship as much as a cure ﺭﺍﺑﻄﻪ ﺧﻮﺏ ﻫﻤﺮﺍﻩ ﺑﺎ ﺩﺭﻣﺎﻥ : ﺍﻧﺘﻈﺎﺭﺑیﻤﺎﺭ Dr-patient relationship itself becomes part of therapeutic process ﺑیﻤﺎﺭ ﺑﺨﺸی ﺍﺯ ﻓﺮﺍیﻨﺪ ﺩﺭﻣﺎﻥ - ﺍﺭﺗﺒﺎﻁ پﺰﺷک

Importance of Effective Doctor-patient Communication Accurate diagnosis. ﺗﺸﺨیﺺ ﺩﻗیﻖ Enhancing patient compliance to treatment plans. ﺗﻘﻮیﺖ پﺬیﺮﺵ ﺑﺮﻧﺎﻣﻪ ﻫﺎی ﺩﺭﻣﺎﻧی ﺗﻮﺳﻂ ﺑیﻤﺎﺭ Contributing to doctor clinical competence and self assurance. . کﻤک ﺑﻪ ﺻﻼﺣیﺖ ﺑﺎﻟیﻨی پﺰﺷک ﻭ ﺍﻃﻤیﻨﺎﻥ ﺍﺯ ﺧﻮﺩ Contributing to patient satisfaction. . کﻤک ﺑﻪ ﺭﺿﺎیﺖ ﺑیﻤﺎﺭ

Importance of Effective Doctor-patient Communication • Contributing to cost and resource effectiveness by preventing unnecessary prescriptions for medication that are either wrongly prescribed or not properly used by patients. کﻤک ﺑﻪ ﻫﺰیﻨﻪ ﺍﺛﺮﺑﺨﺸی ﺍﺯ ﻃﺮیﻖ ﺟﻠﻮگیﺮی ﺍﺯ ﺗﺠﻮیﺰ ﺩﺍﺭﻭﻫﺎی ﻏیﺮﺿﺮﻭﺭی کﻪ ﺑﻪ ﺍﺷﺘﺒﺎﻩ ﺗﺠﻮیﺰ ﺷﺪﻩ ﻭ یﺎ ﺑﻪ ﺩﺭﺳﺘی ﺗﻮﺳﻂ ﺑیﻤﺎﺭﺍﻥ ﻣﺼﺮﻑ ﻧﺸﻮﻧﺪ

Fewer malpractice suits ﺷکﺎیﺎﺕ کﻤﺘﺮﺍﺯ ﻗﺼﻮﺭپﺰﺷکی Fewer ERRORS due to better information Fewer CLAIMS regardless of quality of care 8 Avery JK. Lawyers tell what turns some patients litigious. Med Malpractice Rev 1985; 2: 35– 7. 15

When a group of physicians was asked what enhances their work satisfaction, the most frequently named factor was “relationships with patients. ”

Good doctor-patient communication What does it look like? 18

The Communication Circle q The communication cycle involves an exchange of messages through verbal and nonverbal means.

Communication Effective communication more information greater impact 20

It turns out that the effective transmission of information depends on a strong d-p relationship. ﺍﻧﺘﻘﺎﻝ ﻣﻮﺛﺮ ﺍﻃﻼﻋﺎﺕ ﻭﺍﺑﺴﺘﻪ ﺑﻪ ﺭﺍﺑﻄﻪ ﻗﻮی پﺰﺷک ﺑیﻤﺎﺭ It turns out that the most important component of the strong relationship is empathy. ﻣﻬﻢ ﺗﺮیﻦ ﺟﺰﺀ یک ﺭﺍﺑﻄﻪ ﻗﻮی ﻫﻤﺪﻟی ﺍﺳﺖ So empathy is the most powerful component of effective communication. ﺑﻨﺎﺑﺮﺍیﻦ ﻫﻤﺪﻟی ﻗﺪﺭﺗﻤﻨﺪ ﺗﺮیﻦ ﺟﺰﺀ یک ﺍﺭﺗﺒﺎﻁ ﻣﻮﺛﺮ . ﺍﺳﺖ 21

