- Doctor Patient Rapport
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Context Medical educators have emphasized the importance of teaching patient‐centred care.Objectives To describe and quantify the attitudes of medical students towards patient‐centred care and to examine: (a) the differences in these attitudes between students in early and later years of medical school; and (b) factors associated with patient‐centred attitudes.Methods We surveyed 673 students in the first, third, and fourth years of medical school. Our survey utilized the Patient–Practitioner Orientation Scale (PPOS), a validated instrument designed to measure individual preferences towards various aspects of the doctor–patient relationship. Total PPOS scores can range from patient‐centred (egalitarian, whole person oriented) to disease‐ or doctor‐centred (paternalistic, less attuned to psychosocial issues).
Additional demographic data including gender, age, ethnicity, undergraduate coursework, family medical background and specialty choice were collected from the fourth year class.Results A total of 510 students (76%) completed data collection. Female gender ( P.
'Chapter One: The Doctor-Patient Relationship: A Review'an excerpt from the dissertation of(e-mail)© 1994A. Approaches to the Doctor-Patient Relationship The Parsonsian FormulationTalcott Parsons was the first social scientist to theorize the doctor-patient relationship, and his functionalist, role-based approach defined analysis of the doctor-patient relationship for the next two decades. Parsons (1951, 1958, 1978) began with the assumption that illness was a form of dysfunctional deviance that required reintegration with the social organism. Illness, or feigned illness, exempted people from work and other responsibilities, and thus was potentially detrimental to the social order if uncontrolled. Maintaining the social order required the development of a legitimized 'sick role' to control this deviance, and make illness a transitional state back to normal role performance. In Western society, Parsons saw four norms governing the functional sick role: 1. The individual is not responsible for their illness; 2.
Exemption of the sick from normal obligations until they are well; 3. Illness is undesirable; and 4. The ill should seek professional help.For Parsons, the physician's role is to represent and communicate these norms to the patient to control their deviance. Physicians exemplify for Parsons the shift to 'affect-neutral' relationships in modern society, with physician and patient being protected by emotional distance.
Medical education and social role expectations impart normative socialization to physicians to act in the interests of the patient rather than their own material interests, and to be guided by an egalitarian universalism rather than a personalized particularism. Because physicians have mastered a body of technical knowledge, it is functional for the social order to allow physicians professional autonomy and authority, controlled by their socialization and role expectations.While the basic notion that norms and social roles influence illness and doctoring has remained robust, there have been numerous qualifications to the particular elements that Parsons attributed to the patient-physician role relationship.
For instance, physicians and the public consider some illnesses in the West and in other societies to be the responsibility of the ill, such as lung cancer, AIDS and obesity, making it more difficult for them to be normatively reintegrated into society. Physicians and other providers react less favorably to patients who are held responsible for their illness than to 'innocent' patients (e.g.
Kelly, 1987).Parsons has also been accused of having been overly optimistic about the success of physician socialization to universalism and affective-neutrality. Physicians often react negatively to dying patients, patients they do not like, and patients they believe are complainers (Hafferty, 1988).
Physicians also are subject to personal financial and personal interests in patient care.Another weakness of Parsons' description is that it was specific to acute illness, and did not speak to the increasingly prevalent chronic illnesses and disabilities, a sick role which is permanent and not transitional (Mechanic, 1959). Szasz and Hollender's (1956) work refined Parsons by elaborating different doctor-patient models arising around different types of illness. Szasz and Hollender proposed that patient passivity and physician assertiveness are the most common reactions to acute illness; less acute illness is characterized by physician guidance and patient cooperation; and chronic illness is characterized by physicians participating in a treatment plan where patients had the bulk of the responsibility to help themselves.Critics have also shown that there is a great deal of inter-cultural, and inter-personal variation in sick roles and norms.
The 'American' sick role is not as useful a concept as the more specific 'white, Midwestern, Scandinavian, male' sick role. There is also cross-class variation. Some of the poor adapt to their lack of access to medical care by becoming fatalistic, rejecting the necessity of medical treatment, and coming to see illness and death as inevitable. On the other hand, the educated classes have become more assertive in the relationship, rejecting the norm of passivity in favor of self-diagnosis or negotiated diagnosis.Parsons also based his model of the doctor role on the assumption of a long-term relationship with a family physician. Growing medical specialization and the decline of the solo family practitioner makes this dyadic role model incomplete. Increasingly, several doctors attend various of a patient's ailments, each with a somewhat different set of role expectations and interpretations of the patient's role performance.Professionalization and SocializationThere is also inter-cultural variation in physician roles, and variation among physicians in the success of their role socialization. While Parsons' model of doctors' affective neutrality, collective-orientation, and egalitarianism towards patients did express the professional ideal, some physicians are more affectively neutral than others.
Following Parsons' lead, sociologists began to focus on the socialization of physicians and the factors in medical school and residency that facilitated or discouraged optimal role socialization to doctor-patient relationships (Merton, Reader, and Kendall, 1957; Becker, Geer, Hughes and Strauss, 1961).This work generally took the division of labor in medicine for granted, and painted a more or less heroic picture of medical self-sacrifice. A few writers began to focus on aspects of the physician role and medical education that themselves militated against humanistic patient care. Critics suggested that medical schools and residencies socialized physicians into 'dehumanization,' and to place professional identity and camaraderie before patient advocacy and social idealism (Eron, 1955; Lief and Fox, 1963; and more recently Anspach, 1988; Hafferty, 1988; Sudit, 1988; Conrad, 1989).Professional Power and AutonomyThe most important weakness of Parsons' functionalist account of the doctor-patient relationship, however, arose from his poor understanding of the ecological concepts of dysfunction and niche width. Social structures cannot be assumed to be functional for the social system simply because they exist, any more than an organic structure, such as an appendix, can be assumed to be functional for its organism. All that can be said about a structure, or in this case a role relationship, is that it has not yet pushed the organism outside its niche, causing its extinction.In other words, the study of doctor-patient relationships in one society does not indicate how much the particular structures and norms of the provider-patient relationship are simply the result of historical chance, rather than necessitated by the nature of illness and healing in industrial society. And second, such a study does not indicate whether the particular practices and norms are leading in a dysfunctional direction.
A critical sociology of the doctor-patient relationship thus arose to challenge the internal contradictions of the Parsonsian biological metaphor: were American doctors the perfect immune system for society, or had they developed into a parasitic growth threatening the health of society?To the more critical 60's generation of social scientists, inspired by growing resistance to unjust claims to power, physicians' defense of professional power and autonomy appeared to be merely self-interested authoritarianism. Physicians' battle-cry of the sacred nature of the doctor-patient relationship sounded hollow in their struggles against universal health insurance. Physicians' high incomes and defense of autonomy appeared to result in both bad medicine and bad health policy, and physician's unaccountable power appeared all the more nefarious because of medicine's intimate invasion of the body,In this context, Eliot Freidson's work (1961, 1970, 1975, 1986) crystallized the notion that professional power was more self-interested than 'collectivity-oriented.' Freidson saw the doctor-patient relationship as a bargained interface between a professional system and a lay system, each with its own interests. Freidson's approach to the sick role was influenced by labeling theory (Szasz, 1961; Scheff, 1966), and went beyond Parsons to assert that doctors create the legitimate categories of illness. Professionalization grants physicians a monopoly on the definition of health and illness, and they use this power over diagnosis to extend their control. This control extends beyond the claim to technical proficiency in medicine, to claims of authority over the organization and financing of health care, areas which have little to do with their training.There are now many studies of the way that professional power has been institutionalized in the structure and language of the doctor-patient relationship.
For instance, a recent study of medical students' presentation of cases demonstrated that physicians were being trained to talk about their patients in a way that portrayed the physician as merely the vehicle of an impersonal medicine acting on malfunctioning organs, rather than a potentially fallible human being interacting with another human being. The more highly regarded presenters were found to 1) separate biological processes from the patient, 2) use the passive voice in describing interventions, 3) treat medical technology as the agent, and 4) mark patients' accounts as subjective (the patient 'states,' 'reports,' 'denies,').
