Doctor-Patient relations

Michael Wilson
University of Illinois College of Medicine
University of Illinois Department of Psychology
 What would you do?
Four months ago, when you prescribed fluoxetine (Prozac)
for a patient, you explained the major side effects of the
drug. Today at the next appointment, the patient asks
you whether fluoxetine has any side effects. Your best
response is:

A. “The side effects are nervousness, insomnia, and sexual

dysfunction.”
B. “I will have the nurse go over the side effects with you
again.”
C. “Why do you ask?”
D. “Would you like me to check for possible side effects?”
E. “The side effects are minor; do not worry.”
 Learning objectives
• What is effective communication?
• The biopsychosocial model
• Styles of relating
• Professional boundaries
• Issues of compliance
• Rules for handling difficult doctor-patient
relationships
 What this lecture is not…
• …NOT about learning to take a patient history
– You will learn this in M2

• …NOT about psychiatric disorders

– We will have a few lectures later
– Also longer course on this in M2

• …NOT going to be able to teach you everything

about “people skills”
– Understanding psychological & social aspects of your
patients is life-long process
 What is effective communication?
• Essential part of doctor-patient relationship

– an exchange between medical expert & consumer

– on deeper level, interaction between 2 human beings
about matters of health, illness, death
– to be effective, usually includes
• listening on the part of the clinician
• patient disclosure of medical/social info
• development of comfort
• participation in shared decision making
• patient satisfaction
• empathy
 What is empathy?
• distinct from sympathy or “feeling sorry”
– vital element for the doctor-patient relationship
– not just the “softer side” of medicine
• research suggests increased patient satisfaction, patient
compliance

• = the ability to momentarily experience the

feelings of another & communicate this
– to put oneself in another person’s place
The biopsychosocial model
 The biomedical model
• Traditional approach to the patient

– Only biologic & medical aspects of care discussed

– Doesn’t include psychological factors

• psychiatric illness & stress can worsen medical conditions
• problems caused by illness can cause psych difficulties

– Doesn’t include social environment

• can affect susceptibility to illness & illness outcome
 Complexity of psychosocial level
• Other things besides biological effects of
medication or procedure contribute to
outcome

– doctor-patient communication
– patient understanding and beliefs of illness and
treatment
– social barriers & support
– unconscious barriers and alliances from both
patient and physician
 Complexity of psychosocial level
• Many patients will already have existing
preconceptions of illness, of you, of your
profession

– sick role
• protective role given to ill or injured person; may be assumed
by individual or imposed by custom
– transference
• preconceptions of patient about health care
• may relate how patients relate to you
– countertransference
• preconceptions of you about your patients
• may subtly influence how you relate to patients
 Transference
• Originally a technical psychotherapy term
– now roughly “the transferring of past experiences and
ways of relating to others by the patient onto the
clinician”

• May be positive or negative, depending on the

individual
– clinicians may be surprised when patient views them
negatively
 Countertransference
• The opposite of transference

• Different patients may elicit different emotions

– adoring patients may elicit exaggerated concern
– hostile patient may elicit defensiveness
– older patients may elicit more deference
• increasing research shows some patients receive different
care in ways that does not appear to medically justified
 Styles of relating
• Relationship style may not be consciously chosen
(modeling)
– often adopted from mentors
– some MDs may flexibly adapt style to fit clinical situation

• Active-passive model
– patient completely passive, takes no responsibility for
their treatment
– Stereotype of MD in early 1900s as warm “father figure”
– With technology, evolved into focus on disease
• Still appropriate for infants or demented/agitated/unconscious
patients
 Styles of relating
• Mutual participation model

– more interactive than active-passive model

– Equality & partnership between patient & MD
– MD brings expert advice
– patient brings personal experience & life priorities
– communication is less dominated by MD
– interaction typically warm & empathetic
– essential for chronic illnesses like diabetes, where
active patient participation required for success
 Styles of relating
• Consumer-based style

– options described by physician

– decisions left in the hands of patient or bill-payer
– occurs most frequently in non-serious illnesses (like
plastic surgery)
– interaction often cordial/businesslike
– communication more dominated by patient
– MD present to answer questions
 Styles of relating
• “Friendship” model

