Patient-Doctor Relationships Flashcards
Why consider patient-doctor relationships?
- Successful clinical encounters > Drs clinical knowledge + technical skills
- Qualitative + subjective nature of relationship important
- There are a range of relationships
- Its not all plain sailing
What roles do we expect patients to play in the clinical encounter?
To be truthful/open/honest
Patients expect to be listened to
Co-operation
What roles do we expect doctors to play in the clinical encounter?
Know their limitations
Make diagnoses
Be empathetic
Knowledgeable
How has social relationships in the clinical encounter changed in the last 2 decades?
More openness/honesty
Patients get more choice + control
Less hierarchy/paternalism
What are the expectations about patients + doctors?
Patients + Drs have social roles which define expectations + obligations of each participant. It is shaped by culture but expectation about roles change over time so patient-Dr relationships are constantly changing.
What are the 3 main ideal types of patient-doctor relationship?
- Paternalistic (doctor-led)
- Shared (partnership)
- Informed (patient-led)
Outline the paternalistic model in a step-by-step fashion.
- Dr makes a systematic enquiry asking specific questions
- Patient is passive + answers
- Information flow = largely from Dr -> patient (minimal info given)
- Dr makes decision about what is best for patient (underlying assumption that Dr is best placed to make this decision)
- Expectation that patient will agree as ‘Dr knows best’ + show compliance
= power with doctor
Is the paternalistic model appropriate in any situations? When?
It is appropriate if:
- Patient is too ill to be involved in consultation
- If the patient lacks capacity
- If the patient expresses a preference for this model but this would require explicit discussion (even though it could be argued that a form of partnership exists here)
When is the paternalistic model unlikely to be a good model to use?
It is unlikely to occur if Dr adopts paternalistic model at the outset
Explain the shared model.
2-way exchange of info between patient + Dr at all stages:
Both participants are seen as bringing expertise; Dr brings medical expertise about diseases/treatments + patient brings personal expertise (have some knowledge about disease/treatment) - both seen as having some limitation to knowledge
Patient + Dr reach decision together about best course of action/treatment; each reveal treatment preference + come to agreement/decision on proceedings so depends on building a consensus on appropriate treatment
= partnership
What is the challenge for doctors in the shared model?
Must create an environment in which patients feel able to express treatment preferences
If there is disagreement, process becomes one of negotiation
Describe the informed model.
Dr communicates all relevant info + treatment options including risks + benefits to patient - sufficient info for patient to make informed treatment decision (information giving is Drs key contribution)
Patient is active + expects to make the decision so decision making is the SOLE PREROGATIVE of patient = power with patient
How common is the informed model in the UK?
Seen much less often than others; maybe be seen in some areas of private practice or in cosmetic surgery (could perhaps come more common in the future)
,More common in countries with private insurance systems
What is the current thinking of doctor-patient relationships?
Shared model advocated:
- ‘Partnership’ idea evident in policy + professional discourses
- Shared decision making is seen as key element of person-centred care
BUT need a ‘repertoire of Dr-patient relationships’ (one shoe doesn’t fit all) as nature of relationship may change within/across consultations - need to be guided by patient preference + clinical condition
How does ethics link in with the patient-doctor relationship?
- All 3 models underpinned by ethical principles but can be used inappropriately
- Shared decision making process most important rather than shared decision as outcome
- Key ethical value = respect for persons
What is the ethical principle behind the paternalistic model?
Beneficence (doing good) - acting in patient’s best interests
What are the problems with the paternalistic model?
- Assumption that you know whats best for patient when really it requires a dialogue + sharing of info to find this out (ICE)
- Requires respect for person’s views, values + preferences
What is the ethical principle behind the informed model?
Respect for autonomy
What are the problems with the informed model?
- Respect for autonomy not just about information giving
- Respect for autonomy is not just letting a person choose what they want
- Information may reduce autonomy i.e. information overload
Why is the informed model so complex? What factors must be taken into consideration?
- Must facilitate autonomy by presenting info relevant to patient, their values + preferences & Drs views/preferences = requires dialogue
- Autonomous decision making involves responsibility for consequences of decision (good or bad) so potential psychological harm of living with poor outcome following a decision
- Autonomous choice may be for someone else e.g. Dr, family member to make decision instead
What factors may influence a patients decision in the informed model?
- How info is presented + in what order
- Potential for manipulation of patients decision (paternalism within informed model)
- Coercion (decisions are rarely ever made w/o any external influence)
What is the ethical principle behind the shared decision making model?
Facilitation of autonomy
What are the key characteristics of the shared decision making model when it is carried out properly?
- Shares responsibility
- Includes patient + Dr perspective more explicitly (openness/honesty)
- Requires dialogue
- More complex relationship between patient + Dr
What are the challenges of shared decision making?
Patient access to information
Patient ability to process complex information
Communication difficulties
What if we value shared decision making we need to ensure it is ___ _ __. Why?
Available to everyone
Principle of justice
How can you ensure the care of your patient is your first concern?
Requires developing a relationship with patient
Making decisions in best interest of patient from their perspective
Respect their preferences/values (including preference for model of decision making)
All requires dialogue
What is the point in shared decision making?
- Consultations more satisfying
- Patients more engaged
- Increased engagement = better outcomes
- What anyone would want as a patient
- Time consuming but in long run creates less workload
- Less risk to patient
What are the GMC duties of a doctor?
- Partnership with patients
- Listen/respond to patients concerns/preferences
- Give patients info they want/need in a understandable way
- Respect patient’s rights to reach decisions with you about treatment/care
- Support patients in self-care to improve/maintain health
What is the point in doing ICE in a consultation?
- Involve + engage them
- Identify their agenda in addition to ours
- Patients feel cared about + listened too
- Patients feel you are addressing their problem
What questions can you ask in the Ideas section of ICE?
Have you an idea what might be causing this?
Do you think this is the same as something you’ve had before?
Tell me what you think is the cause?
What do you think the problem might be?
Have you any theories about what is going on?
What questions can you ask in the Concerns section of ICE?
Is there anything in particular that is worrying you about this?
What is your biggest concern about this?
What questions can you ask in the Expectations section of ICE?
Is there anything in particular you were hoping I would be able to do for you today?
You’ve obviously given this some thought, what were you expecting to happen?
When you came here today, was there anything in particular you were hoping I could do?
What are the proven positive outcomes for patients in terms of shared decision making?
- Increased patient satisfaction as they feel more engaged with decisions + that they make better decisions
- Reduced anxiety
- Improved medication compliance
- Improved self-management of conditions (asthma + diabetes)
- Improved clinical outcomes; better self-management -> concordance
- More efficient diagnoses; fewer diagnostic tests + unnecessary referrals
