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Flashcards in The Physician-Patient Relationship Deck (55):
1

Only about ...?

1/3 of Americans with symptoms seek medical care.
--> Most contend with illnesses at home with OTC medications and home management.

2

Medical practice - Seeking psychiatric care:

1. In the USA, there is a STIGMA to having a psychiatric illness.
2. Psychiatric symptoms are considered by many Americans to indicate a MORAL WEAKNESS or a LACK OF SELF-CONTROL.
3. Because of this stigma, many patients fail to seek help.

3

Why is it important for patients to seek psychiatric care?

Since there is a strong correlation between psychological illness and physical illness.
--> Morbidity rates and mortality rates are much higher in patients who need psychiatric attention.

4

The "sick role"?

A person assumes a particular role in society and certain behavioral patterns when he or she is ill (the "sick role", described by T.Parsons).

5

The sick role includes ...?

Exemption from usual responsibilities and expectation of care by others, as well as working toward becoming healthy and cooperating with health care personell in getting well.

6

Critics of the sick role argue that ...?

1. It applies ONLY TO MIDDLE-CLASS patients with ACUTE physical illness.
2. Emphasizes the power of the physician.
3. Undervalues the individual's social support network in getting well.

7

Telling patients the truth:

In the USA, adult patients generally are TOLD THE COMPLETE TRUTH about the diagnosis, the management and its side effects, and the prognosis of their illness.
--> Falsely reassuring or patronizing statements in response to patients questions (eg "Do not worry, we will take care of you" or "You still have one child" [after miscarriage]) are NOT APPROPRIATE.

8

Telling patients the truth - Information about the illness must be given ...?

DIRECTLY to the adult patient and NOT relayed to the patient through relatives.
--> Patients decide if, how, and when such information will be given to an ill child.

9

Patient personality style and behavioral characteristics during illness - Paranoid:

Blames the physician for the fact that he or she is ill.

10

Patient personality style and behavioral characteristics during illness - Schizoid:

Becomes even more withdrawn during illness.

11

Patient personality style and behavioral characteristics during illness - Schizotypal:

Bizzare behavior may mask serious illness.

12

Patient personality style and behavioral characteristics during illness - Histrionic:

May be dramatic, emotionally changeable, and approach the physician in an inappapropriate sexual fashion during illness.

13

Patient personality style and behavioral characteristics during illness - Narcissistic:

Has a perfect self-image, which is threatened by illness and may refuse needed treatment which can alter his or her appearance.

14

Patient personality style and behavioral characteristics during illness - Antisocial:

May self-write or alter prescriptions and lie to the physician.

15

Patient personality style and behavioral characteristics during illness - Borderline:

Idealizes the physician at first, may make gestures of self-harm when ill.

16

Patient personality style and behavioral characteristics during illness - Avoidant:

Interprets physician health suggestions as criticisms, fears rejection by doctor, is overly sensitive to a perceived lack of attention or caring.

17

Patient personality style and behavioral characteristics during illness - Obsessive-Compulsive:

Fears loss of control and may in turn become more controlling during illness.

18

Patient personality style and behavioral characteristics during illness - Dependent:

Becomes more needy during illness and wants the physician to make all decisions and assume all responsibility.

19

Patient personality style and behavioral characteristics during illness - Passive-Aggressive:

Asks for help but then does not adhere to the physician's advice.

20

Adherence - Patients characteristics associated with adherence - Adherence refers to ...?

The extent to which a patient follows the recommendations of the physician, such as taking medications on schedule, having a needed medical test or surgical procedure, and following directions for changes in lifestyle, such as diet or exercise.

21

What may decrease or increase adherence?

Patients' UNCONSCIOUS transference reactions to their physicians, which are based in childhood parent-child relationships, can increase or decrease adherence.

22

Only about ... of patients adhere fully to management recommendations.

1/3 --> FULLY.
1/3 --> Some.
1/3 --> NOT.

23

Factors that decrease or increase adherence?

1. NOT related to patient intelligence, education, sex, religion, race, socioeconomic status, or marital status.
2. Adherence is most closely related to HOW WELL THE PATIENT LIKES THE DOCTOR.

24

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Angry patient - DO:

Acknowledge the patient's anger.

25

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Angry patient - DO NOT:

Take the patient's anger personally (the patient is probably fearful about becoming dependent as well as of being ill).

26

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Complaining patient: About another doctor - DO:

Encourage the patient to speak to the other physician directly if the patient complains about a relationship with another physician.

27

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Complaining patient: About another doctor - DO NOT:

Intervene in the patient's relationship with another physician unless there is a medical reason to do so.

28

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Complaining patient: About you or your staff - DO:

Speak to your own office staff if the patient has a complaint about one of them.

29

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Complaining patient: About you or your staff - DO NOT:

Blame the patient for problems with you or your office staff.

30

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Crying patient - DO:

Acknowledge the patient's sadness and quietly wait for the patient to speak.