These devices make the physician more powerful by emphasizing technology and eliminating the agency of both physician and patient (Anspach, 1988).Since its publication, Starr's (1982) The Social Transformation of American Medicine has quickly become the canonical history of the institutionalization of professional power, its effect on the organization of health care, and the profession's metastasized influence in the political sphere. Though Starr draws on many theoretical sources, he paints a picture of the American doctor-patient relationship as a successful 'collective mobility project' (Parry and Parry, 1976), whose contours were not at all determined by the functional prerequisites of society. While Starr does not goes so far as to say that we do not need 'doctors' at all, he argues that there are a range of possible structures that medicine could have taken in industrial society, and that American physicians are an extreme within that range.Marxist and Feminist ApproachesDrawing on, and extending the professional power analysts, the growing school of Marxist sociologists interpreted the doctor-patient relationship within the context of capitalism. In the Marxist analysis, the American doctor-patient relationship is conditioned by the 'medical-industrial complex' (Ehrenreich and Ehrenreich, 1970; Waitzkin and Waterman, 1976; McKinlay, 1978; Waitzkin, 1986); profit-maximization drives the innovation of technologies and drugs and constrains physician decision-making. The most orthodox advocate of this analysis, Vincente Navarro (1974, 1986, 1987), rejects the analyses of those such as Illich (1975), Freidson and Starr who see professional power as having some autonomy from, and sometimes being in direct conflict with, capitalism and corporate prerogatives. For Navarro, physicians are both agents and victims of capitalist exploitation, engineers required to fix up the workers and send them back into community and work environments made dangerous and toxic by capitalism.But the professions are anomalous for traditional Marxist theory; only those who own the means of production are supposed to accrue occupational autonomy and great wealth. This anomaly has led Marxist medical sociologists to propose the thesis of physician proletarianization (McKinlay & Arches, 1985).
Theorists of physician proletarianization point to the rising numbers of salaried physicians, the deskilling of some medical tasks, and the shifting of some tasks from physicians to less skilled technical personnel. (I will examine the proletarianization/deprofessionalization thesis in greater detail below as it relates to the doctor-hospital relationship.)Parallel to, and often included in the Marxist account, has been the growing feminist literature on medicine.
In particular, feminists have focused on the patriarchal nature of the male physician-female patient relationship, documenting the history of medical pseudo-science that has portrayed women as congenitally weak and in need of dubious treatments (Ehrenreich and English, 1972, 1973, 1978; Arms, 1975; Scully, 1980; Mendelsohn, 1981; Shorter, 1983; Corea, 1984; Fisher, 1986; Martin, 1987; Todd, 1989). There is also extensive work done on the history of exclusion of women from medicine (Walsh, 1977; Levitt, 1977; Achterberg, 1991), and the effects of the growing numbers of female doctors on the doctor-patient relationship. Women physicians tend to choose poorly paid primary care fields over the more lucrative, male-oriented surgical specialties, are more likely to be employed as opposed to in private practice, and are less likely to be in positions of authority (Martin, 1988). Women providers are also better communicators (Weisman and Teitelbaum, 1985; Shapiro, 1990).Economic ApproachesThe growth of studies on cost-containment, and the economistic trend of 1980's social science, led to the rise of methodologically individualistic 'rational choice' studies of the doctor-patient relationship. These studies usually ignored the functionalists' interest in norms and roles, as well as the critical theorists' interest in power and exploitation. Instead, the economists' model starts from the assumption of a mutual 'utility-maximizing' agency contract between the doctor and patient (Dranove and White, 1987; Buchanan, 1988).
The patient is interested in maximizing consumption of health, and the physician is interested in maximizing income. The studies then focus on the effects of insurance, reimbursement and utilization control structures on doctor behavior, the doctor-patient relationship and the success of medical agency (Eisenberg, 1986; Salmon and Feinglass, 1989). For instance, a number of studies have documented that patients without health insurance have less access to doctors, and receive less care from them when they have access (Hadley, Steinberg and Feder, 1991; Kerr and Siu, 1993). Research has also demonstrated that different payment structures affect physician behavior (Moreno, 1990; Rodwin, 1992). For instance, a recent study of Medicaid case-management found that pediatricians who received augmented Medicaid fees provided a higher volume of services to children than either a group receiving fees-for-service, or a group covered by capitation (Hohlen, et al., 1990).Another strain of economistic research picks up on the Freidson observation of physicians' power to define illness, and explores the degree to which physicians 'induce demand.'
Induced demand theorists (Wennberg, Barnes and Zubkoff, 1982; Rice and LaBelle, 1989) argue that physicians' financial incentives to treat, and patients' ignorance of their true needs, lead to inappropriate over-treatment.Communication and OutcomesTwo trends led to the rapid growth of research on doctor-patient communication. The first trend was the interest of physicians and medical educators in improving their ability to elicit patient histories and concerns, and inform patients of their conditions and treatment needs, and thereby achieve successful diagnosis and treatment compliance.
Literally thousands of analyses of consultations have been done since the 1950s to develop methods to teach and improve physician communication skills (Stewart and Roter, 1989).A second trend, the rise of health consumerism, has encouraged more contractual and conflictual relationships between patient and doctor. An increasingly well-educated population has begun to challenge medical authority, and treat the doctor-patient relationship as another provider-consumer relationship rather than as a sacred trust requiring awe and deference (Reeder, 1973; Haug and Lavin, 1983). Opinion polls indicate a steadily declining faith in physicians, and in the American medical system in general (Blendon, 1989). The consumer, women's health (Ruzek, 1978), the holistic health movements, and the perception of physician indifference and greed, have also encouraged patients to distrust physicians.
These trends were often portrayed by medical sociologists as democratizing (Haug, 1976; Haug and Lavin, 1979, 1983), but perceived by physicians with alarm, especially in light of the rise of malpractice litigation.Encouraged by these two trends, symbolic interactionists (Anderson and Helm, 1979; Strauss, 1985) and discourse analysts began detailed analyses of doctor-patient communication to tease apart the workings of power and authority within them. In particular, Howard Waitzkin (1976, 1984, 1989, 1991) has drawn attention to the way that American medical communication reinforces individualistic, bio-medical interpretations of problems with social origins and social solutions, and thus reflects and reproduces social inequality and disenfranchisement.Another example is the work of Hayes-Bautista (1976) who studied the bargaining between the patient and the doctor over treatment. The patients were observed using 'convincing tactics' of a) demands, b) disclosure that the treatment has not worked, c) suggestions, and d) leading questions. If these did not achieve the desired change in treatment, they turned to 'countering tactics' of arguing that the treatment is too weak, too powerful or insufficient. To augment their authority, the doctors used tactics of a) wielding overwhelming knowledge, b) medical threats about the consequences of ignoring advice, c) disclosures that the treatment may take longer to work for the patient; or d) a personal appeal to the patient as an acquaintance. The outcome measures of this game theoretic situation were a) continuation of the relationship, b) patient termination of relationship, c) physician termination, and d) mutual termination.Health care marketing became a third major impetus for studies of doctor-patient communication, largely with the goal of identifying the kinds of interactions that improved patient satisfaction. Research found, not surprisingly, that people like to have doctors talk to them in an egalitarian way, listen, ask a lot of questions, answer a lot of questions, explain things in a simple way that the patient can understand, and allow patients to make decisions about their care (DiMatteo, 1980; Hall, Roter and Katz, 1988; Roter, Hall and Katz, 1987, 1988; Roter and Hall, 1989; Gerteis, Edgman-Levitan, Daley and Delbanco, 1993).Researchers also began to demonstrate that different patterns of communication have effects on the clinical outcomes of patient care.
The kinds of medical care that patients find satisfying tends to alleviate psychosomatic symptoms and make patients more compliant with their treatment regimes, and thereby produce better clinical outcomes (Egbert, et al., 1964; Greenfield, Kaplan and Ware, 1985; Greenfield, Kaplan, Ware, Yano and Frank, 1988; Kaplan, Greenfield and Ware, 1989).B. The Decline of the Professions and the Doctor-Patient RelationshipTo change the health system at all, much less to create a medical system which maximally utilizes self-help and mutual help and which encourages an active rather than a passive role for the patient, will require radical deprofessionalization. We will have to expand radically the use of community health aides; to spread medical knowledge to patients and to non-physician health workers; to minimize the social distance between doctors and patients.I should emphasize that deprofessionalization has nothing to do with eliminating the skills of the doctors.
Skills are of course needed, and I am not proposing that incompetent people perform medical services-we have too much of that as it is! It is the privileges, the power, and the monopolization of medical knowledge that I am speaking of removing when I speak of deprofessionalization.(Ehrenreich and Ehrenreich, 1978: 70)Having access to a strong provider-patient relationship, with good participative communication, has been shown to be important for the experienced and objective quality of care. But a number of social trends have converged to reduce the ability of patients to have these relationships with physicians.
The critical theorists, in turn, have raised questions about whether radically different relationships, with radically different providers of care, might be possible and preferable.Over-Specialization and the Decline of Primary CareOne trend has been the rapid proliferation of specialization among American physicians. Only one in ten American physicians are in 'general practice' (general or family practitioners, pediatricians and geriatricians), with a claim to a holistic approach to patients' concerns. Many researchers assume that increasing specialization will continue to 'technologize' and 'compartmentalize' doctor-patient interaction. As patients see increasing numbers of poorly coordinated specialists for their myriad problems, the need for 'case-managing' generalists becomes ever more acute.Declining Autonomy and Rise of the OrganizationRemaining independent of organizations, including insurance companies, unions and the government as well as hospitals, has been a consistent and explicit theme of physicians since the turn of the century. Professional autonomy and independence is the most important factor in their satisfaction with their worklife. One early study was Freidson and Mann's (1971) analysis of 1962 and 1963 data collected from physicians in the nation's large group practices. They performed a factor analysis on all the variables in the study, both organizational and attitudinal, and discovered eight factors.
