IzBen C. Williams, MD, MPH Lecturer

BEHAVIORAL SCIENCE

IzBen C. Williams, MD, MPHLecturer

Lecture # 17

THE PHYSICIAN-PATIENT

RELATIONSHIP

What is?I. INTRODUCTION

A. The physician-patient relationship is the matrix within which medical care is maintained and delivered. It is a dyadic interaction wherein both the physician and the patient have roles and responsibilities.

The most important factors for this dyadic structure are the psychological substrates that bond patient to healer.

Physician’s Responsibilities

I. INTRODUCTIONThe physician-patient relationship transcends the traditional “bedside manner,” which is the physician’s personal style and only one part of the relationship.The physician’s responsibilities are to: a. Diagnose acute and chronic illnessb. Cure disease whenever possiblec. Maximize patient’s function and minimize pain d. Provide solace and palliative treatment in terminal

cases

.I. INTRODUCTION

B. The physician provides emotional support and legitimizes illness; both functions contribute significantly to the effectiveness of active treatment or, conversely in a poor relationship, significantly compromises the effectiveness of treatment. The relationship is an important mediator of the therapeutic effect of every treatment program.

II – Patient’s Responsibilities (the sick role)

A. SOCIETAL EXPECTATIONS (Ground Rules): Society assigns a specific role to the ill person by virtue of his being ill. Sociologist Talcott Parsons ascribes four key aspects to the sick role

1. The sick person is exempt from normal social-role responsibility (this ‘right’ must be legitimized)

2. The sick person is not to be blamed for his illness3. The sick person is obliged to want to get well4. The sick person is obliged to seek technical

competent help

II - The Sick RoleB. PERFORMANCE OF THE SICK ROLE: How

an individual actually behaves when he becomes sick is influenced by several factors.

1. Economica. Individuals who are financially hard pressed b. Individuals who are injured on the job

(malingering)c. Students and those individuals embarking

upon careers (interruption of career objectives)

II - The Sick RoleB. PERFORMANCE OF THE SICK ROLE:

2. Personal experiences. Exposure to individuals who have benefitted from being sick may influence an individual to seek at opportune time the exemption and secondary gains inherent in the sick role

3. Society’s view of a particular illness may affect an individual’s motivation in assuming the sick role. He may be reluctant to do so because stigmatized illnesses such as STDs, mental disorders, and drug addiction have stigmatic connotations


4. Implications of seeking psychiatric care: In the US there is a stigma to having a psychiatric illness.

Psychiatric symptoms are considered by many Americans to indicate a moral weakness or lack of self control. Because of this stigma, many patients fail to seek help

However, there is a strong correlation between psychological illness and physical illness; hence the importance of seeking psychiatric care early must be emphasized. Morbidity rates and mortality rates are much higher in patients who need psychiatric attention.


5. Psychological factors.a. The personality types, (habitual pattern of

thought, behavior, and feelings) of individuals are loosely defined categories that are useful in the context of medical care for understanding the very important influence of personality on the perception and performance of the sick role. There are some eight types usually encountered in regard to the sick role (see table in; Chap. 21)


5. Psychological factors.b. The personal meaning of illness is a second

category of psychological factors that may influence the behavior of the patient. Feeling constrained and threatened by his disorder, especially when it is serious or chronic, and markedly affected by his personality type, the sick individual typically searches for a personal meaning for the illness. He may view or interpret his illness as:

5b cont’d………


5. Psychological factors. The personal meaning of illness:

i. A challenge to be met or an obstacle to overcomeii. Evidence of an inherent weaknessiii. An enemy threatening to destroy himiv. A punishment for past transgressions (often sexual)v. A strategy to cope with life’s demandsvi. A relief or reprieve from social responsibilitiesvii. An overwhelming irreplaceable loss or irreparable

damageviii. A positive experience bringing meaning to life, …etc.


5. Psychological factors.c. The method of coping with illness reflects both

the personality type of the patient and his personal interpretation of the illness. It encompasses the individual’s characteristic ways of perceiving, thinking, problem-solving, and acting when ill. There may be:

Cognitive responses (processes of perception, memory, judgment, and reasoning)

Behavioral responses


5. Psychological factors./ Cognitive responses to illness a) Minimization: the tendency to ignore, deny, or

rationalize the personal significance of one’s illness. It includes delusional denial, the selective misrepresentation of facts, as well as reasonable doubting

b) Vigilant focusing: a brisk response to perceived danger signals and an ongoing effort to reduce ambiguity and uncertainty about all aspects of the illness. It encompasses hyper-vigilance, exaggeration of all threats to bodily integrity, delusional gathering and arranging of pieces of medical information, anxious rumination as well as rational planning based on the realistic recognition of the bodily threats and changes in lifestyle that are inherent in the disease