Relationships depend on empathy: the ability to put oneself in another’s shoes. "Identification with, understanding of, and vicarious experience of another person's situation, feelings, and motives. ” The bridge between us and “the other. ” The American Heritage Stedman's Medical Dictionary 22

But…ignoring emotion is inefficient “When opportunities for empathy are missed by physicians, patients tend to offer them again, sometimes repeatedly. ﺳﺒﺐ ﺗکﺮﺍﺭﻣکﺮﺭ ﻣﻮﺿﻮﻋﺎﺕ ، ﻧﺎﺩیﺪﻩ گﺮﻓﺘﻦ ﻓﺮﺻﺖ ﻫﻤﺪﻟی ﺗﻮﺳﻂ پﺰﺷکﺎﻥ ﺗﻮﺳﻂ ﺑیﻤﺎﺭﺍﻥ This phenomenon can lead to longer, more frustrating interviews, return visits, and "doctor shopping" by patients who feel dismissed or alienated. ” ﻭیﺰیﺘﻬﺎی ، ﺍیﻦ پﺪیﺪﻩ ﻣﻨﺠﺮ ﺑﻪ ﻣﺼﺎﺣﺒﻪ ﻫﺎی ﻃﻮﻻﻧی ﺗﺮﻭﺧﺴﺘﻪ کﻨﻨﺪﻩ ﻣﺠﺪﺩ 23 Hardee, J. T. A Focus on Patient-Centered Care and Office Practice Management: The

. . . آﻨچﻪ ﺑﺎیﺪ ﺗﻮﺟﻪ ﺩﺍﺷﺖ 1. Learn to listen with both ears – keep one ear out for emotion. 2. Reflect back what you’re hearing to your patients: find out if you’re right! 3. Express your empathy – let them know you care. 24

How to avoide complaints? that the doctor is really listening; گﻮﺵ ﺩﺍﺩﻥ ﺩﻗیﻖ that the doctor cares enough to take the time to pursue your concerns; unpleasant emotion and so you can be honest, and ﺻﺎﺩﻕ ، ﻋﻮﺍﻃﻒ ﻧﺎﺧﻮﺷﺎیﻨﺪ ﺑیﻤﺎﺭ ، پیگیﺮی ﻧگﺮﺍﻧیﻬﺎ ، ﺍﻫﻤیﺖ ﺩﺍﺩﻥ ﺑﻮﺩﻥ that the doctor really cares how you feel. ﺗﻮﺟﻪ ﺑﻪ ﺍﺣﺴﺎﺳﺎﺕ ﺑیﻤﺎﺭ 25

What do patients expect their physicians to do? Patients want to be able to trust the competence and efficacy of their caregivers. . ﺍﻋﺘﻤﺎﺩ ﺑﻪ ﺷﺎیﺴﺘگی ﻭ ﺍﺛﺮﺑﺨﺸی ﻣﺮﺍﻗﺒﺖ کﻨﻨﺪگﺎﻥ Patients want to be able to negotiate the health care system effectively and to be treated with dignity and respect. ﻣﺬﺍکﺮﻩ ﻣﻮﺛﺮﺑﺎ ﺳیﺴﺘﻢ ﻣﺮﺍﻗﺒﺖ ﻫﺎی ﺑﻬﺪﺍﺷﺘی ﻭ ﺭﻓﺘﺎﺭ ﺗﻮﺍﻡ ﺑﺎ ﻋﺰﺕ ﻭ ﺍﺣﺘﺮﺍﻡ Patients want to understand how their sickness or treatment will affect their lives, and they often fear that their doctors are not telling them everything they want