One of the factors they labeled 'physician satisfaction,' composed of several highly inter-correlated items: having little controversy among one's fellow physicians over the division of income, and having a small clerical and large paramedical staffs. This physician-pleasing constellation positively correlated with the 'egalitarianism' of the firm, and negatively related to its 'bureaucratization.' Egalitarianism consisted of.
The doctor–patient relationship has been and remains a keystone of care: the medium in which data are gathered, diagnoses and plans are made, compliance is accomplished, and healing, patient activation, and support are provided. To managed care organizations, its importance rests also on market savvy: satisfaction with the doctor–patient relationship is a critical factor in people's decisions to join and stay with a specific organization. –The rapid penetration of managed care into the health care market raises concern for many patients, practitioners, and scholars about the effects that different financial and organizational features might have on the doctor–patient relationship. – Some such concerns represent a blatant backlash on the part of providers against the perceived or feared deleterious effects of the corporatization of health care practices. But objective and theoretical bases for genuine concern remain.
This article examines the foundations and features of the doctor–patient relationship, and how it may be affected by managed care. A SPECIAL RELATIONSHIPThe relationship between doctors and their patients has received philosophical, sociological, and literary attention since Hippocrates, and is the subject of some 8,000 articles, monographs, chapters, and books in the modern medical literature. A robust science of the doctor–patient encounter and relationship can guide decision making in health care plans. We know much about the average doctor's skills and knowledge in this area, and how to teach doctors to relate more effectively and efficiently., We will first review data about the importance of the doctor–patient relationship and the medical encounter, then discuss moral features. We describe problems that exist and are said to exist, we promulgate principles for safeguarding what is good and improving that which requires remediation, and we finish with a brief discussion of practical ways that the doctor–patient relationship can be enhanced in managed care.The medical interview is the major medium of health care.
Most of the medical encounter is spent in discussion between practitioner and patient. The interview has three functions and 14 structural elements. The three functions are gathering information, developing and maintaining a therapeutic relationship, and communicating information. These three functions inextricably interact. For example, a patient who does not trust or like the practitioner will not disclose complete information efficiently. A patient who is anxious will not comprehend information clearly.
The relationship therefore directly determines the quality and completeness of information elicited and understood. It is the major influence on practitioner and patient satisfaction and thereby contributes to practice maintenance and prevention of practitioner burnout and turnover, and is the major determinant of compliance. Increasing data suggest that patients activated in the medical encounter to ask questions and to participate in their care do better biologically, in quality of life, and have higher satisfaction.
Effective use of the structural elements of the interview also affect the therapeutic relationship and important outcomes such as biological and psychosocial quality of life, compliance, and satisfaction. Effective use gives patients a sense that they have been heard and allowed to express their major concerns, as well as respect, caring, empathy, self-disclosure, positive regard, congruence, and understanding, and allows patients to express and reflect their feelings and relate their stories in their own words.
Interestingly, actual time spent together is less critical than the perception by patients that they are the focus of the time and that they are accurately heard. Other aspects important to the relationship include eliciting patients' own explanations of their illness, giving patients information, and involving patients in developing a treatment plan.
(For an overview of this area of research, see Putnam and Lipkin, 1995. )A series of organizational or system factors also affect the doctor–patient relationship. The accessibility of personnel, both administrative and clinical, and their courtesy level, provide a sense that patients are important and respected, as do reasonable waiting times and attention to personal comfort. The availability of covering nurses and doctors contributes to a sense of security.
Reminders and user-friendly educational materials create an atmosphere of caring and concern. Organizations can promote a patient-centered culture, or one that is profit- or physician-centered, with consequences for individual doctor–patient relationships. Organizations (as well as whole health care systems) can promote continuity in clinical relationships, which in turn affects the strength of in those relationships. For instance, a market-based system with health insurance linked to employers' whims, with competitive provider networks and frequent mergers and acquisitions, thwarts long-term relationships.
A health plan that includes the spectrum of outpatient and inpatient, acute and chronic services has an opportunity to promote continuity across care settings.The competition to enroll patients is often characterized by a combination of exaggerated promises and efforts to deliver less. Patients may arrive at the doctor's office expecting all their needs to be met in the way they themselves expect and define. They discover instead that the employer's negotiator defines their needs and the managed care company has communicated them in very fine or incomprehensible print. Primary care doctors thus become the bearers of the bad news, and are seen as closing gates to the patient's wishes and needs.
When this happens, an immediate and enduring barrier to a trust-based patient-doctor relationship is created.The doctor–patient relationship is critical for vulnerable patients as they experience a heightened reliance on the physician's competence, skills, and good will. The relationship need not involve a difference in power but usually does, especially to the degree the patient is vulnerable or the physician is autocratic. United States law considers the relationship fiduciary; i.e., physicians are expected and required to act in their patient's interests, even when those interests may conflict with their own.
In addition, the doctor–patient relationship is remarkable for its centrality during life-altering and meaningful times in persons' lives, times of birth, death, severe illness, and healing. Thus, providing health care, and being a doctor, is a moral enterprise. An incompetent doctor is judged not merely to be a poor businessperson, but also morally blameworthy, as having not lived up to the expectations of patients, and having violated the trust that is an essential and moral feature of the doctor–patient relationship. Trust is a fragile state. Deception or other, even minor, betrayals are given weight disproportional to their occurrence, probably because of the vulnerability of the trusting party (R.L. Jackson, unpublished manuscript). EFFECTS OF MANAGED CAREA managed care organization serves a defined population with limited resources in an integrated system of care.
Thus, a single organization may both provide and pay for care. Organizations as providers have duties such as competence, skill, and fidelity to sick members. Organizations as payers have duties of stewardship and justice that can conflict with provider duties. Managed care organizations thus have conflicting roles and conflicting accountability.An organization's accountability to its member population and to individual members has a series of inherent conflicts. Is the organization's primary accountability to its owners, to employer purchasers, to its population of members, or to individual, sick members? If these constituents somehow share the accountability, how are conflicting interests resolved or balanced?
For example, the use of the primary care clinician to coordinate or restrain access to other services involves the primary care clinician in accountability for resource use as well as for care of individual patients. Although unrestricted advocacy for all patients is never really achievable, the proper balance and the principles of balancing between accountability to individual patients, a population of patients, or an organization need to be made explicit and to be negotiated in new ways. –Does paying physicians by salary, capitation, risk withholds, or bonuses, with a variety of incentives to withhold (more or less) needed care from patients, represent a conflict of interest for physicians and violate the fiduciary nature of the relationship?
All mechanisms for paying physicians, including fee-for-service reimbursement, create financial incentives to practice medicine in certain ways. We still lack a calculus to minimize or even describe in fine detail how such conflicts affect our ability to justify trusting relationships.
Even-handed social attention seems appropriate to all the different mechanisms of payment. Balanced assessment of how the details of remuneration systems influence doctor's willingness to act on behalf of patients will best protect both the health of the public and the health of doctor–patient relationships. This is a priority for a new form of empirical, ethical research.“Whose doctor is it anyway?” expresses one of the most critical problems inherent in managed care for the doctor–patient relationship.
Patients correctly wonder if doctors are caring for them, the plan, or their own jobs or incomes (the latter is equally problematic in fee-for-service care). This ambiguity erodes trust, promotes adversarial relationships, and inhibits patient–centered care. The recent controversy over gag rules has only confirmed this set of fears in the mind of the public which is now seeking regulation of the managed care industry through the political process. As illustrated in, the interests of patients, plans, and doctors can overlap to a greater or lesser extent. Professional ethics dictate that physicians attempt, as individuals and as a profession, to ensure that their interests and those of their patients are congruent in clinical practice.
Plan interests, however, can pull physicians away from this goal, as the organization's values and their implementation inevitably influence attitudes, behavior, and experiences. Alternatively, plans could promote patient-centered care by trying to maximize the extent to which patient, doctor, and plan interests overlap. For example, promoting continuity, communication, and prevention can further all three interests so long as value (and not cost alone) is seen as the plan's product. Similarly, resource stewardship can be honestly promoted as a way to ensure that quality care is available for future patients. Overlapping and conflicting interests. The interests of patients (top circle), doctors (left circle), and health plans (right circle) may overlap to a greater or lesser degree, depending on the actors and the circumstances. Employers' interests are likely to be approximated by plans' interests, as plans in a competitive market respond to buyers.
