Unit 7 PhysicianPatient Relationship College English Center College

Unit 7 Physician-Patient Relationship College English Center College of Foreign Languages and Literature Fudan University Page 167

Issues to be covered n n The shift from paternalistic paradigm to patient-centered paradigm in medical decision making The importance of good physician-patient relationship in both the medical practice and the patient’s recovery Things that counts in maintaining a amiable physician-patient relationship The way to communicate properly and effectively with the patients Page 167 -188

Words talk with different overtones! doctor n physician n medical practitioner n provider n patient n client n customer n Page 167

Words talk with different overtones! n n Physician: denoting a practitioner of the art of healing; Doctor: referring to a “teacher” to show, to teach, or to appear right, and carrying a connotation of being seemly, fitting, and decent; Medical practitioner: a technique term without much connotation; Provider: a generic term more or less related to business; Page 167

Words talk with different overtones! Patient: indicating a suffering or sick person under medical treatment; n Client: referring to a person who is willing to pay for a good or a service; n Customer: denoting one who pays a fee n Page 167

Three different situations where doctors may be asked to make “tough decisions” for the patients n n n Decide whether life-support system should be continued or withdrawn; Decide whether euthanasia should be considered; Decide whether a new therapy should be tried; Decide whether surgery should be the first choice or the last resort; Decide whether transfer or referral is needed. Page 168

Text A n Letting Doctors Make the Tough Decisions q Pauline W. Chen Page 168

What difficult situation is the young doctor facing? (Pre. 1) A dying patient n Decision whether to withdraw lifesupport machines and medication and start comfort measures n The family’s refusal to make any decision or withdraw any treatments n Page 169, P 2

Language Focuses n n …who was impressive not only for his clinical skills but also for his devotion to patients 他身材高大伟岸，但是从来不让人有咄咄逼人 的感觉 He was large and powerfully built but never seemed to loom over his patients… Page 168 -169, P 1

Language Focuses n n n 护士站 nursing station 停止使用呼吸机并停药/停止治疗 withdraw life-support machines and medications /treatment I told them suffering or comfort — it was their decision. But in the end, they made no decision and just walked right out of the room. Page 169, P 2

What is paternalistic decision-making in medicine? (Pre. 2) Doctors as exclusive decision maker n Patients as participants without little say in the final choice n Page 169, P 4

Language Focuses n n The way doctors and patients approach medical decisions has changed sharply over the last 50 years. and patients, if they participated, often had little say in the final choice. Page 169, P 4

Language Focuses n n …as movements calling for patient empowerment grew and medical ethicists began articulating principles regarding the ethical care of patients. …要求病人授权的呼声越来越高，而且医学伦 理学家也开始阐述病人伦理关怀的相关原则。 Page 169, P 4

In what way can patient empowerment be good for the patient? (Pre. 3) n n n Respect for the patient, especially the patient’s autonomy Patient-centered care The Patients as decision maker based on the information provided by the doctor Page 169, P 5 -6

Two principles /tenets / notions involved in the decision-making process n respect for the person q n a new clinical ideal: patient-centered care in wards, clinics and operating rooms respect for a person’s autonomy q letting patients make their own decisions Page 169, P 5 -6

Language Focus One tenet that gained particular traction among clinicians… n 临床医生们尤为拥护的一条宗旨 n n n …this ethical principle led to a new clinical ideal: patient-centered care …这条伦理原则导致了一种新的临床理念 的出现：以病人为中心的医护。 Page 169, P 5

Language Focus n n …young doctors, myself included, would be trained to restrain ourselves from making anything but emergency or mundane decisions for patients …包括我在内，年轻医生将接受培训，学 会除了一些紧急状况或日常琐事，不为病 人作其他任何决定。 Page 169, P 6

Consequence incurred by the two principles /tenets / notions n Young doctors, myself included, would be trained to restrain ourselves from making anything but emergency or mundane decisions for patients. q Offer your comments on that? Page 169, P 5 -6

Language Focus n n …and that interpretation would work its way into the teaching programs of medical schools and into state laws that mandated discussion of treatment options with patients. …而且，对病人自主性的解释逐渐进入了 医学院校的课程，也被写进各州的法律， 规定医生必须与病人讨论治疗方案的选择。 Page 169, P 6