Patients want to discuss the effect their illness will have on their family, friends, and finances. ﺩﻭﺳﺘﺎﻥ ﻭ ﺍﻣﻮﺭ ﻣﺎﻟی ، آگﺎﻫی ﺍﺯ ﺗﺎﺛیﺮ ﺑیﻤﺎﺭی ﺑﺮ ﺧﺎﻧﻮﺍﺩﻩ Patients worry about the future. ﻧگﺮﺍﻧی ﺍﺯ آیﻨﺪﻩ Patients worry about and want to learn how to care for themselves away from the clinical setting. ﻧگﺮﺍﻧی ﻭ ﻧیﺎﺯ ﺑﻪ یﺎﺩگیﺮی ﻣﺮﺍﻗﺒﺖ ﺍﺯ ﺧﻮﺩ ﺩﺭ ﺟﺎیگﺎﻫﻬﺎی ﻏیﺮ ﺑﺎﻟیﻨی

Types of Communication Positive or negative Verbal or non-verbal

Positive Communication promotes the patient’s comfort and well-being Encourage patients to ask questions Speak slowly and clearly

Body Language Facial expression Eye contact Posture Open Closed Touch Personal space In many instances, people’s body language conveys their true feelings, even when their words may say otherwise.

Improving Communication Skills Listening skills Passive listening Active listening Improve listening skills Prepare to listen Relax and listen attentively Maintain eye contact Maintain personal space Think before you respond Provide feedback

Improving Communication Skills (cont. ) Interpersonal skills Warmth and friendliness ﺻﻤیﻤیﺖ ﻭ ﺩﻭﺳﺘی Empathy ﻫﻤﺪﻟی Respect ﺍﺣﺘﺮﺍﻡ Genuineness ﺻﺪﺍﻗﺖ Openness ﺑﺎﺯ ﺑﻮﺩﻥ Consideration and sensitivity ﺗﻮﺟﻪ ﻭ ﺣﺴﺎﺳیﺖ

Structure Analysis four prototypes of doctor-patient relationship Paternalism Consumerism Mutuality Default

Prototypes of doctor-patient relationship Physician control (Low) Physician control (High) Patient control (Low) Default Paternalism Patient control (High) Consumerism Mutuality

Paternalism Is widely regarded as the traditional form of doctor-patient relationship A passive patient and a dominant doctor

Paternalistic: The paternalistic approach is typified by a doctor centered style. پﺰﺷک ﻣﺤﻮﺭ It relies on closed questions designed to elicit yes or no answers. ﻣﺘکی ﺑﺮ ﺳﻮﺍﻻﺕ ﺑﺴﺘﻪ The doctor will tend to use a disease centered model and be focused on reaching a diagnosis, rather than the patients unique experience of illness.

The Paternalistic Approach “If I’ve told you once I told you 1, 000 times, stop smoking!!”

Patient’s role Permitted to: Give up some activities and responsibilities Regarded as being in need of care ﺩﺳﺖ کﺸیﺪﻥ ﺍﺯ ﺑﺮﺧی ﺍﺯ ﻓﻌﺎﻟیﺖ ﻫﺎ ﻭ ﻣﺴﺌﻮﻟیﺖ ﻫﺎ ﺑﺎ ﺩﺭ ﻧﻈﺮ گﺮﻓﺘﻦ ﻧیﺎﺯﻫﺎی ﻣﺮﺍﻗﺒﺘی In Return : Must want to get better quickly Seek help from and cooperate with a doctor ﺩﺭﺧﻮﺍﺳﺖ ﺳﺮیﻊ کﻤک ﺍﺯ ﻭ ﺑﺎ ﻫﻤکﺎﺭی پﺰﺷک ، ﺩﺭﺧﻮﺍﺳﺖ ﺑﻬﺒﻮﺩ یﺎﻓﺘﻦ →passive and dependent

Patient controlled consultation Consumeristic : Here the patient knows exactly what they want and forces the doctor into a patient centered approach یک ﺭﻭیکﺮﺩ ﺑیﻤﺎﺭ ﻣﺤﻮﺭ “You’re paid to do what I tell you!!”

