L2: Physician-Patient Relationship Flashcards
Only about ……. of Americans with symptoms seek medical care; most people contend with illnesses at home with OTC medications and home management.
- one-third
Patients’ behavior when ill are influenced by:
- Culture
- Previous experiences with medical care
- Physical and mental conditions
- Personality styles
- Coping skills.
Many psychiatric patients fail to seek help
WHY?
- As There is a stigma to having a psychiatric illness (Psychiatric symptoms are considered a moral weakness or a lack of self-control).
- Morbidity rates and mortality rates increase between psychological illness and physical illness in patients who need psychiatric attention.
The Sick Role
Patient Personality Styles & Behavioral Characteristcs During Illness
- Paranoid
Blames the physician for the fact that he or she is ill
Patient Personality Styles & Behavioral Characteristcs During Illness
- Schizoid
Becomes even more withdrawn during illness
Patient Personality Styles & Behavioral Characteristcs During Illness
- Schizotypal
Bizarre behavior may mask serious illness
Patient Personality Styles & Behavioral Characteristcs During Illness
- Histirionic
May be dramatic, emotionally changeable, and approach the physician in an inappropriate sexual fashion during illness
Patient Personality Styles & Behavioral Characteristcs During Illness
- Narcisstic
Has a perfect self-image, which is threatened by illness and may refuse needed treatment which can alter his or her appearance
Patient Personality Styles & Behavioral Characteristcs During Illness
- Antisocial
May self-write or alter prescriptions and lie to the physician
Patient Personality Styles & Behavioral Characteristcs During Illness
- Borderline
Idealizes the physician at first, may make gestures of self-harm when ill
Patient Personality Styles & Behavioral Characteristcs During Illness
- Avoidant
Interprets physician health suggestions as criticisms, fears rejection by the doctor, is overly sensitive to a perceived lack of attention or caring
Patient Personality Styles & Behavioral Characteristcs During Illness
- Obsessive-Compulsive
Fears loss of control and may in turn become more controlling during illness
Patient Personality Styles & Behavioral Characteristcs During Illness
- Dependent
Becomes more needy during illness and wants the physician to make all decisions and assume all responsibility
Patient Personality Styles & Behavioral Characteristcs During Illness
- Passive-aggresive
Asks for help but then does not adhere to the physician’s advice
Telling patients the truth
- Adults
In the United States:
- adult patients must be told the medical information directly (not relayed to the patient through relatives).
- The patient is told the complete truth about the diagnosis, the management and its side effects, and the prognosis of their illness.
- Falsely reassuring in response to patient questions is not appropriate (e.g., “Do not worry, we will take good care of you” or “You can get pregnant again” [after a miscarriage]).
Telling patients the truth
- Child
- Parents decide if, how, and when such information will be given to an ill child.
Telling patients the truth
- Relatives
- With the patient’s permission, the physician can tell relatives this information in conjunction with, or after, telling the patient.
- Relieving the fears of close relatives of a seriously ill patient → encourage the support system → help the patient.
Patients may be afraid to ask questions about distressing issues (e.g., sexual problems) or fear provoking (e.g., laboratory results).
- HOW TO DEAL?
A physician should not try to guess what is troubling a patient; address them truthfully and fully with the patient.
- Physicians have the primary responsibility or dealing with adherence issues as well as with angry, seductive, or complaining behavior by their patients.
- Referrals to other physicians should be reserved only when a medical and psychiatric problems outside of the treating physician’s range of their knowledge.
…..
Def of Adherence
- It refers to the extent to which a patient follows the recommendations of the physician, such as taking
medications on schedule, having a needed medical test or surgical procedure, and following directions or changes in lifestyle, such as diet or exercise.
Patients need to recognize that their behavior or condition (e.g., obesity) is problematic before they are motivated to change or seek medic care.
……
Patients’ unconscious transference reactions to their physicians, which are based in childhood and parent-child relationships, can affect adherence.
….
Percentage of Patients adherence
Only about one-third of patients adhere fully to management recommendations, one-third adhere some of the time, and one third do not adhere to such recommendations.
Factors that increase or decrease adherence (In Brief)
- Adherence is not related to patient intelligence, education, sex, religion, race, socioeconomic status, or marital status.
- Adherence is most closely related to how well the patient likes the doctor.
- The strength of the doctor-patient relationship is also the most important factor in whether or not patients sue their doctors when an error or omission is made or when there is a poor outcome.
…
what are factors that increase adherence?
- Good physician patient relationship
- Patient feels ill and usual activities are disrupted by the illness
- Short time spent in the waiting room
- Belief that the benefits of care outweigh its financial and time costs
- Written diagnosis and instructions for management
- Acute illness
- Recommending only one behavioral change at a time
- Simple management schedule
- Older physician
- Peer support
What are factors that decrease adherence?
- Poor physician-patient Relationship
- Patient experiences few symptoms and little disruption of usual activities
- Long time spent in the wailing room
- Belief that financial and time costs of care oulweigh its benefits
- Verbal diagnosis and instructions for management
- Chronic illness
- Recommending multiple behavioral changes at once
- Complex management Schedule
- Younger physician
- Little peer support
Effect on Adherence
- Physian-Patient Relationship
Effect on Adherence
- Presence of Symptoms
Effect on Adherence
- Waiting Time
Effect on Adherence
- Belief that benefits of care outweight its cost
Effect on Adherence
- Type of illness
Effect on Adherence
- No of behavioural changes
Effect on Adherence
- Simple or complex managment schedule
what to do and what not to
- Angry Patient
what to do and what not to
- Patient complaining about another doctor
what to do and what not to
- Patient Complaining about you & your staff
what to do and what not to
- Crying Patient
what to do and what not to
- Nonadherent patient: Needs to improve health behavior
what to do and what not to
- Nonadherent patient: Needs a lest or treatment (e.g., mammogram)
what to do and what not to
- Seductive Patient
what to do and what not to
- Suicidal Patient
Stages of Change model
aim of interview
To obtain the patient’s psychiatric history, including information about prior mental problems, drug and alcohol use, sexual activity, current living situation, and sources of stress.
How to interview patients?
interviewing young children
- First establish rapport by interacting with the child in a non-medical way (e.g. drawing pictures).
- Use direct rather than open-ended questions (see next page), for example, “What is your sister’s name?” rather than “Tell me about your family.”
- Ask questions in the third person, for example, “Why do you think that the little boy in this picture is sad?”
Direct questions
Direct questions are used to elicit specific information quickly from a patient:
- in an emergency situation (e.g., “Have you been shot?”)
- when the patient is seductive or overly talkative.
Open-ended questions
- open-ended types of questions are more likely to aid in obtaining information about
the patient, and not close off potential areas of pertinent information. - Using open-ended questions (e.g., “What brings you in today?”), the interviewer gives little structure to the patient and encourages the patient to speak freely.
Aims of the Clinical Interview and Specific Interviewing Techniques
