Doctor and Patient Relation

Objectives
● Describe the factors needed during a medical interview
● Define empathy
● Apply the techniques in building rapport to your patients
● Apply the techniques in building rapport to your patients
● Discuss professionalism

The medical interview

● Major medium of patient care
● If successful: Accurate and complete data
● Represents a dialogue that determines whether the patient agrees to take a medication, undergo a test, hange uet, undergo certain
activities
● More than 8-%- Diagnosis
● Interview-related factors: Outcomes of care symptoms, symptoms resolution, pain control, functional status, emotional health
● Key to practioner;s sense of professional well-being
● Average length of time per ambulatory patient (20 Minutes)
● For psychiatrists (1 hour and 30 minutes)
● For physical therapists (0 Minutes Interview, 30 Min to 1 hour activity)
● Specialized set of questions for certain cases - questionnaires, checklists, symptoms scale

Why improve on interviewing skills?

● Increased efficiency in use of time
● Increased accuracy and completeness of data
● Improved diagnosis
● Fewer tests and procedures
● Increased compliance
● Increased physician satisfaction
● Increased patient satisfaction
● Increased mutual learning from each other

Examples of Specific Questionnaire (CAGE)

Structural Elements of the Interview

1. Prepare the environment
● Create a private area

Reference: 1
 ● Eliminate noise and distractions
● Provide comfortable seating at equal eye level
● Provide easy physical access
2. Prepare Yourself
● Eliminate distractions and interruptions
● Let intrusive thoughts pass
3. Observe the patient
● Practice in variety of settings
● Notice physical signs
● Note patient’s presentation and affect
● Note what is said and not said
4. Greet the patient
● Introduce oneself
● Check patient’s name and how is it pronounced
5. Begin the interview
● Explain one’s role and purpose
● Check patient’s expectations
6. Detect and overcome barriers to communication
● Deafness, delirium
● Language, culture
● Psychological obstacles
7. Survey problems
8. Negotiate priorities
9. Establish a safety net
● ROS
10. Present findings and options
11. Negotiate plans
12. Close the interview
● Schedule next interview
● Say goodbye

Function of an Interview
1. Gather information and monitoring progress
2. Developing, maintaining, and sometimes concluding therapeutic relationships
3. Educating the patient and implementing a treatment plan

Gathering Information and Monitoring progress

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 ● Acquire knowledge of patient’s disease, psychological issues, illness behavior
● Skills: use open-ended questions the gradually narrowing it down; Use minimal encouragers such as “uh-huh” to facilitate flow

Developing and Maintaining therapeutic Relationship

● Naming feelings, communicating unconditional positive regard, expressing empathy, understanding, being emotionally congruent produce
the best outcomes
● Requires defining type of relationship (Short or long term, consultation, primary care, disease-episode oriented)

Educating the patient

● Awareness of patient’s level of knowledge, understanding, motivation, and cognitive style
● Includes: Communicating the diagnostic significance of the problems, negotiating and recommending appropriate diagnostic and treatment
options, enhancing patients coping ability
● Motivational Interviewing (Miller and Rollnick)
○ Directive, patient-centered counseling approach designed to motivate people for change by helping them clarify goals, explore
perceived barriers to behavior change, and commit to such changes

Empathy
● Many of the lay public regard empathy as ana venue to the restoration of compassion and humanism to the doctor-patient relationship,
which has been increasingly impersonal and threatened by technology and financial pressures
● Physician empathy increases patient satisfaction and improves clinical outcomes

Neurobiology of Empathy
● Discovery of a sensorimotor neuron in the cortex has suggested a mechanism whereby behaviors can trigger an unconscious reciprocal
response in an observer
● These mirror neurons fire when subject performs a particular task or when the subject observes another individual performing the task

Empathy as a Clinical Too

● Defined as an intellectual identifications with or experiencing of the feelings, thoughts , or attitudes of another
● There are both cognitive and affective dimensions of empathy
● Empathy skills are behaviors that demonstrate empathy (Clinician’s most powerful therapeutic tool)
● Can be taught

Barriers to Discussing Emotions

● Doctor
○ Takes too much time
○ Too draining
○ Cannot fix patient’s distress
○ Not my job
○ Perceived conflicts of interest
● Patient
○ Cultural taboo about discussing emotions
○ Preference for interpreting distress in biomedical model
○ Somatization disorder
○ Desire to meet doctor;s expectations
○ Worry about being emotionally overwhelmed
○ Lack of language for emotions