Physicians should be both empowered and motivated to continually increase the size of area A; the more that their interests and the interests of patients (sick and well) overlap, the greater the likelihood of decision making that maximizes patient well-being. Plans may try to increase area C, by aligning financial incentives for physicians to correspond with greater profit (or other organizational goals) in order to ensure that physicians make decisions in the plan's interest. Plans may also strive to increase area B, for instance, by cutting physician reimbursement, in order to make the plan more attractive to potential enrollees. Ideally, area D is large, representing the confluence of plan, patient, and doctor interests, and all three parties strive to continually increase it.Another feature of managed care organizations is their emphasis, in principle, on primary care.
They often rely on primary care clinicians to manage, coordinate, or restrain access to other services. Members are required to choose or are assigned a primary care physician. With the primary care emphasis comes an opportunity for the development of strong relationships between primary care doctors and their patients.
In addition, new relationships with patients who in the past never sought care and seldom entered into a doctor–patient relationship may be more likely in a system that emphasizes wellness and primary care, although this may be more apparent than real. It is unclear at present how a “relationship” between a primary care physician and a member of the physician's panel, who have never met, should be characterized, or what responsibilities are associated with it.
It is not yet demonstrated that an emphasis, in principle, on primary care leads to stronger relationships, and to what extent countervailing forces such as lack of continuity counter this.Integrated systems, characteristic of most managed care plans, introduce opportunities for improvement in continuity across the spectrum of care. For example, opportunities arise for case management or for coordinating care between doctors' offices, hospitals, nursing homes, and home care so that individuals do not fall through the cracks of a fragmented system.
With integration come new responsibilities for doctors and other health care practitioners for communication, teamwork, and a more longitudinal approach to patient care. This continuity may be thwarted, however, by turnover in staff or members.Standardization of practice, sometimes relying on “evidence–based medicine,” is often used by managed care to minimize costs or maximize or ensure quality of care. Standardization is often touted as promoting fairness by treating like individuals in like manner. Both standardization and the application of evidence-based principles in choosing care standards, however, rely on value judgments about what counts as good evidence and how that evidence should be interpreted and applied. The danger to the doctor–patient relationship in these movements is that individual patients with their individual needs and preferences may be considered secondary to following practice guidelines, adherence to which may form part of an evaluation measure of physician's performance. Using practice guidelines and the “standard of care” to determine which benefits are covered, and for whom, ignores the incredible variation in patient preferences and characteristics.
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This approach treats the disease without reference to the illness. Rather than treating individuals with similar illnesses in like manner, the result is that individuals who merely have the same disease are treated in like manner. Fairness is sacrificed to uniformity. Reliance on “data” may discount the patient's own story, thus discounting specific evidence about personal aspects of disease and its meaning and value. King of cards-free slot machine game.
Obviously, discounting the person depreciates the relationship.Continuous quality improvement and total quality management are industrial strategies lately applied in the health care arena. Although quality improvement efforts are by no means unique to managed care organizations (MCOs) in the health care industry, a few individual MCOs and the American Association of Health Plans have been leaders in promoting quality initiatives and include them in the accreditation process. Implementing continuous quality improvement may work for the doctor–patient relationship by enhancing competence and the perception of competence, or it may work against the doctor–patient relationship if it diminishes practitioner flexibility or accountability, or if it is perceived by practitioners as a manifestation of distrust by the organization.The effort to cut costs to increase competitiveness or profit means having doctors be more “productive” by seeing patients faster. The first thing dropped as visit length shortens is psychosocial discussion. So far, the average length of visits in the United States does not seem to have dropped significantly, probably because of inherent inefficiencies in scheduling and doctors' abilities to finagle time to fit the needs of patients. Yet both patients and doctors feel a heightened sense of time pressure, and patients worry about being on a conveyor belt with a production-line-oriented doctor.
As companies attempt to increase providers' efficiency, these fears will be realized unless thwarted by consumers, professionals, or more visionary organizations. Less time, otherwise, will mean less relating time and damage to care: less-accurate and incomplete data; difficulty in identifying the real problems; less efficiency in test and treatment choices based on knowledge of the individual patient; less trust; less healing; more errors and more waste. A penny of good communication time may avert a pound of unnecessary or even harmful spending used to reassure an anxious patient or substitute for a sketchy history.We believe that in the long run the trust of the public that the physician is doing the absolute best for the patient must be maintained so that the doctor–patient relationship preserves its healing functions. At the moment, the momentum of control is such that industry and corporate leaders have the upper hand and care is or will suffer as a result. Only if consumers and the medical profession stand together and insist on standards that protect the doctor–patient relationship will it endure the acid raining against its delicate face.
WHAT PRACTITIONERS CAN DOlists several principles physicians can follow to retain professional standards and nurture and sustain the public's trust in doctor–patient relationships. The first priority is to enhance knowledge, skills, and attitudes of doctors, patients, and plans in the doctor–patient relationship. Currently, neither doctors and patients, nor plans have adequate skills in the doctor–patient relationship. Most doctors currently practicing have never been critically observed interviewing a patient, breaking bad news, or denying a patient's request for an unnecessary test. Doctors need no longer suffer from a lack of this skill—it is learnable and quickly taught. Physicians should each ensure their own competence in this vital area. Physicians should focus on continuity: in their relationships with individual patients, between their patients and other clinicians (including specialists and nurses), and with the organization as a whole.
Trust is most realistic when a relationship has a history of reliability, advocacy, beneficence, and good will (R.L. Jackson, unpublished manuscript). Continuity encourages trust, provides an opportunity for patients and providers to know each other as persons and provides a foundation for making decisions with a particular individual. It allows physicians to be better advocates for their patients and allows patients some power by virtue of the personal relationship they have with this physician. Patients value continuity in and of itself, apart from its effect on health outcomes, although its current value seems to be about $15 per month in added premium.
Industry estimates are that an average patient will change plans and doctors if continuity costs more than $180 per year. Rapid changes between plans, mergers, acquisitions, closings, changing panels of providers within plans, and physician non-competition clauses all detract from the continuity of patient care. Physicians should advocate for continuity as an important goal for themselves in their individual practices, as members of a group practice, as a profession, and within their organizations.Practitioners should work to protect the interests and the preferences of individuals. Utilization management, standardization, guidelines, and other cost–containment efforts are morally neutral. They may be necessary to ensure that resources needed to care for those who are not yet sick are available when the time comes. Whereas administrators and managers must responsibly steward the pooled resources of health insurance premiums, each physician in a managed care organization should primarily be an advocate for individual patients.
This is not to say that physicians should ignore the cost implications of their decisions, or that they should be unconcerned with resource stewardship, merely that their primary responsibility as practitioners should be for the care of their patients.Health care administrators, whose primary responsibility is stewardship, should not ignore the need for competence, compassion, and individualization of care. Physicians' roles as patient advocates mean they must attend to the needs of individual patients who may be exceptions to the rules or otherwise have special needs. As patient advocates, physicians must ensure that policies and procedures put in place that threaten the ability to individualize care do not go unchecked.
Since this power may be beyond the capacity of individual physicians, it may require organization at the level of the whole profession.Practitioners should contribute to quality improvement efforts. For efforts to be focused on improving the quality of care and not solely on restraining resource use, the role of physicians is indispensable. Physicians know when access is too tightly restrained and their patients' care is suffering, when restrictions on the use of particular drugs or equipment constitute unacceptable impingements on the quality of care, or in what circumstances a procedure is probably unnecessary. Physicians can, and should, serve as “quality police” by noticing, remarking, and, ideally, working for change when they see a feature that is detrimental to patient care.
In addition, they should be proactive in spearheading and making clinically and humanly relevant quality improvement efforts in their organization.Practitioners can practice prudence. Physicians should be prudent in their use of resources, and at a minimum should not waste resources by providing services of no benefit to patients.
Physicians often complain that patients come in asking for x-rays, blood tests, and other services when physicians are skeptical of any benefit. Conversely, many patients have noted physician's overuse of “tests.” The role of insurers in the health care system means that a service rarely has direct costs for an individual patient, though it may be costly. Indeed, our culture seems to rely on technology to answer questions with a greater certainty than the technology can deliver.
Doctor Patient Rapport
Physicians themselves have contributed to a culture of medical practice in which objective test results are given more credence and are felt to be more reliable than the subjective story of the patient or assessment of the physicians. In truth more than 80% of diagnoses are made by history alone. Physicians need to control their own reliance on objective but noncontributing data.
By fostering a system of care in which concern for cost is acceptable and unnecessary services are not provided, physicians can be perceived as being socially responsible and perhaps restore some credibility in this area to the profession.Because it is a matter of integrity not to waste resources on tests or other services, physicians must talk to patients, find out why they are requesting certain services, and meet those needs in other ways. We must educate patients about the limited ability of medical technology and the potential for harm in any treatment.
