The Patient-Doctor Relationship

Diana M. de Castro, MD, FPPA

The quality of patient-doctor or patient-therapist relationship is crucial to the practice of medicine and psychiatry.

 An effective relationship is characterized by good rapport. Rapport is the spontaneous, conscious feeling of harmonious responsiveness that promotes the development of a constructive therapeutic alliance.
It implies an understanding and trust between the doctor and the patient.

Ekkehard Othmer and Sieglinde Othmer defined the development of rapport as encompassing six strategies:
(1) putting patients and interviewers at ease; (2) finding patients' pain and expressing compassion; (3) evaluating patients' insight and becoming an ally; (4) showing expertise; (5) establishing authority as physicians and therapists; and (6) balancing the roles of empathic listener, expert, and authority.

Empathy
Empathy is a way of increasing rapport.
It is an essential characteristic of psychiatrists, but it is not a universal human capacity.

Transference
Transference is generally defined as the set of expectations, beliefs, and emotional responses that a patient brings to the patient-doctor relationship.

Countertransference
Just as the patient brings transferential attitudes to the patientdoctor relationship, doctors themselves often have countertransferential reactions to their patients.

Models of Interaction Between Doctor and Patient

The Paternalistic Model
In a paternalistic relationship between the doctor and patient, it is assumed that the doctor knows best. He or she will prescribe treatment, and the patient is expected to comply without questioning. Moreover, the doctor may decide to withhold information when it is believed to be in the patient's best interests. In this model, also called the autocratic model, the physician asks most of the questions and generally dominates the interview.

The Informative Model

The doctor in this model dispenses information. All available data are freely given, but the choice is left wholly up to the patient. This model may be appropriate for certain onetime consultations where no established relationship exists and the patient will be returning to the regular care of a known physician. At other times, the informative model places the patient in an unrealistically autonomous role and leaves him or her feeling the doctor is cold and uncaring.

The Interpretive Model

Doctors who have come to know their patients better and understand something of the circumstances of their lives, their families, their values, and their hopes and aspirations, are better able to make recommendations that take into account the unique characteristics of an individual patient. A sense of shared decision-making is established as the doctor presents and discusses alternatives, with the patient's participation, to find the one that is best for that particular person. The doctor in this model does not abrogate the responsibility for making decisions, but is flexible, and is willing to consider question and alternative suggestions.

The Deliberative Model The physician in this model acts as a friend or counselor to the patient, not just by presenting information, but in actively advocating a particular course of action. The deliberative approach is commonly used by doctors hoping to modify injurious behavior, for example, in trying to get their patients to stop smoking or lose weight.

Illness Behavior
The term illness behavior describes patients' reactions to the experience of being sick. Aspects of illness behavior have sometimes been termed the sick role, the role that society ascribes to people when they are ill. The sick role can include being excused from responsibilities and the expectation of wanting to obtain help to get well.

Biopsychosocial Model
In 1977, George Engel at the University of Rochester, published a seminal paper that described the biopsychosocial model of disease, which stressed an integrated systems approach to human behavior and disease. The biopsychosocial model is derived from general systems theory. The biological system emphasizes the anatomical, structural, and molecular substrate of disease and its effects on the patient's biological functioning; the psychological system emphasizes the effects of psychodynamic factors, motivation, and personality on the experience of illness and the reaction to it; and the social system emphasizes cultural, environmental, and familial influences on the expression and the experience of illness. Engel postulated that each system affects, and is affected by, every other system. Engel's model does not assert that medical illness is a direct result of a person's psychological or sociocultural makeup but, rather, encourages a comprehensive understanding of disease and treatment.

Spirituality
The role of spirituality and religion in sickness and health has gained ascendancy in recent years, with some suggesting that it become part of the biopsychosocial model. Some evidence suggests that strong religious beliefs, spiritual yearnings, prayer, and devotional acts have positive influences on a person's mental and physical health.

Beginning the Interview

How a physician begins an interview provides a powerful first impression to patients, which can affect the way the remainder of the interview proceeds.