Overcoming Barriers to Empathy

● Understanding the feelings, attitudes, and experiences of the patient is the first step toward a more potent therapeutic alliance
● Emotions can be difficult for both patient and doctor
● From patient’s point of view, denial may be a first reaction to a psychological interpretation of symptoms

Physician’s mention these barriers to discussing emotion to patients:

1. It takes too much time
● Concern about tie are legitimate
● Organize framework (Few minutes to deal with emotions)
● Few extra minutes to address emotional issues (Time is more compensated by fewer phone calls and fewer unscheduled visits)
2. It is too draining
● However it can be far more efficient to make an emotional connection that to expend so much energy resisting it

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 3. I cannot fix it for the patient
● Patients o not expect their feelings t be eliminated; They just want to be understood
4. It is not my job
● When the patient keeps returning with the same complaint, unimproved by the physician’s intervention, patient is trying to
communicate a message

The empathic Skills

● Reflection
○ Refers to naming the emotion the doctor sees and reflecting it back to the patient
● Validation
○ Information the patient that you understand the reason for the emotion
○ Effect of normalizing the emotion and making the patient feel less isolated
● Respect
● Support
○ An expression of support tells the patient that the physician cres about them and is willing to be present to their emotions
● Partnership
○ Implie’s a team approach in which the patient and the doctor work together towards the same goal
○ An advantage of this may help motivate patients to take an active role in their improvement and may lay a foundation for a
contract for behavior change
Part 2 (Notes 1.6)

Giving bad News

● Bad news s defined as “any information which adversely and seriously affects an individual;s view of his or her future
● Bad news is a subjective experience that depends in the patient;s e petitions and understanding of the situation
● Effective communications can help a patient to better understand and move forward with the information tailored to their particular situation
● Cultural and ethnic variables further complicate the process
SPIKES (Protocol for delivery of unfavorable news)
● Set up the interview
○ Advanced preparation, pay attention to physical settings: Sit down, make eye contact, avoid interruptions, and invite the patient to
ask family to stay
● Assess patient’s PERCEPTION
○ “Tell em who you are doing”
○ “What do you understand about what happened so far”
● Obtain the Patient’s Invitation
○ “Is it ok to speak freely about the information that i have here?”
○ “Is there anything that you wouldn't want to know?”
● Give knowledge and information to the patient
○ “I'm afraid that have bad news for you”
○ The biopsy confirmed cancer
● Address the patient’s emotions with empathic responses
○ “I wish I had better news for you”
○ “I can see that you’re upset. Tell me more about what you’re feeling”
● Set goals
○ Summarize the conversation and make a plan to go forward
An Approach to Responding to Patient Emotions

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Difficult Patient/Situations

● Possible causes of patient anger:

○ Difficulty in getting to the office
○ Problems with the office staff
○ Anger toward the illness from which the person suffers
○ Anger at the cost of healthcare
○ Unanticipated problems or complications form the procedure
○ Absent or miscommunications form the healthcare team unrelated to medical-family issues
● Tips for approaching difficult situations or patient's behavior

● Possible causes of silence in patients

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 ● Possible reasons for demanding additional interventions

Professionalism
● Requires attention to several domains of healthcare behavior, including truth-telling, confidentiality, disruptive behavior, assuming
responsibility, respectful communication with patients, and colleagues, bullying, sexual harassment, personal appearance and
attire
● Competency-based curriculum has further defined, benchmarked, and assessed professionalism
● What does it entail

Social Media
1. Formal/informal Curriculum
● Many students are unaware of the risks of using social media
● Education can be effective
● Modeling professional behavior in the informal curriculum
○ Engaging students in respectful dialogue
○ Enlisting student leaders

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 2. Faculty Development
● Faculty de programs focusing on the use and abuse of social media
3. Institutional Response
● Written policies that specifically deal with social networking

Plagiarism
1. Formal/Informal Curriculum
● Certification (Alternative Teaching to plagiarism)
2. Faculty Development
● Seminars raising awareness of the faculty
3. Institutional Response
● Academic policies
Core values of Physical Therapist
● Critical Elements of Professionalism for Physical Therapists
○ Accountability
○ Altruism
○ Compassion/Caring
○ Excellence
○ Integrity
○ Professional Duty
○ Social Responsibility

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