Patient’s role Health shoppers Indications of consumer behavior Cost-consciousness Information seeking Exercising independent judgment Consumer knowledge ﺧﺮیﺪﺍﺭﺍﻥ ﺳﻼﻣﺘی ﻧﺸﺎﻧﻪ ﻫﺎی ﺭﻓﺘﺎﺭ ﻣﺼﺮﻑ کﻨﻨﺪﻩ آگﺎﻫی ﺍﺯ ﻫﺰیﻨﻪ ﺟﺴﺘﺠﻮی ﺍﻃﻼﻋﺎﺕ ﻗﻀﺎﻭﺕ ﻣﺴﺘﻘﻞ ﺩﺍﻧﺶ ﻣﺼﺮﻑ کﻨﻨﺪﻩ

Mutual Styles It’s serious isn’t it doctor?

Default : This is where the patient centered style fails. • ﺷکﺴﺖ ﺷیﻮﻩ ﻣﺒﺘﻨی ﺑﺮ ﺑیﻤﺎﺭ The doctor is trying to relinquish control but the patient is unwilling to accept it, ﺩکﺘﺮ ﺩﺭ ﺗﻼﺵ ﺑﻪ ﻭﺍگﺬﺍﺭی کﻨﺘﺮﻝ ﻋﺪﻡ ﺗﻤﺎیﻞ ﺑیﻤﺎﺭ ﺑﻪ پﺬیﺮﺵ آﻦ The result is an impasse. ﺭﺳیﺪﻥ ﺑﻪ ﺑﻦ ﺑﺴﺖ

Doctor-patient relationship in the past Paternalism Because physicians in the past are people who have higher social status ﻣﻮﻗﻌیﺖ ﺍﺟﺘﻤﺎﻋی ﺑﺎﻻﺗﺮ “doctor” is seen as a sacred occupation which saves people’s lives ﺷﻐﻞ ﻣﻘﺪﺱ The advices given by doctors are seen as paramount mandate ﺑﻪ ﻋﻨﻮﺍﻥ ﺩﺳﺘﻮﺭﺑﺎ ﺍﻫﻤیﺖ

Doctor-patient relationship at present Consumerism and mutuality Patients nowadays have higher education and better economic status The concept of patient’s autonomy The ability to question doctors

Reasons for the change Doctors’ condition Patients’ condition Environmental factors

Factors which influence Dr-Patient Communication Patient-related factors Dr-related factors The interview setting

Patient-related factors Physical symptoms Psychological factors Previous experience Current experience

Dr-related factors Training in communication skills Self-confidence in ability to communicate Personality Physical factors Psychological factors

The interview setting Privacy Comfortable surroundings An appropriate seating arrangement

A) Core communication skills: Physician need To Acquire Doctor-patient interpersonal skills. Information gathering skills. Information giving skills. ﻣﻬﺎﺭﺗﻬﺎی ﺑیﻦ ﻓﺮﺩی پﺰﺷک ﻭﺑیﻤﺎﺭ ﻣﻬﺎﺭﺗﻬﺎی گﺮﺩآﻮﺭی ﺍﻃﻼﻋﺎﺕ ﻣﻬﺎﺭﺗﻬﺎی ﺍﺭﺍﺋﻪ ﺍﻃﻼﻋﺎﺕ ﻭ آﻤﻮﺯﺵ ﺑیﻤﺎﺭ

Core Communication Skills 2 - Information gathering skills: b) Silence: To allow time for the patient to collect his thoughts. To assess levels of anxiety.