 Physicians should initially make sure that they know a patient's name and that the patient knows the physician's name. Physicians should introduce themselves to other people who have come with the patient and should find out if the patient wants another person present during the initial interview. The request for the presence of another person should be granted, but the physician should also attempt to speak with patients privately to determine if there is anything that they want the doctor to know but would be reluctant to say in front of someone else.

The Interview Proper

In the interview proper, physicians discover in detail what is troubling patients. They must do so in a systematic way that facilitates the identification of relevant problems in the context of an ongoing empathic working alliance with patients. The content of an interview is literally what is said between doctor and patient: the topics discussed, the subjects mentioned.

Specific Techniques
Open-Ended Versus Closed-Ended Questions
Interviewing any patient involves a fine balance between allowing the patient's story to unfold at will and obtaining the necessary data for diagnosis and treatment. Most experts agree that an ideal interview begins with broad, open-ended questioning, continues by becoming specific, and closes with detailed direct questioning.

Reflection
In the technique of reflection, a doctor repeats to a patient, in a supportive manner, something that the patient has said. The goal of reflection is twofold: to assure the doctor that he or she has correctly understood what the patient is trying to say and to let the patient know that the doctor is perceiving what is being said.

Facilitation Doctors help patients continue in the interview by providing both verbal and nonverbal cues that encourage patients to keep talking. Nodding one's head, leaning forward in the chair, and saying, Yes, and then ? Uhor huh, go on, all examples of are facilitation.

Silence
Silence can be used in many ways in normal conversations, even to indicate disapproval or disinterest. In the doctor patient relationship, however, silence can be constructive and, in certain situations, allow patients to contemplate, to cry, or just to sit in an accepting, supportive environment in which the doctor makes it clear that not every moment must be filled with talk.

Confrontation The technique of confrontation is meant to point out to a patient something to which the doctor thinks the patient is not paying attention, is missing, or is in some way denying. The confrontation is meant to help patients face whatever needs to be faced in a direct but respectful way.

Clarification In clarification, doctors attempt to get details from patients about what they have already said. For example, a doctor may say, You are feeling depressed. When do you feel most depressed.

Interpretation The technique of interpretation is most often used when a doctor states something about a patient's behavior or thinking of which the patient may not be aware. The technique requires the doctor's careful listening for underlying themes and patterns in the patient's story. Interpretations usually help clarify interrelationships that the patient may not see.

Summation Periodically during the interview, a doctor can take a moment and briefly summarize what a patient has said thus far. Doing so assures both the patient and doctor that the doctor has heard the same information that the patient has actually conveyed. For example, the doctor may say, OK, I just want to make sure that I've got everything right up to this point.

Explanation Doctors explain treatment plans to patients in easily understandable language and allow patients to respond and ask questions.

 Transition The technique of transition allows doctors to convey the idea that sufficient information has been obtained on one subject; the doctor's words encourage patients to continue on to another subject. For example, a doctor may say, You've given me a good sense of that particular time in your life. Perhaps now you could tell me a bit more about an even earlier time in your life.

 Self-Revelation Limited, discreet self-disclosure by physicians may be useful in certain situations if physicians feel at ease and can communicate a sense of self-comfort. Conveying this sense may involve answering a patient's questions about whether a physician is married and where he or she comes from.

Positive Reinforcement The technique of positive reinforcement allows patients to feel comfortable telling a doctor anything, even about such things as noncompliance with treatment. Encouraging a patient to feel that the doctor is not upset by whatever the patient has to say facilitates an open exchange. For example, a doctor might say, I appreciate your telling me that you have stopped taking your medication.

 Reassurance Truthful reassurance of a patient can lead to increased trust and compliance and can be experienced as an empathic response of a concerned physician. False reassurance, however, is essentially lying to a patient and can badly impair the patient's trust and compliance. False reassurance is often given from a desire to make a patient feel better, but once a patient knows that a doctor has not told the truth, the patient is unlikely to accept or believe truthful reassurance.