5. Psychological factors./ Behavioral responses to illness

a) Tackling: An active attitude toward the challenges and tasks posed by the illness or disability

b) Capitulation: characterized by passivity and either withdrawal from or dependent clinging to others in times of illness.

c) Avoidance: pertains to active attempts to escape from the exigencies of the illness (“flights into health”). It is typically associated with marked minimization or denial of the illness. Social interactions with others generally remain unchanged

II - The Sick Role C. EXCEPTIONS TO THE SICK ROLE:

1. Incurable illnesses necessitate adjustment and adaptation rather than motivation to get well

2. Minor illnesses by definition necessitate neither exemption from normal social roles nor contact with a physician

3. Legitimate sick roles, such as some physical handicaps, do not necessitate exemption from usual responsibilities, continuing attention by a physician, or a motivation to recover.

III - The Role of the PhysicianA. SOCIETAL EXPECTATIONS: Five key

aspects of the physician’s role. 1. Technical competence. Up-to-date 2. Medical role “universalism”: 3. Functional specificity: within specialty,

hippocratic 4. Affective neutrality: objectivity, equity

without favor, 5. Collective orientation: subordinate personal

gains to patient welfare

III - The Role of the PhysicianB. PATIENT EXPECTATIONS: in addition to the

preceding five factors the patient has specific clinical expectations of the physician.

1. Relief from distress. Regardless of underlying disease, the patient requires and expects relief from symptoms

2. An unhurried setting and atmosphere in which the patient can tell his story, is to be created by the physician. He wishes also to be informed about findings, diagnosis, treatment options, and any other questions

3. Expects the physician to “always be my doctor”

III - The Role of the Physician

C. PHYSICIAN EXPECTATIONS: Every physician seems to have vague but firm ideas concerning the behavior expected of a patient. This belief system is powerful and influences practically every detail of the physician’s interaction with his patients.

III - The Role of the PhysicianC. PHYSICIAN EXPECTATIONS:

1. A patient is perceived as ‘good’ when he:a. Is seen to be suffering legitimately from his

symptoms rather than presenting with a minor or trivial complaint

b. Presents with objective signs and symptoms of a treatable disease process

c. Cooperates in the treatment process d. Does not make any emotional demands on the

physiciane. Displays gratitude for the physicians efforts

III - The Role of the Physician

C. PHYSICIAN EXPECTATIONS: 2. Blaming the patient is typical when these

five conditions are not fulfilled, and problems develop, even though such problems may stem from the physician’s:

a. Failure to communicate effectively his expectations of the patient, and his attitudes about how he practices medicine

b. Deficiency in technical skills, knowledge or judgment

IV - The Clinical InterviewA. COMMUNICATION SKILLS:

1. All aspects of the physician-patient relationship are improved by good communication

2. One of the most important skills for a physician to have is how to interview patientsa. The physical setting for the interview should be as

private as possible, with no desk or other obstacle between physician and patient, and eye-level seating

b. First, establish trust in the rapport with the patient then, and only then, gather bio-psycho-social information.

cont’d…………

IV - The Clinical InterviewA. COMMUNICATION SKILLS:

2. … how to interview patientsc. The physician should obtain backup (eg.

Hospital security) as soon as it appears that a patient is dangerous or threatening

3. The interview serves to obtain the patient’s psychiatry history including information about prior mental problems, drug and alcohol use, sexual history, current living situations and sources of stress

IV - The Clinical InterviewA. SPECIFIC INTERVIEWING TECHNIQUES:

1. Direct questions are used to elicit specific information quickly from a patient in an emergency situation or when the patient is seductive or overly talkative (as in mania)

2. Open-ended questions are more likely to elicit useful information about the

patient and not close off potential areas of pertinent information

The open-ended question (eg.”What brings you to see me today?”) encourages the patient to speak freely

V – Compliance / Adherence A. Compliance and adherence refers to the

extent to which a patient follows the instructions of the physician, such as:

Taking medication on schedule Having a needed medical test or surgical

procedure Following instructions for change in

lifestyle, such as diet or exercise

V – Compliance / Adherence Compliance is not related to patient’s intelligence,

education, gender, race, religion, socioeconomic status or marital status.

About one-third of patients comply fully with treatment, one-third some of the time, and one-third do not comply.

Patients’ unconscious transference reactions to their physicians, which are based on childhood parent-child relationships, can increase or decrease compliance (see Table 21-3 in Fadem).