2 - Information gathering skills: Core Communication Skills Clarifying the information given to the patient. Active listening: To show that therapist is attending closely the patient. Sequencing of events. Directing the flow of information. Summarizing. ﺳﻮﺍﻝ کﺮﺩﻥ ﻧکﺎﺕ کﺎﺭﺑﺮﺩی ﺍﺭﺗﺒﺎﻃی ﺩﺭ ﺣیﻦ ﻣﺼﺎﺣﺒﻪ ﺗکﻨیکﻬﺎی کﻤکی ﺍﺭﺗﺒﺎﻁ پﺰﺷک ﻭﺑیﻤﺎﺭ ﻣﻮﺍﻧﻊ ﺭﻭﺍﻥ ﺷﻨﺎﺧﺘی ﺍﺭﺗﺒﺎﻁ ﻧکﺎﺕ ﺍﺭﺗﺒﺎﻃی ﺣیﻦ ﻣﻌﺎیﻨﻪ

Communication with Coworkers

Communication with Coworkers Develop rapport with coworkers Rules for the medical office Use proper channels Have a proper attitude Plan an appropriate time for communication

Dealing with Conflict Do not “feed into” others’ negative attitudes Be personable and supportive Refrain from passing judgments Do not gossip Do not jump to conclusions

Dealing with Difficult Consultations Difficult Patients: Exploring the Patient Perspective 123

Objectives be able to define difficult patients be able to list types of difficult patients be able to explain how the problem can effect patientphysician relationships. be able to define causes for difficult patients be able describe the strategies on how to cope with difficult patients. 124

Not all difficult encounters can be blamed on the patient side of the interaction 125

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Definition Difficult patient is the one with whom the physician has trouble forming an effective working relationship. 127

Who are “difficult” patients? What characteristics make a patient “difficult”? Mental health disorders Multiple symptoms Chronic pain Functional impairment Unmet expectations Lower satisfaction with care High users of health care services Dr. Tom O’Dowd coined the term “heartsink patient” BMJ, 1988

Types of Difficult Patients Somatic fixation (patients who express personal distress in the form of somatic symptoms) Dependent Patient (Dependent on prescription drugs). Demanding Patient (frequent visit for minor things; requesting medications, tests, &referrals ). Manipulative help rejecter) (Do not follow doctor instructions) Self destructive patients (Diabetic patients who induce frequent attacks of ketoacidosis) 129

Cont…… Seductive patients. ﺑیﻤﺎﺭﺍﻥ گﻤﺮﺍﻩ کﻨﻨﺪﻩ Angry patients. Patients who are shopping from one doctor to another for the same problem. 130

Why not just ignore them? Because we can’t. At least 1 in 6 patients are “difficult” and so we see them every day. Photo by Chat-Lunatique

Difficult Consultations: q. Patient with Hidden Agenda (Patient Reluctant to Talk Freely) q. Talkative Patient q. Angry Patient q. Demanding Patient 132

Patient Reluctant to Talk Freely Causes : �Patient Factors : Examples : �The topic �Cultural barrier Dr. Factors : Circumstances : �Social class barrier �Dr. authority �Time constrains �Presence of 3 rd party 133

Patient Reluctant to Talk Freely Verbal Communication Non - verbal Com. �Giving reason for the question. �Showing sympathy & empathy �Comments on the patient attitude �Showing real interest �Generalization of the problem �Unhurried manner �Asking at the right time �Touch for reassurance �Reflection �Use of physical examination �Mirroring �Confrontation 134

Talkative Patient communication skills Verbal Communication Summarization Prioritization Non - verbal Comm. Use of touch Sympathy & empathy Behaviors which brake the Interruption Close ended question relationship : 135

Angry Patient n n Goal is to help the patient express anger constructively Steps in communicating with an angry patient Recognize anger and its cause Remain calm and demonstrate respect Ask patient to be specific concerning cause Present your point of view Focus on physical and medical needs Avoid breakdown of communication Maintain adequate personal space Leave if you feel physically threatened Do not take anger personally

Angry Patient Communication Skills Empathy Non-judgmental attitude Respect patient autonomy Support Flexibility 137

Even Angry Customers Are Always Right Marsha L. Miley and Thomas J. Weida, MD 7 steps for satisfying angry patients: 1. Handle problems privately 2. Listen to patients' complaints 3. Disarm anger with kindness 4. Delegate up when necessary 5. Follow through on promises 6. Involve the patient in prevention 7. Be grateful 138