 Advice In many situations it is not only acceptable but desirable for doctors to give patients advice. To be effective and to be perceived as empathic rather than inappropriate or intrusive, the advice should be given only after patients are allowed to talk freely about their problems so that physicians have an adequate information base from which to make suggestions. Giving advice too quickly can lead a patient to feel that the doctor is not really listening but, rather, is responding, either out of anxiety or from the belief that the doctor inherently knows better than the patient what should be done in a particular situation.

Ending the Interview

Physicians want patients to leave an interview feeling understood and respected and believing that all the pertinent and important information has been conveyed to an informed, empathic listener. To this end, doctors should give patients a chance to ask questions and should let patients know as much as possible about future plans. Doctors should thank patients for sharing the necessary information and let patients know that the information conveyed has been helpful in clarifying the next steps. Any prescription of medication should be spelled out clearly and simply, and doctors should ascertain whether patients understand the prescription and how to take it. Doctors should make another appointment or give a referral and some indication about how patients can reach help quickly if it is necessary before the next appointment.

Specific Issues in Psychiatry

Fees Before clinicians can establish an ongoing relationship with patients, they must address certain issues. For instance, they must openly discuss payment of fees. Discussing these issues and any other questions about fees from the beginning of the relationship can minimize misunderstanding later.

Confidentiality
Psychiatrists and mental health professionals should discuss the extent and limitations of confidentiality with patients, so that patients are clear about what can and cannot remain confidential. As much as physicians must legally and ethically respect patients' confidentiality, it may be wholly or partially broken in some specific situations.

Supervision
It is both commonplace and necessary for doctors in training to receive supervision from experienced physicians. This practice is the norm in large teaching hospitals, and most patients are aware of it. When young doctors are receiving supervision from senior physicians, patients should know from the beginning.

Missed Appointments and Length of Sessions

Patients need to be informed about a doctor's policies for missed appointments and length of sessions. Psychiatrists generally see patients in regularly scheduled blocks of time ranging from 15 to 45 minutes. At the end of this time, psychiatrists expect patients to accept the fact that the session is over. Nonpsychiatric physicians may schedule somewhat differently, by putting aside 30 minutes to an hour for an initial visit and then perhaps scheduling patient visits every 15 to 20 minutes for follow-up appointments.

Availability of Doctor
What are a doctor's obligations to be available between scheduled appointments? Is it incumbent on physicians to be available 24 hours a day? Once a patient enters into a contract to receive care from a particular physician, the doctor is responsible for having a mechanism in place for providing emergency service outside scheduled appointment times. Patients should be told what the mechanism is, whether it is an emergency phone number or a covering physician. If the physician is going to be away for a period of time, coverage by another physician is necessary, and patients must be informed how to reach the covering doctor.

Follow-Up
Many events can disrupt the continuity of the patient-doctor relationship. Some of these events are routine, such as residents ending their training and moving on to another hospital; others are out of the ordinary and thus unpredictable, for example, when physicians become ill and can no longer take care of their patients. Patients must be assured that regardless of what occurs in the course of a particular patient-doctor relationship, their care will be ongoing.

Character and Qualities of the Physician*

Imperturbability. The ability to maintain extreme calm and steadiness Presence of mind. Self-control in an emergency or embarrassing situation so that one can say or do the right thing Clear judgment. The ability to make an informed opinion that is intelligible and free of ambiguity Ability to endure frustration. The capacity to remain firm and deal with insecurity and dissatisfaction Infinite patience. The unlimited ability to hear pain or trial calmly Charity toward others. To be generous and helpful, especially toward the needy and suffering

Character and Qualities of the Physician*

The search for absolute truth. To investigate facts and pursue reality Composure. Calmness of mind, bearing, and appearance Bravery. The capacity to face or endure events with courage Tenacity. To be persistent in attaining a goal or adhering to something valued Idealism. Forming standards and ideals and living under their influence Equanimity. The ability to handle stressful situations with an undisturbed, even temper *After William Osler, M.D.

Learning to balance these interrelated aspects of the physician's role allows the doctor to cope productively within daily work that involves illness, pain, sadness, suffering, and death.