VI – Stresses on the Physician-Patient Relationship

A. “DIFFICULT” PATIENTS:

Typically, it is the patient who is identified as difficult when problems arise in the physician-patient relationship [ie. When the patient does not meet the physician’s expectations]. Although individuals of particular personality types can become, in extreme cases, difficult patients, it is useful to be guided by a categorization which takes into account all personality types



1. Covertly self-destructive patients (eg. Those with emphysema who continue to smoke; those with liver damage who continue to drink)

2. Uncooperative patients; often labeled as such by physicians with high priorities of control, omnipotence and omniscience when they:

1. Question treatment2. Refuse procedures, tests and treatments3. Demand that the hospital make concessions to their needs4. Request a second opinion5. Do not get well (such failure being viewed by the overly sensitive

physician as ‘lack of cooperation)



3. Somatizing patientsa. These patients have long-standing, recurrent physical

complaints in the absence of any significant, underlying physical disease or physiologic abnormalities. Their symptoms spring from psychological problems and are psychologically adaptive efforts to deal with:

Intrapsychic conflict (eg. alleviation of guilt through suffering) Problematic interpersonal relationships (eg. refusal of

sexual relations because of recurrent headache) Social and environmental problems



3. Somatizing patientsb. These patients are often perceived by the physician as

“not playing by the rules” (imaginative feigning). This perception may lead to physician frustration, annoyance, anger, and to (covert) wish that patient seeks help elsewhere

c. Somatizing patients are generally seeking a relationship with the physician, a relationship they are not getting from significant others



3. Somatizing patientsd. These patients generally fall into one of the following

diagnostic categoriesi. Somatization disorder (extends over many years)ii. Conversion disorder (sudden conversion)iii. Psychogenic pain disorder (chronic c/o unrelenting pain)iv. Hypochondriasis (fearful preoccupation with having xyz)v. Atypical somatoform disorder (delusion belief of illness) vi. Factitious disorder (faking symptoms)vii. Malingering (understandable deception)



4. Pts. with chronic cognitive impairment (COBS)a. These patients generally have significant chronic

dysfunction of one or more of their cognitive abilities (memory, calculation, attention, abstraction, judgment, concentration, and orientation) as a result of irreversible brain damage from various causes (eg. Alzheimer’s disease, cerebral anoxia, and alcohol abuse)

b. They often demonstrate “sun-downing”: the worsening of confusion and agitation toward evening and at night, apparently resulting from decrease in sensory input and orienting cues



4. Pts. with chronic cognitive impairment (COBS)c. They often are perceived as uncooperative and

negativistic by physicians who fail to perform a careful mental status examination and therefore do not diagnose milder form of this syndrome.

d. Patients may be derogated or judged infantile by physicians who, having diagnosed the syndrome, perceive them to be much more helpless, insensitive, uncomprehending, and untreatable than they actually are



5. Physicians as Patients introduce even more complexity and stress into the physician-patient relationship as a result of the following issues:

a. Physician patients usually choose a physician with whom they are comfortable or with whom they do not fear loss of “equality” in the relationship, rather than the most competent individual

b. The custom of professional courtesy may cause the physician patient to think that he may be exploiting his non-billing colleague and thus feel reluctant to ask for more time and visit



5. Physicians as Patients introduce even more complexity ……..

c. The treating physician who is reluctant to treat the colleague as a patient may expect him to write his own history, understand with little or no explanation the reasons for tests and procedures, and manage his own medications

d. The treating physician may fear criticism of his knowledge, skills, and judgment by his patient and thus feel anxious and ambivalent about taking care of him


B. DIFFICULT CLINICAL ISSUES:

1. Pain. The development of rapport and trust between a patient in pain and the physician may be seriously undermined or impeded as a result of the following:

a. The physician may have exaggerated and unwarranted concerns about turning his patient into a drug addict. The resultant under-prescribing of narcotic analgesics leads to unnecessary suffering and anxiety in the patient who suppresses his resentment but engages in more pain behavior to get more analgesic, thereby causing more discomfort in the physician



2. Dying: Helping the dying patient to accommodate psychologically to impending death and avoiding the twin dangers of saccharine reassurance and brutal confrontation are challenges made more difficult by physicians who equate dying with professional failure and a threat to their omnipotence. The relationship of such physicians with their dying patients often deteriorate as a result of the following:



2. Dying: The relationship …. often deteriorate as a result of the following:

a. The physician usually avoids the patient because he feels that he can no longer do anything for him (and “just” being with the patient does not count).

b. The physician may be uncomfortable about openly and fully informing the patient of his status, even though the patient may strongly suspect it and often wishes to know. This discomfort may be projected onto the patient. Without the physician’s initiative in fostering honest communication, meaningful discussions and critical decisions requiring the patient’s participation will be left unattended (eg. resusci…)