This, again, involves skills that many physicians need to learn in order to understand the patient's underlying concerns, cultural background, and life history.Physicians need to pay close attention to financial and nonfinancial incentives that might provide a strong conflict of interest when making decisions for individual patients. Physicians must look at how they are paid, realize how it might influence the care of their patients, and take steps to ensure that such concerns do not intrude unduly into decisions at the individual patient level. Remuneration schemes must be scrutinized for this possibility by paying attention to the number of patients the scheme affects, the ability to spread risks over a large population of patients in the case of capitated payment schemes, the implicit and explicit goals of remunerative strategies (including cost containment, but also potentially quality, patient satisfaction, continuity, and other worthy goals), and the extent to which the arrangements are public or, at least, open and understandable to patients. It is important to recognize that large fee–for–service payments and salaries without productivity standards or quality standards are equally likely to influence the care of individual patients and should be scrutinized with equal seriousness. Similarly, things like the size of a physician's panel of patients, its cultural variety, or morbidity can affect relationships because of their influence on time available per patient visit.When taking on responsibility for a panel of patients, physicians could be said to join a relationship in theory that does not yet exist in reality. Physicians, working with their plan, should spearhead efforts to reach out to such members if only to ensure they are educated about preventive medicine issues and encourage them to follow healthy lifestyles.
Although patients and doctors alike will not find frequent visits necessary when someone remains healthy, still the relationship between patient and physician may become important later, should the patient become seriously ill. Something as simple as an annual “Health Care Maintenance Reminder” postcard (with the doctor's name) may help members feel their faceless doctor is nonetheless caring for them. Developing relationships with all enrolled members is also a way for physicians and plans to become more accountable for the care of those who are not seen in clinical practice. STRATEGIES FOR MANAGED CARE PLANSA number of strategies that MCOs can use to strengthen doctor–patient relationships are listed in. Often, plans do not know how to detect and remediate problems in doctor–patient relationships, how to train their practitioners and their staff to relate effectively and efficiently, or how to train their enrollees to be effective in their own care.
As we now know how to do all of these things, there is no longer justification for poor performance in the encounters between providers and patients. Doctors need training in dealing with difficult patients, about common aspects of life adjustment such as reaction to illness, in recognizing the underlying psychological problems that remain a leading cause of seeking medical care, in negotiating, and in handling tough situations like breaking bad news. Courses such as those of the American Academy on Physician and Patient (AAPP) can provide such skill.
Patients need to be taught to organize their approach to care, to ask questions, to negotiate, and to discuss feelings. The AAPP, the Northwest Institute, the Bager Institute, and others can provide such training.Plans can promote a culture that is patient- and member-centered. This variation on “put the customer first” acknowledges the vulnerability of patients as ill persons needing care, compassion, and special attention. It also implicitly and explicitly makes care, not profit, the center of attention for those doing the daily work of providing health care. Physicians and other clinicians are encouraged to put their patients' good first, ahead of profit (their own or the organization's), politics (e.g., reluctance to whistleblow or disclose mistakes), or personnel (e.g., the convenience of the other staff). Conserving resources for future patients or to expand services becomes an important part of serving the member population.
Although creating a culture that is patient-centered is not a quick or easy task, there are resources available.It is useful for plans to separate patient care from administrative rules communication. Too often, the practitioner is the person who has the difficult task of saying “no” to a patient. Plans can be purposefully deceptive or vague in communicating what they will not do for a member, when they are trying to enroll new members.
It would ease the situation between doctor and patient if the patient clearly understood when the doctor said no that (when applicable) this is not the doctor's decision but the plan's. This approach is likely to require regulatory change.Plans can structure contracts with employers that encourage accountability to the membership rather than the employer. It is hard to balance the competing interests of sick and well members, those who need resources now and those who may need them later, staff and the community. Employers' standing in decisions that affect primarily their employee members adds more complexity, and is fraught with conflict. The illusion remains that employers pay for health insurance. Actually their not paying the premiums would increase real wages for their employees, drop the cost of living, increase profits, or increase income due to greater competitiveness. This illusion, however, affects how health insurers view their accountability.
Managed care plans do what it takes to please employers, because employees are their customers. The member, sick or well, has little voice. One way to alleviate this situation is to ensure that members have a voice, either through their employer or union, or in the health plan itself, for example, through representation on guideline development initiatives or benefits committees.
If policies can be said to be self-imposed by the membership, physicians making judgments about resource use are acting for their patients, current and future, and not for employers., Another strategy is to require management to use the same plans their employees do.Plans must eliminate intrusive incentives in contracting with physicians. Intrusive incentives are those that combine strength (i.e., are large either in absolute or relative terms) with a tight linkage to individual patient care decisions. If a single decision about a single patient (including the decision to accept a chronically ill person into one's practice) is likely to result in a significant financial loss to the physician, then the relevant incentive is too intrusive. The intrusiveness of incentives is a product of the incentive's size (e.g., how much money is at stake) and its link to individual care decisions. For instance, if referring a patient to a specialist “costs” a physician a loss out of the physician's pool, it is tightly linked.
If, however, a prepaid arrangement covers several thousand patients, the relative size (or impact) of the incentive is small. Incentives need not be only financial; peer pressure, leisure time, the threat of deselection, or a sense of fulfillment from work may also influence patient care decisions and thus also should be subject to scrutiny.Plans can standardize “with heart.” Moderating the variation in clinical practice has often been touted as a way to save money without compromising quality of care. Yet some variation is necessary and inevitable. An organization that does not allow clinicians to open the gate for the justifiable exception to the rule, or is overly skeptical of clinical judgment about those with rare or poorly characterized conditions, ignores to its peril the rich variety of the human condition.The openness and honesty of a system or organization can contribute to a climate of trustworthiness. For instance, discrepancies between marketing messages (“we provide everything”) and the availability of medications, equipment, or specialty care (“that's not covered in your plan”) create entitlement and convert it to disenchantment, resulting in an atmosphere of distrust that inevitably includes the doctor–patient relationship.
Health care organizations may not relish the idea of promoting honest talk about limited resources and their consequences, but should at a minimum not try to raise expectations of unlimited access to unlimited services.Plans should promote patient privacy and confidentiality. The expectation of privacy is one of the most important aspects of the doctor–patient relationship and influences the disposition to trust, but confidentiality is no longer solely in the doctor's control. Organizational personnel have access to patient information and must be required to keep it private, taught how to keep it private, and monitored to be sure they do.Time is another prerequisite for trust. Plans should determine a reasonable minimum average time for doctor visits. They should pay attention when doctors or patients complain they do not have enough time together.
Because the time of visit varies by type of visit, type of doctor, and complexity of the patient, patient complaints about visit time may be a useful patient-centered indicator of potential trouble in doctor–patient relationships.Plans can encourage consideration of psychosocial issues in all forms of patient care. An organization can use continuing education, promotional materials, patient-directed education, and quality improvement efforts to promote this aspect of patient care.
In doing so, discussions about these areas between doctors and patients will be enabled, patient satisfaction will increase, and unnecessary visits, such as to the emergency department for panic attacks, may even go down. Organizational change may be a more efficient way to promote caring than changing either medical education or the process by which medical students are selected.Plans should avoid business decisions that interrupt continuity between doctors and patients. Mergers and acquisitions, adding and deleting physician groups, agreeing to short-term contracts with employers, expanding or selling out, all are decisions with profound implications for one-on-one relationships between doctors and patients. To minimize harm when these decisions are unavoidable, exceptions can be made for those with important, established relationships. The “old doctor” may accept the standard fee, or the patient may be willing to contribute to some degree. If necessary, the patient's care can be gradually (as opposed to abruptly) established with a new physician “in the plan.” The latter strategy enables patients to take control over their choice of doctors and gives them time to find one acceptable to them in the network. CONCLUSIONSAs Chairman Mao said, the first step in solving a problem is calling it by its right name.
Only then can it be discussed and its particular features in a given site identified. The second step is agreeing on its high priority. The third step is obtaining appropriate consultation and choosing solutions.
The solution will often be training practitioners and staff. To everyone's regret, there is no quick fix here although major improvements can be initiated in as short as a daylong course.
Such interventions need to be part of an ongoing commitment to this area, steady work through a continuous quality improvement-type process, and regular training and renewal of skills. Groups like the AAPP can provide such long-range training efforts. Many plans already monitor practitioner skills in these areas through patient satisfaction surveys, and these may effectively identify those needing extra help.
Attention to the training of patients is another critical part of creating effective partners for care. So also is employers' education as to the importance of this area, as their decisions may be critical in directing resource allocation. Finally, we believe the medical profession needs to provide data-based standards and establish principles physicians will not violate and to which plans must adhere. Otherwise, this will be done in a haphazard way by corporate interests.We have outlined briefly the fundamentals of the doctor–patient relationship, some features of the health care system found particularly in managed care settings that affect it, and approaches for protecting and sustaining the doctor–patient relationship in these settings.
These are aimed at physicians and plans, but should be of interest to policy makers, other health care administrators, and consumer groups. In change there is opportunity. Our current opportunity is to examine the doctor–patient relationship, the context in which that relationship operates, and in particular, the influence of changes in the financing and organization of health care. The doctor–patient relationship deserves our serious attention and protection during these dangerous times.