Why does the author say too much physician restraint may not be that good for the patient? (Pre. 4) n n n The patients are forced to make decisions they never want to. Patients, at least a large majority, prefer their doctors to make final decisions. Shifting responsibility of decision making to the patients will bring about more stress to the patients and their families, especially when the best option for the patient is uncertain Page 169 -170 P 8 -11

Language Focuses n n While doctors might equate letting patients make their own decisions with respect… 虽然医生也许认为让病人自己作决定就是尊重 病人… Page 169 P 8

Language Focuses n …a majority of patients are being left to make decisions that they never wanted to in the first place Page 170 P 8

Language Focuses n n When it came to medical decisions, almost all the respondents wanted their doctors to offer choices and consider their opinions. But a majority of patients — two out of three — also preferred that their doctors make the final decisions regarding their medical care. Page 170 P 9

Language Focuses: How many? n n n When it came to medical decisions, almost all the respondents wanted their doctors to offer choices and consider their opinions. But a majority of patients — two out of three — also preferred that their doctors make the final decisions regarding their medical care. …most patients don’t want to make these decisions on their own Page 170 P 8 -10

The challenges n n …not when the medical choices are obvious, but when the best option for a patient is uncertain …when doctors pass the burden of decisionmaking to a patient or family, it can exacerbate an already stressful situation. Page 170 P 11

What kind of considerations may have prevented doctors from making decisions for their patients? (Pre. 5) n Doctors are very much cautious about committing some kind of ethical transgression. q ‘Who am I to presume to know what my patients need? ’ Page 170 P 12

Language Focuses n n n …doctors may be grappling with their own set of worries Some will resort to veiling their own opinions in a halfhearted attempt to direct the decision. 有些医生采取的做法是隐藏自己的观点，用隐 隐约约的方式引导病人作决定。 Page 170 P 12

Language Focuses n n While the doctors might be convinced that they are being objective and dispassionate, more often than not they are sending mixed messages. 虽然医生坚信自己的态度客观冷静，但往往他 们在向病人发出莫衷一是的信息。 Page 170 P 12

A Case in Point: Language Makes a Difference n n Tell relatives that it is their choice to withdraw life support from a dying patient. But that doctor may also use value-laden language to describe the options. One alternative may be described to the family as “reasonable” or “comforting, ” while the other is depicted as “invasive, ” “aggressive” or “painful. ” Page 170, P 13

Dr. Curlin’s Wisdom I n n Bizarre dishonest of communication Patients end up feeling manipulated and will resist making any decision at all. Page 170, P 14

Dr. Curlin’s Wisdom II Page 170, P 14

Dr. Curlin’s Wisdom II n n “We have to stop drawing a circle around patients and their families, ” “We have to stop subjecting them to the loneliness and burden of autonomy and instead begin standing in that circle with them. ” Page 171, P 16

Do you agree that doctors should be prepared to make any decisions together with their patients? (Pre. 6) n Shouldering responsibility together with the patient may be better than having the patient make decision on their own alone. n Balancing between paternalism and respect for patient’s autonomy constitutes a large part of medical practice. Page 167 -171

Language Focus n n the key to preserving patient autonomy — and patient-centered care — lies not in letting patients make the final decisions alone but in respecting their opinions and shouldering the responsibility together. I admit, myself, will need to be more mindful of whether patients want them to share information, be directive or hand over the responsibility of the decision. Page 170 -171, P 15 -16

To Sum Up n n Watch the Video and see what are tips given by Dr. Thaddeus Bell to build a Amiable PP relationship Doctor-Patient Relationship Page 170 -171, P 15 -16

Assignment for Group Presentation n Hospice movement has been a popular concept in recent decades in the field of health care. Work in a small group and explore relevant information about this subject in the following aspects: q 1. definition q 2. history q 3. advantages q 4. development in China Page 181

Presentations for Unit 8 1. How are research and practice related to each other? (P 195) 2. Elaborate the principle of respect for persons. 3. Explain the principle of beneficence. (P 195) 4. How is the principle of beneficence related to Hippocratic Oath. (P 195) Page 195

Presentations for Unit 8 5. Illustrate the principle of justice with concrete examples. (P 195) 6. Define informed consent and exemplify its application. (P 195) 7. What are the considerations involved in selection of human subjects in research? (P 195) Page 195