Dealing with Demanding Patient 139

Negotiation Skills (think win-win) Set limit Reinforcement Compromise Be flexible 140

Dealing with Demanding Patients � Negotiate agenda & goals : q Set limit Reinforcement Compromise & Be flexible � Avoid argumentation, � Explain your rationale, � Pay attention to the way you say no, and, � If all else fails, breathe deeply and start over. � Exceptionally, for some patient firm boundaries are the rule 141

Communication in Special Circumstances Anxious patient Can interfere in communication process May not listen well or pay attention to what you are saying Observe for Tense appearance Increased blood pressure and breathing Sweaty palms Irritability and agitation

Patients from Other Cultures Each patient has his or her own behaviors, traditions and values Strive to understand be tolerant Stereotyping Negative statement about specific traits of a group applied to an entire population Generalization Statement about common trends within a group

Patients from Other Cultures (cont. ) Attitudes about health care Beliefs about causes of illness Symptoms and what they mean Treatment expectations Language barriers

Patients with Visual Impairment Use large-print materials Use adequate lighting in all areas Use a normal speaking voice Talk directly and honestly Do not talk down to the patient Preserve the patient’s dignity

Patients with Hearing Impairment Find a quiet area to talk Minimize background noise Position yourself close to and facing the patient Speak slowly Remember that elderly patients lose the ability to hear high-pitched sounds first Verify understanding Use written material Speak clearly but do not shout

Mentally or Emotionally Disturbed Determine what level of communication the patient can understand Suggestions Remain calm if the patient becomes agitated or confused Avoid raising your voice Avoid appearing impatient

The Elderly Patient Be respectful Do not talk down to elderly person Tips for communication Act as if you expect the patient to understand Respond calmly to any confusion Tell the truth and use simple questions and terms Ask the patient to relax, speak slowly, and ask the patient to repeat if you do not understand

Terminally Ill Patients Often under extreme stress, so offer support and empathy Kubler-Ross’s Stages of Dying Denial Anger Bargaining Depression Acceptance

Young Patients and Their Parents Recognize and accept their fear and anxiety Explain all procedures Use praise Do not tell children that a procedure will not hurt if it will, or you will lose their trust Reassuring and keeping parents calm will also help the child relax

Patients with AIDS/HIV Stigma of disease Guilt Anger Depression You must have accurate information about the disease and the risks involved to answer the patient’s questions Patients need human contact and to be treated with dignity

Patient’s Family and Friends Provide emotional support to the patient Acknowledge family members and friends Keep them informed about patient’s progress Remember to protect patient confidentiality Ask the patient what information can be given to family or friends.

Cues for the physician Difficult patients evokes a feeling of anxiety, pressure, boredom, or frustration 153

Often during life-altering experiences, patients and their loved ones need a shoulder to cry on or someone to comfort them. It is important for them to know support is there. —Lindsey D. Fisher (The Healers Art)

Thanks 155

1. Hahn SR, Kroenke K, Spitzer RL, Brody D, Williams JB, Linzer M, de Gruy FV 3 rd. The difficult patient: prevalence, psychopathology, and functional impariment. J Gen Internal Medicine. 1996 Jan; 11(1): 1 -8. 2. Mathers N, Jones N, Hannay D. Heartsink patients: a study of their general practitioners. Br. J Gen Pract. 1995; 45(395): 293 -296. 3. Hahn SR. Physical Symptoms and Physician-Experienced Difficulty in the Physician. Patient Relationship. Ann Internal Med. 2001 May 1; 129(9 pt. 2): 897 -904. 4. Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic. Arch Intern Med. 1999; 159: 1069 -1075. 5. Hahn SR, Thompson KS, Wills TA et al. The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol. 1994: 47: 647 -657. 6. Hinchey, SA, Jackson AL. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med. 2011 Jan 25. 156