A physician performs a standard on his patient.A patient must have confidence in the competence of their physician and must feel that they can confide in him or her. For most physicians, the establishment of good with a patient is important. Some medical specialties, such as and, emphasize the physician–patient relationship more than others, such as or, which have very little contact with patients.The quality of the patient–physician relationship is important to both parties. The doctor and patient's values and perspectives about disease, life, and time available play a role in building up this relationship. A strong relationship between the doctor and patient will lead to frequent, quality information about the patient's disease and better health care for the patient and their family.
Enhancing the accuracy of the diagnosis and increasing the patient's knowledge about the disease all come with a good relationship between the doctor and the patient. Where such a relationship is poor the physician's ability to make a full assessment is compromised and the patient is more likely to distrust the diagnosis and proposed treatment, causing decreased to actually follow the medical advice which results in bad health outcomes. In these circumstances and also in cases where there is genuine divergence of medical opinions, a from another physician may be sought or the patient may choose to go to another physician that they trust more.
Additionally, the benefits of any are also based upon the patient's subjective assessment (conscious or unconscious) of the physician's credibility and skills.and together pioneered the study of the physician patient relationship in the UK. Michael Balint's 'The Doctor, His Patient and the Illness' (1957) outlined several case histories in detail and became a seminal text. Their work is continued by the, The International Balint Federation and other national Balint societies in other countries. It is one of the most influential works on the topic of doctor-patient relationships. In addition, a Canadian physician known as was known as one of the 'Big Four' professors at the time that the Johns Hopkins Hospital was first founded. At the Johns Hopkins Hospital, Osler had invented the world's first system.
In terms of (i.e. The outcome of treatment), the doctor–patient relationship seems to have a 'small, but statistically significant impact on healthcare outcomes'. However, due to a relatively small sample size and a minimally effective test, researchers concluded additional research on this topic is necessary. Recognizing that patients receive the best care when they work in partnership with doctors, the UK issued guidance for patients 'What to expect from your doctor' in April 2013. Aspects of relationship The following aspects of the doctor–patient relationship are the subject of commentary and discussion.Informed consent. Main article:The default medical practice for showing respect to patients and their families is for the doctor to be truthful in informing the patient of their health and to be direct in asking for the patient's consent before giving treatment.
Historically in many cultures there has been a shift from, the view that the 'doctor always knows best,' to the idea that patients must have a choice in the provision of their care and be given the right to provide to medical procedures. There can be issues with how to handle informed consent in a doctor–patient relationship; for instance, with patients who do not want to know the truth about their condition. Furthermore, there are ethical concerns regarding the use of.
Does giving a sugar pill lead to an undermining of trust between doctor and patient? Is deceiving a patient for his or her own good compatible with a respectful and consent-based doctor–patient relationship?
These types of questions come up frequently in the healthcare system and the answers to all of these questions are usually far from clear but should be informed by.Shared decision making. Main article:Shared decision making is the idea that as a patient gives informed consent to treatment, that patient also is given an opportunity to choose among the treatment options provided by the physician that is responsible for their healthcare. This means the doctor does not recommend what the patient should do, rather the patient's autonomy is respected and they choose what medical treatment they want to have done. A practice which is an alternative to this is for the doctor to make a person's health decisions without considering that person's treatment goals or having that person's input into the decision-making process is grossly unethical and against the idea of personal autonomy and freedom.The spectrum of a physician’s inclusion of a patient into treatment decisions is well represented in World at Risk. At one end of this spectrum is Beck’s Negotiated Approach to risk communication, in which the communicator maintains an open dialogue with the patient and settles on a compromise on which both patient and physician agree. A majority of physicians employ a variation of this communication model to some degree, as it is only with this technique that a doctor can maintain the open cooperation of his or her patient.
At the opposite end of this spectrum is the Technocratic Approach to risk communication, in which the physician exerts authoritarian control over the patient’s treatment and pushes the patient to accept the treatment plan with which they are presented in a paternalistic manner. This communication model places the physician in a position of omniscience and omnipotence over the patient and leaves little room for patient contribution to a treatment plan.
Physician superiority. This section does not any. Unsourced material may be challenged. ( June 2017) The physician may be viewed as superior to the patient simply because physicians tend to use big words and concepts to put him or herself in a position above the patient.
The physician–patient relationship is also complicated by the patient's suffering ( patient derives from the Latin patior, 'suffer') and limited ability to relieve it on his or her own, potentially resulting in a state of desperation and dependency on the physician. A physician should be aware of these disparities in order to establish a good and optimize communication with the patient. Additionally, having a clear perception of these disparities can go a long way to helping the patient in the future treatment. It may be further beneficial for the doctor–patient relationship to have a form of with to take a major degree of responsibility for her or his care.Those who go to a doctor typically do not know exact medical reasons of why they are there, which is why they go to a doctor in the first place. For a patient to not be able to understand what is going on with their body, because they can’t understand lab results or their doctor isn’t sharing or explaining them, can be a frightening and frustrating situation to be in. The medical doctor, with a by his side, is performing a at a hospital in 1980.
A good bedside manner is typically one that reassures and comforts the patient while remaining honest about a diagnosis. Vocal tones, openness, presence, honesty, and concealment of attitude may all affect bedside manner. Poor bedside manner leaves the patient feeling unsatisfied, worried, frightened, or alone.
Bedside manner becomes difficult when a healthcare professional must explain an unfavorable diagnosis to the patient, while keeping the patient from being alarmed.Dr. Rita Charon launched the narrative medicine movement in 2001 with an article in the. In the article she claimed that better understanding the patient's narrative could lead to better medical care.Researchers and Ph.D.s in a BMC Medical Education journal conducted a recent study that resulted in five key conclusions about the needs of patients from their health care providers. First, patients want their providers to provide reassurance. Second, patients feel anxious asking their providers questions; they want their providers to tell them it’s ok to ask questions. Third, patients want to see their lab results and for the doctor to explain what they mean. Fourth, patients simply do not want to feel judged by their providers.
And fifth, patients want to be participants in medical decision-making; they want providers to ask them what they want.An example of how body language affects patient perception of care is that the time spent with the patient in the is perceived as longer if the doctor sits down during the encounter. Examples in fiction.
This section needs additional citations for. Unsourced material may be challenged and removed.Find sources: – ( July 2017). (of the show ) has an acerbic, insensitive bedside manner. However, this is an extension of his normal personality. In, compliments 's ability to care for Dr.
Bailey's baby by saying 'it speaks to a good bedside manner.' . Doc Martin from the British TV series is a good example of a physician with a bad bedside manner. from the British TV series is another example of a Foundation Doctor with a poor bedside manner, whereas her colleague, has a better one.
In, tells that his bedside manner 'sucks'. Later in the episode, Jack is told by his father to put more hope into his sayings, which he does when operating on his future wife. The comments continue in other episodes of the series with sarcastically telling Jack that his 'bedside manner leaves something to be desired' after Jack gives him a harsh negative diagnosis.
In, Larry, the physician tells Anna when they first meet that he is famed for his bedside manner. In, is presented as an example of a physician with great bedside manner, while is a physician with bad or non-existent bedside manner at first, until she evolves during her tenure at Sacred Heart. Is an interesting subversion, in that his manner is brash and undiplomatic while still inspiring patients to do their own best to aid in the healing process, akin to a drill sergeant.
This show also comically remarked that the most amount of time that a doctor needs to be in the presence of the patient before he finds out everything he needs to know is approximately 15 seconds. In, often compliments himself on the charming bedside manner he developed with the help of. In, and all possess a caring and humorous bedside manner meant to help patients cope with traumatic injuries. Initially possesses no real bedside manner, acting with detached professionalism, until the rigors of his job help him develop a sense of compassion for his patients. Has a poor bedside manner, constantly minimizing the seriousness of his patients' injuries, accusing them of cowardice and goading them to return to the front lines.Patient behavior The behavior of the patient affects the doctor–patient relationship. Rude or aggressive behavior from patients or their family members can also distract healthcare professionals and cause them to be less effective or to make mistakes during a medical procedure.
When dealing with situations in any healthcare setting, there is stress on the medical staff to do their job effectively. Whilst many factors can affect how their job gets done, rude patients and unappealing attitudes can play a big role. Research carried out by Dr.
Pete Hamburger, associate dean for research at, evidences this fact. His research showed that rude and harsh attitudes shown toward the medical staff reduced their ability to effectively carry out some of their simpler and more procedural tasks.
This is important because if the medical staff are not performing sufficiently in what should be simple tasks, their ability to work effectively in will also be impaired.While it is completely understandable that patients are going through an extremely tough time compounded by stress from other external and internal factors, it is important for the doctors and medical staff to be wary of the rude attitudes that may come their way. See also.