3. Informed consent: refers to the patient’s right to choose among several treatment options or diagnostic procedures for his disorder on the basis of a thorough understanding of the potential benefits and risks. (It includes, of course, the right to refuse all treatment).

a. For many physicians who are committed to a paternalistic model of relationship, informed consent is typically perceived as an affront to their authority and competence. The patient’s request is experienced as distrust, which may elicit disappointment, irritation, anger, or explicit threats to transfer to the care of another physician



3. Informed consent: refers to the patient’s right to choose …. (It includes, of course, the right to refuse all treatment).

b. Patients show a wide variation in the extent to which they want to be informed. However, mutual trust and rapport are enhanced when pts are invited to participate actively and maturely in such decision making unless there is clear evidence of psychological regression.

c. If the physician values knowing the person as highly as he values understanding the disease, he will come to know about his patient’s capacity and wishes with regard to issues of informed consent



4. Sexuality. Many physicians seem to feel more at ease doing pelvic and rectal examinations (and other discomforting procedures) than asking patients about sexual functioning. (this may be related to their own anxieties about some aspect of sexuality). The omission of this aspect of history-taking, and frank discussion often:

a. Leaves important diagnostic data undisclosedb. Communicates to the patient the physician’s discomfort, thus

inhibiting the development of optimal trust and candorc. Generalizes; thereby inhibiting discussion on other sensitive

issues lest the physician manifest discomfort also


C. TRANSFERENCE & COUNTERTRANSFERENCE:

1. Transference to the individual’s unconscious tendency to project unto someone in the present feelings and attitudes originally linked to important people in the patient’s early life (eg., parents and siblings). When intense, it introduces distortions that interfere with the capacity to relate to others. In medical settings, transference may interfere with the development of an effective, working alliance between the physician and the patient



Transferencea. Patients may reactivate an infantile need for a non-demanding,

gratifying, omnipotent parent in the relationship with their physician. When these unrealistic expectations are not met, the relationship suffers

b. Transference may manifest repressed, negative feelings through counterproductive action (eg. Noncompliant behavior)

c. Negative transference reactions may elicit from physicians inappropriately angry responses. Inappropriately personal or erotic responses may be elicited also to some positive transference reactions



Countertransference refers to an analogous phenomenon in physicians. The physician’s misperceptions of and inappropriate behavior toward patients, which stem from unconsciously determined emotional responses, can undermine the physician patient relationship as readily as a patient’s strong transference reaction

VII – Models of the Physician-Patient Relationship

The four models described have their prototype in the developmental stages of the relationship between parents and children.A. ACTIVITY-PASSIVITY MODELB. GUIDANCE-COOPERATION MODELC. MUTUAL PARTICIPATION MODEL D. SOCIAL INTIMACY MODEL (no clinical

use)


For each model there are the following descriptive parameters:

Task definitionsRoles and role images,Tacit understandings and behavior codes,Gratifications and Clinical applicationsThe social intimacy model represents a developmental dysfunction in the physician and is therefore not applicable in clinical practice


A. ACTIVITY-PASSIVITY MODEL. The oldest conceptual model is based on one person’s influencing another in such a way and under such conditions that the individual acted upon is unable to contribute actively or is considered to be inanimate

Clinical applications: This type of relationship is required when the patient is delirious, comatose, immobilized by acute trauma, or anesthetized


B. GUIDANCE-COOPERATION MODEL. Underlying most of current medical practice, this model continues to emphasize the dominant and controlling role of the physician. The prototype is that of the parent-child (adolescent) relationship

Clinical applications: This most commonly used model is employed in situations that are less desperate than those mentioned in the activity-passivity model; for example, it may be employed when the patient has an acute infection or is convalescing from surgery


C. MUTUAL PARTICIPATION MODEL. This model is based on the belief that equality among human beings is desirable. Its prototype is the relationship between two adults interacting (transacting) for professional or business purposes

Clinical applications: This model is well suited for the management of chronic diseases such as diabetes, or multiple sclerosis, where, over time, the patient may learn as much about the disease as the physician


D. SOCIAL INTIMACY MODEL. While this model is also based on the desirability of equality among individuals, its prototype is the relationship between two close friends

Clinical applications: In view of its contravention of societies’ expectations of the physician of functional specificity and affective neutrality, this model clearly reflects stepping over the bounds, and it is not only not functional but in many cases is not ethical. It represents a developmental dysfunction in the physician and is not applicable in clinical practice

IzBen C. Williams, MD, MPH Lecturer

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