– patients who feel “understood” often want to be

friends
– generally dysfunctional or unethical
– professional boundaries may be blurred with sharing
personal info, lending money, sexual contact
• if severe, can lead to a malpractice suit or loss of license
 Professional boundaries
• Doctor-patient relationship is a fiduciary one that
has at its core the element of trust

– fiduciary = One that stands in a special relation of

trust, confidence, or responsibility in certain
obligations to others
– [Latin fīdūciārius, from fīdūcia, trust]
 Professional boundaries
• Physician-patient relationship is not equal

– no matter how egalitarian you are

– patients seek your help as an expert
– you may be described as almost superhuman
– you are generally seen as an authority figure
• like teachers or lawyers
– usually present in a distressed or fearful state
• intensity of emotional experience usually more powerful
 Professional boundaries
• Since some emotional involvement is good (ie,
empathy), where to draw the line?

– in general not well defined, but involve breach of

fiduciary relationship

• business transactions
• gifts & services
• special scheduling or duration of appointments
• romantic physical contact
– this is always unethical
 Professional boundaries
• Professional organizations/Hippocratic oath
state sex with patients to be unethical

– Risk of exploitation since meaningful consent

impossible
– less clear about former patients
– less clear about “key third parties”
– AMA estimates 5-10% of MDs have had romantic
contact with patients
• usually starts with nonsexual boundary violations
 Compliance
• Ultimate goal of any MD-patient interaction =
ensuring effective treatment
– Compliance = patient’s record of following MD’s
clinical recommendations

• Poor compliance is major problem

– as many as 50% of patients do not comply
• not related to intelligence, education, gender, or race

– many factors increase compliance

• most important factor = therapeutic alliance (relationship
between patient & clinician)
 Compliance
• Increase compliance
– good therapeutic alliance
• more important than technical
skill
– patient feels ill
– short time in waiting room
– belief that benefits of care
outweigh time & cost
– written diagnosis & instructions
for treatment
– good social support
– older physician
• Decrease compliance
– poor therapeutic alliance
• if MD unapproachable,
compliance decreases
– patient has few symptoms
– long time in waiting room
– Financial & time costs outweigh
benefits of care
– verbal diagnosis & instructions
for treatment
– little social support
– younger physician
 Difficult relationships
• In general, difficult situations

• Rules of thumb when dealing with difficult patients (or

difficult patient questions)
– you have primary responsibility for treating illness; referral
inappropriate unless patient needs care you can’t provide
– you must not let your patient’s emotions interfere with your
judgment
– you must always tell your patient the truth
– you must identify problems that are a barrier to treatment
• includes psychological problems (anger) or social problems (inability
to comply)
 Difficult relationships
• A 50 year-old businessman angrily greets the
doctor in the emergency department by
complaining how long he had to wait before
being seen.
 Difficult relationships
• A 34 year-old female patient behaves in a
seductive manner and asks for the physician’s
home phone number
 Difficult relationships
• A 50 year-old patient who smokes 2 packs of
cigarettes a day comes to your office. After
explaining the health hazards of smoking, you
step out of the room. The patient then steps
outside and begins to smoke.
 Difficult relationships
• A 44 year-old male comes to your office and
complains about both his previous doctor’s
treatment and your new secretary.
 What would you do?
Four months ago, when you prescribed
fluoxetine (Prozac) for a patient, you
explained the major side effects of the
drug. Today at the next appointment, the
patient asks you whether fluoxetine has
any side effects. Your best response is:

C. “Why do you ask?”

 Why?
Saying “why do you ask?” is an open-ended
question that encourages the patient to speak
freely. It is likely that the patient is experiencing
sexual side effects (these are common with
fluoxetine), and is uncomfortable discussing
them.

It is not appropriate simply to repeat a list of side

effects, reassure the patient, or call in the nurse.
You are responsible for identifying psychological
& social aspects of your patient’s care!
 Summary
• Doctor-patient relationship requires
– effective communication
– empathy

• There are different styles for relating to patients

– all must maintain fiduciary relationship
– must think carefully about the ethics of relating
– difficult patients require special treatment
– regardless of style, doctors do not treat patients by themselves
• Must work in partnership with patients
• patients themselves will primarily implement treatment
 Readings
• Read Fadem (BRS) chapter 21