The doctor-patient relationship is an intricate concept in which patients voluntarily approach a doctor and become part of a contract by which they tend to abide by doctor’s instructions. Over recent decades, this relationship has changed dramatically due to privatization and commercialization of the health sector. A review of the relevant literature in the database of MEDLINE published in English between 1966 and August 2015 was performed with the following keywords: doctor-patient relationship, physician-patient relationship, ethics, and Islam. The Muslim doctor should be familiar with the Islamic teachings on the daily issues faced in his/her practice and the relationship with his/her patients. The basis of Islam is to believe that there is no God but Allah, and Muhammad (PBUH) is the messenger of Allah. The life of a human being on earth is just a preparation or examination for the eternal life after death. Good is from Allah in the Holy Quran and demonstrated by Prophet (PBUH), and bad is the influence of Satan (who again is created by Allah).
The good or bad consequence of eternal life depends on how much a Muslim believes in and obey Allah. Medical practice is considered a sacred duty in Islam, and the physician is rewarded by God for his good work. Islamic scholars have agreed that the study and practice of medicine is an obligation that falls upon Muslims to have sufficient numbers of followers to practice (Fard Kifayah). Among a doctor and patient, both can be Muslim, or either can be Muslim. The Islamic perspective of the doctor-patient relationship is applicable to these groups; but possibley not the non-Muslim doctor- patient groups.
A Muslim is first a Muslim then he/she is a doctor/patient. Therefore, those who claim themselves as Muslim should obey Allah, hence, should obey what Allah has said or Prophet Muhammad (PBUH) has demonstrated regarding the doctor-patient relationship. Obviously, like other Islamic issues, there should be the scope of “Ijma” (Consensus of Islamic Scholars) and “Qiyas,” (analogy) when any new issue arises.
Building a fruitful doctor-patient relationship is a vital part of successful medical care, and one of the most complicated professional responsibilities of physicians. Despite worldwide emphasis on the distinguished responsibility of physicians, teaching the art of physician-patient relationship has not yet been incorporated, into the curriculum of many medical schools. Every medical practitioner should possess an adequate degree of knowledge and skills and should exercise a reasonable degree of patient’s care. Doctors are expected to act according to acceptable medical opinion and current medical knowledge. Over the years, the relationship between doctors and patients has evolved from a largely paternalistic model to a more interactive relationship. The principles of autonomy, beneficence, informed consent, patient’s access to medical information, and medico-legal concerns all now influence the doctor-patient relationship.
The UK General Medical Council published “What to expect from your doctor: a guide for patients”. The guide is a provisional step trying to help patients getting the best outcome from the interaction with their physicians. The importance of the intimate personal relationship between the doctor and the patient cannot be over emphasized, as both the diagnosis and treatment are directly dependent on it, and the failure of a young physician to establish this relationship is attributed to his inefficiency in the care of his patients. The only and sole interest the doctor should consider, is the best interest of his/her patient. Francis Peabody ended his speech to medical students of Harvard University on 21 October 1926 by saying: “ Time, compassion, and understanding should be generously dispensed, but the reward is to be expected in that personal binding, which creates the greatest satisfaction of the practice of medicine.
One of the greatest qualities of a physician is his interest in humanity, as the secret of care of the patient lies in the caring for his patient”. Doctors mannersDuring the history-taking period, the doctor should not only obtain essential clinical information, but must use this opportunity to understand his patient as a human being. This is also when the patient begins to identify his/her doctor as a person and decide whether he is a caring and kind person or not! Globally, patients expect a certain kind of treatment from their doctors because of the nature and goals of the medical profession. The physician is expected to be kind, humble, compassionate, honest, trustworthy, and respecting confidentiality.
He must have the interest of the patient at heart. He should avoid wrongdoing, not abusing his/her status for monetary gain, and not misleading his/her patient because God does not love the liars and wrongdoers. The Prophet (PBUH) said: “ Those who have a perfect faith are those who have the best character”. The doctor is expected to be kind, humble, and compassionate.Islamic ethics instructs human beings not only to be virtuous, but also to contribute to the moral health of society. The Qur’an says:“You enjoin what is right and forbid what is wrong”.
The character of the Muslim is exemplified in a verse of the Holy Qur’an saying:(“Indeed, Allah orders justice and good conduct” and “ forbids immorality and bad conduct and oppression”). The characteristic features of a virtuous physician are firmly rooted in the Qur’an and the Sunna. Consequently, the Muslim physician, guided by these 2 primary sources of Islamic law, should possess the essential manners of a good physician, and this will lead to a healthy doctor-patient relationship. The major distinction of Islamic medical ethics in relation to principalism-based medical ethics is that the former gives a religious basis to morality. Prophet Muhammad says; “ The best of you is the one who is most beneficial to others”.
“Hazrat Jaber (Radiallhu tala anhu)”, a companion of the Prophet said: “We were with the Prophet when a scorpion bit one of us. A companion asked, “ O Prophet, may I do Ruqyah (recitation of Qur’an and supplications) to him.” The Prophet said: “ Whoever can do anything beneficial to one of his brothers, he should just do it”.During the time of the Prophet (PBUH) a man was injured and the blood was congested in the wound. The man then called 2 doctors from Bani Amir to examine him. The man then claimed that the Messenger of Allah asked them, ‘Who is the best doctor among you?’ They Asked: Is there preferability among physicians, O Messenger of Allah? He said, ‘The One, Who has sent down the disease also sent down the cure.
Those who Know it will know it, and those who do not know it will not know it.” This Hadith indicates that Muslims should seek the best authority in each and every matter and field because such expertise will ensure that the job is carried out with excellence.Islam has enjoined 3 important points on which the doctor establishes a sound and healthy relationship with his/her patients: The first of these is justice among his patients. The second point enjoined is “Ihsan”, which has no equivalent in English. It means to be good, tolerant, sympathetic, forgiving, polite, cooperative, and so forth. The third point, which has been enjoined, is good treatment of a patient’s relatives, which is a specific form of Ihsan.Prominent physicians of the Islamic civilization involved themselves with medical ethics; among these were Al-Ruhawi, and Al-Razi. They wrote the earliest and most meticulous books on medical ethics over a thousand years ago. Al-Razi, in his book “Akhlaq Al-Tabib”, the physician duties to the patients.
The first of which is to treat the patients kindly, not to be rude or aggressive, but should be soft-spoken, compassionate, and behave modestly. The physician should inspire the patients even those who have no hope for recovery.
To Al-Razi, another duty of the physician to his patients is to treat the patients equally regardless of their wealth or social status. The aim of the physician should not be the money he will get after treatment, but the cure. Doctors should be even keener on treating the poor and needy than the rich and wealthy. CommunicationGlobally, a patient’s complaints of doctors’ communication skills are recorded at the top of the analyzed complaint lists.
It is crucial to treat the patient, not only the disease. Modern technology makes the physician’s skills focused on the treatment of the disease with less emphasis on the patient himself. Consequently, the symptoms of the disease are temporarily alleviated, while the root of the problem is still present. Hippocrates made an invaluable remark saying “ where there is love for human being, there is love for the art of healing”. It was reported that Avicenna used to tell his patient: Look! You, I and disease are “3”.
If you help me and stand beside me, we become “2”, and the disease will be left alone; then we will overcome it and compel your illness. But if you stand beside the disease, you will become “2” and I will be alone, then you will overcome me, and I will not be able to cure you.A physician taking a history from his patient in a way similar to an interrogating lawyer, and paying little attention to his patient’s answers is doomed to be a poor clinician.
Many doctors are reluctant to improve communication, which is one of the crucial elements of treatment. Despite the efforts of some medical universities to reform their medical curriculums and implement communication skills, it seems that many doctors do not appear to build effective relationships with their patients. Since the clinics became more crowded, with an increase in referrals to specialists, doctor-patient exposure decreases as visits became shorter, and patients are frequently exposed to different physicians.
Unfortunately, patients are becoming more distant from their doctors. They have more access than ever to medical information. They are far more knowledgeable on pathology and modes of therapy, and often express their desire to participate in treatment decisions. We are going to see an amazing progress in technology shortly, and the practice of medicine will be very interesting, but very different from today. Communication with children’s parentsMost parental complaints of dissatisfaction are attributed to lack of communication or due to a cold, rough, or indifferent attitude, or behavior, of the doctor or any member of the treating team, and not due to lack of knowledge and skills or unsatisfactory treatment of the patient. The patients and parents should have the feeling of being treated with respect and dignity at all times. Physicians should be tactful and careful in deciding not only “what to tell the parents” but “how to tell” as well.
Parents should be informed the condition of the child in a simple language without medical jargons. They should also be pragmatic and honest in telling them the true medical status of the child, while keeping the hope alive, which has great healing capacity. Patient’s satisfaction and trustImprovement of patient’s satisfaction is a major target for hospitals and is often dictated by patients’ perception of the level of communication of the hospital team. When doctors communicate effectively with patients, they identify patients’ problems more accurately, and the patients are more satisfied.