31

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Crying patient - DO NOT:

1. Rush the patient or use patronizing statements such as "do not worry" to comfort the patient.
2. Say "I understand". The patient makes that judgement.

32

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Nonadherent patient: Needs to improve health behavior - DO:

Examine the patient's willingness to change his or her health-threatening behavior (eg smoking); if he or she is not willing, you must address that issue first.

33

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Nonadherent patient: Needs to improve health behavior - DO NOT:

Attempt to scare the patient into adhering (eg showing frightening photographs of untreated illness).

34

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Nonadherent patient: Needs a test or treatment (eg mammogram) - DO:

Identify the real reason (eg fear) for the patient's refusal to adhere to or to consent to a needed intervention and address it.

35

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Nonadherent patient: Needs a test or treatment (eg mammogram) - DO NOT:

Refer the patient to another physician.

36

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Seductive patient - DO:

1. Call in a chaperone when you are with the patient.
2. Do gather information using direct rather than open-ended questions.
3. Do set limits on the behavior that you will tolerate.

37

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Seductive patient - DO NOT:

1. Refuse to see the patient.
2. Refer the patient to another physician.
3. Fail to act if the patient crosses a social boundary.

38

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Suicidal patient - DO:

1. Assess the seriousness of the threat.
2. Suggest that the patient remain in the hospital voluntarily if the threat is serious.

39

Do's and Do Not's for answering USMLE questions involving common problems in the physician-patient relationship - Suicide patient - DO NOT:

1. Assume that the threat is not serious.
2. Release a hospitalized patient who is a threat to himself or herself (patients who are a threat to self or others can be held involuntarily).

40

The clinical interview - Communication skills - What is improved by good physician-patient communication?

1. Patient adherence with medical advice.
2. Detection of both physical and psychological problems.
3. Patient satisfaction with the physician.

41

One of the most important skills for a physician to have is ...?

HOW TO INTERVIEW PATIENTS.

42

The physician setting for the interview should be ...?

1. As private as possible.
2. There should be no desk or other obstacle between the physician and patient.
3. The participants should interact at EYE LEVEL (eg both seated).

43

During the interview, the physician must first ...?

Establish TRUST IN and RAPPORT WITH the patient and then gather physical, psychological, and social information to identify the patient's problem.

44

Finally the physician should try to ...?

EDUCATE the patient about the illness and MOTIVATE the patient to adhere to management recommendations.

45

When interviewing young children the physician should:

1. First establish rapport by interacting with the child in a nonmedical way, for example, drawing pictures.
2. Use direct rather than open-ended questions, for example, "What is your sister's name?" rather than "Tell me about your family."
3. Ask questions in the third person, for example, "Why do you think that the little boy in this picture is sad?"

46

Specific interviewing techniques - Direct questions:

Used to elicit specific information quickly from a patient in an emergency situation (eg "Have you been shot?") or when the patient is seductive and overly talkative.

47

Specific interviewing techniques - Open-ended questions:

1. Although direct questions can elicit information quickly, open-ended types of questions are more likely to aid in obtaining information about the patient, and not close off potential areas of pertinent information.
2. Using open-ended questions (eg "What brings you in today?"), the interviewer gives little structure to the patient and ENCOURAGES THE PATIENT TO SPEAK FREELY.

48

Factors associateed with adherence to medical advice - Increased adherence (10):

1. Good physician-patient relationship.
2. Patient feels ill and usual activities are disrupted by the illness.
3. Short time spent in the waiting room.
4. Belief tha the benefits of care outweigh its financial and time costs.
5. Written diagnosis and instructions for management.
6. Acute illness.
7. Recommending only one behavioral change at a time.
8. Simple management schedule.
9. Older physician.
10. Peer support.

49

Factors associateed with adherence to medical advice - Decreased adherence (10):

1. Poor physician-patient relationship.
2. Patient experiences few symptoms and little disruption of usual activities.
3. Long time spent in the waiting room.
4. Belief that financial and time costs of care outweigh its benefits.
5. Verbal diagnosis and instructions for management.
6. Chronic illness.
7. Recommending multiple behavioral changes at once.
8. Complex management schedule.
9. Younger physician.
10. Little peer support.

50

Most important factor in adherence?

Liking the physician - Even more important than the physician's technical skill.

51

Aims of the clinical interview and specific interviewing techniques - 3 AIMS:

1. To establish rapport.
2. To maximize information gathering.
3. To clarify information.

52

Technique to establish rapport:

1. Support and empathy.
2. Validation - To give value and credence to the patient's feelings.

53

Technique to maximize information gathering?

1. Facilitation.
2. Reflection.
3. Silence.

54

Technique to clarify information:

1. Confrontation.
2. Recapitulation.

55

Medical practice - Seeking medical care:

Patients' behavior when ill and their expectations of physicianss are influenced by their:
1. Culture.
2. Previous experiences with medical care.
3. Physical and mental conditions.
4. Personality styles (not necessarily personality disorders).
5. Coping skills.