An American study of 500 difficult patients in general medicine revealed that only one patient out of 2 is leaving the doctor’s office satisfied with the care provided. This satisfaction increased to 63% when the same patients were asked about their feelings 3 months later.
The most satisfied patients were those over the age of 60 who saw an improvement in their health. A relationship characterized by a high level of trust in the physician leads to an increase in adherence to treatment, improvement in follow-up, and reduction in unnecessary investigations, and requests for a second opinion.
Consequently, the overall cost of healthcare will be significantly reduced. A greater number of problems may be solved during a consultation when patients have a deeper relationship with their doctors.
The gender issue in the doctor-patient relationshipModesty is an important issue for Muslim women, and many female patients may tune out what the doctor is saying, out of nervousness over having their bodies exposed. For a Muslim woman, it could be very stressful to expose her body in front of a male physician, or even to discuss with him sensitive issues related to her health. Consequently, some Muslim women may not reveal their health problems to a male physician or may not even seek medical care.Patients typically prefer same-gender providers and may feel uncomfortable when alone with a physician of the opposite gender. If that’s unavoidable, leave the door or privacy curtain partly open (as long as your patient is dressed).
It is quite common for the husband to ask to stay with his wife during a physical examination. Having a female nurse available for examinations may help a Muslim woman to feel more comfortable, and is mandatory in all countries in the world. Posting a sign stating, “Please knock on the door before entering.” may also be-helpful. Informed consentInformed consent is the cornerstone of the doctor-patient relationship, and is a recognized legal obligation for the medical profession.
Physicians must obtain informed consent from the patients or their legal guardian, in case of minors or mentally deficient, before undertaking any medical or surgical procedure, providing a clear explanation of the planned procedure, intended benefits, potential risks, and complications. DelPozo and Fins note that informed consent addresses the individual rights of patients. However, Islamic law respects the privacy of person and family.
They conclude that the Western way of obtaining informed consent in a patient from the Eastern culture may involve providing “too much information and may leave the patient feeling misinformed.” Giving too much information, at times, may raise suspicion that the physician might be withholding information or even concealing the truth.”, To respect the autonomy of the patient, the doctor should have more knowledge of the cultural values and behaviors of his/her patient. For a Muslim patient, absolute autonomy is very rare; he/she will have a feeling of responsibility towards God, and live in social cohesion, in which the influence of relatives play a significant role. The patient-doctor relation is continuously changing, and informed consent will never prevent unfortunate outcomes, leading to serious questioning of doctor’s performance and the proper use of resources. Even if this reaches an exemplary level, it does not guarantee the patient’s satisfaction with the medical service provided, and avoid possible legal accusation. The role of family/companions in medical consultationsThe family is the basic structural element of a stable Islamic society.
Family members frequently accompany patients to the clinic or hospital, and medical decision-making usually involves the patient’s immediate family even when the patient is compos mentis. The family may deliver bad news gradually to the patient. Although a patient may choose to pay attention to the influence of family and friends, the ultimate decision to agree with the procedure, or surgery must be made by the patient. The role of the family should be affirmed and respected, but this recognition must be balanced with the priority of patient autonomy. All communication regarding the risks and benefits of medical procedure, or surgery must be understood by the patient.
It is not acceptable to ask a surrogate for consent for a capable and conscious adult patient unless the patient chooses to permit it. Companions usually play a supportive role in the majority of consultations. They give emotional support, help in transport, and may express patients’ concerns. During the procedure or surgical operation, relatives often recite prayers or read the Quran, appealing for the cure of their loved ones.
Ethical issues in visual recordingVisual recording of patients is commonly used for clinical, research, legal, and academic purposes. It is frequently used in the specialties of plastic surgery, dermatology, wound care, maxillofacial surgery, and otolaryngology. Guidelines for biomedical recording have been issued by several health authorities, associations, and journals. Photographing patients may have an indirect effect on treatment, by aiding diagnosis; and written consent should be obtained from the patient or his/her legal representative before carrying out the procedure. The identity of the patient should always be concealed.
In recent years, doctors have been investigated for uploading medical data that can identify patients onto public internet forums. Muslim jurists’ rulings on human recording vary from being permissible to bing discouraged, and forbidden.
However, the ruling is ultimately dependent on the intended use of the images or recording, the way images were obtained, and the potential usage of the whole procedure. For images to be permissible, the procedure must not contradict Islamic law. Only the minimum necessary area should be photographed. Subjects’ rights and dignity must not be violated, and their religious and cultural background respected. ConfidentialityBreaching confidentiality can be acceptable or required by medical authorities, when failure to act can lead to physical harm, to either the patient or people in contact with that patient; such as the case of certain infectious diseases, where the doctor or researcher has a duty to protect the health of those who may be at risk. Certain circumstances demand a breach of patients’ confidentiality to protect other individuals or society as a whole. Breach of confidentiality under such conditions is justifiable in Islam.
Examples include reporting, to the assigned authorities, probable criminal acts (such as domestic violence or child abuse), serious communicable diseases or circumstances, which pose a threat to others’ lives (such as an epileptic patient working as a driver), notification of births and deaths, medical errors, and drug side effects. If the patient agrees to disclose the complexity of his medical condition to the family, then there is no breaking of confidentiality. If a consort has an HIV infection, then the physician’s duty is to inform the other consort of the true diagnosis. The doctor should take the permission from the infected person, or ask him to tell his consort, in his presence, the true diagnosis.In a fatwa issued by the International Islamic Fiqh Academy in 1993, jurists affirmed that a breach of confidentiality can be acceptable only if the harm of maintaining confidentiality overrides its benefits.
The fatwa describes some situations in which breaching confidentiality is allowed, or mandatory. “Such cases are of 2 categories: a) Cases where a confidence must be broken on grounds of the rational of committing a lesser evil and obviating the greater one, and the rational of seeing to a public interest, which favor enduring individual harm so as to prevent public harm if needed.
Importance Of Doctor Patient Relationship Pdf
These include 2 sets: Those which involve protecting society against some prejudice, and those which involve protecting an individual against some prejudice. B) Cases where a confidence may be broken: 1) To ensure a public interest. 2) To prevent a public damage. In all such cases the objectives and priorities are set out by Shari’ah (Islamic law) regarding preserving the faith, human life, reason, descendants, and wealth”.
Breaking bad news/disclosureBreaking bad news, defined as “any information that seriously and adversely affects an individual’s view of his or her future,” is a nerve-racking moment in the relationship between doctors and their patients. It is very stressful for patients, especially if the clinician is inexperienced. Health care workers in Muslim communities are required to modify the Western-based recommendations to match the culture of their patients and their families. In all cultures and communities, the statement of Buckman firmly stands: “ if the breaking of bad news is badly done, patients and their families may never forgive us, but if it is done properly they will never forget us.”Full disclosure and patient’s autonomy are the focal point of medical ethics in the West. Consequently, Western medical practice advocates free and open communication with patients, to the point that they are fully aware of their disease and treatment.
Four Types Of Doctor Patient Relationships Ppt
Nondisclosure of a cancer diagnosis is common practice in many Eastern communities. Consequently, families often approach oncologists with requests for nondisclosure. As a result, most doctors opt to break a cancer diagnosis to the family before informing the patient himself.
Nondisclosure may carry high costs to the patient and family, who may receive less than optimal supportive and medical care. The patient may be deprived of the chance to finalize his affairs and say goodbye. For many Muslim patients, it is God who permits death, hence giving up hope is not welcome in religious teaching.In conclusion, the practice of medicine firmly relies on the relationship between the doctor and his/her patient. Consulting with a patient is a complicated skill that is gradually learned during medical training and perfected when one grows to take his/her role as a doctor.
Medicine is not a business to be learned, but a profession to be satisfied with. Medical technology should not be allowed to dehumanize further medicine, and the declining image of the medical profession should be rectified.
The caring doctor is the one who does not over-test or over-treat his/her patients and communicate with them properly. The success of the doctor-patient relationship is evident when doctors treat patients with respect and courtesy. Physicians are expected to possess scientific knowledge, technical skill, and a human touch and understanding. Physicians should be kind, decent and modest, well mannered, and insist on the treatment of poor and needy patients as much as law and regulations can permit. However, these regulations may hamper such good will.
These are considered to be doctor’s essential duties to the patients and the society.Continuous education and model leadership are required to maintain the portrait in which doctors see their patients as people and not a disease. This will not only improve the relationship between physicians and patients, but often improve the clinical outcomes. All medical schools should initiate regular education programs in medical ethics, social, and behavioral sciences, and the art of communication for both undergraduate and postgraduate medical students. We also recommend developing a monitoring and evaluation system for doctors working in hospitals, clinics in public and private sectors to monitor for how they adhere to the “Code of Islamic medical ethics.”.