How to establish an effective Doctor Patient Relationship

Dr Sunila

Most physicians before about 1940 were valued almost exclusively for their communication skills. The satisfaction that both doctor & patient feel after an interview is often a reflection of the interpersonal interaction, occasionally the interpersonal interaction is the treatment

The doctor-patient relationship is one of the most unique and privileged relations. The only relation which stands above this is the mother-child bond. The other relationship which can come near it is that between a teacher and disciple. A patient to a doctor is at once a dependent child, an eager student, a friend and a person needing advice, help, sympathy, understanding and hope.

In our own culture, the ancient physician, Charaka, said a physician must be fearless, merciful and tolerant. The physician having such qualities gives life to the patients and cures their diseases”, he said.

The famous physician and teacher, Sir William Osler, who worked in Canada, the USA and Oxford, wanted the doctor not only to give him his best but employ sense of humor, cheer his patients when everything looked bleak and dark. His famous quote, “Not to take the hope away from the patient under any circumstances …eternal hope which comes to us all”, should be remembered by all.

The doctor’s role

1. The doctor needs to pay full attention towards patient’s symptoms, his story and above all his anguish and sufferings.
2. Listening to the patient is very important even if the diagnosis is written on his face.
3. Maintenance of patient’s confidentiality is absolutely essential and should never be breached except in a court of law.
4. Maintaining of a good record is very good both for the doctor and the patient perhaps even more for the doctor. According to Kent without records, you are at sea without compass. With a record, Hahnemann says, “He can then study it in all parts, & draw from it the characteristic marks,” that is you have the nature of the disease continuously in mind.
5. Patient should be offered choice and alternative not in a superficial manner but in a very formal manner so that the patient as the feeling of participation in the decision making.
6. Refer the patient to a colleague in time.
7. Even if something has gone wrong, taking the patient into confidence would help in most of the circumstances.
8. Whereas the patient or the family needs to be informed about the nature of the disease which is not always optimistic or hopeful, but it need not be traumatic. Somebody has said, “The truth may be brutal but the telling of it need not be”.
9. The consent taken for any procedure should not be a mere formality but should be explained to the patient fully in his own language and his own level.
10. Never assure a complete cure.
11. Doctor should not be judgmental about patient’s personal habits or attitudes. 

The patient:

• Should choose his doctor or the hospital carefully and with awareness. Having done this, full trust and faith should be reposed in the doctor.
• Should provide full information about the illness and all the relevant social and family background.
• Should not hesitate to ask as much information as he wants and clarify the instructions without any hesitation.
• Reports in case of any drug reaction or other adverse happening.
• Should ask the doctor for any alternative or choice available. This is his right.
• Avoid shopping around with multiple doctors and alternative systems.
• Avoid believing in heresy, rumors and not readily believe the facts printed in non-professional publications.
• Should differentiate between a complication or mishap and negligence and not blame the doctor for every thing that goes wrong.
• The patient has every right to terminate a relationship with his doctor at any time and seek the help of another. A reciprocal right rests with the doctor. The General Medical Council of Great Britain upholds the right of doctors to refuse to accept individual patients when a satisfactory relationship between the doctor and patient does not exist for want of commitments.

Most of the essential diagnostic information arises from the interview.

The patient centered interview
The patient centered interview consists of five steps.

Set the stage: seek ways to put the patient at ease.

Determine the agenda: ask patients to describe their chief complaint & to list any other issues they want to discuss.

Open the lines of communication: it is important to use active listening skills, such as silence, gestures & neutral or nonverbal encouragement.

According to aphorism 84, we must keep silence and allow them to say all they have to say & refrains from interrupting them unless they wander off to other matters.

Elicit & handle emotions: we need to address their emotions with an empathetic response. Using the mnemonic “NURSE” can really help. 

• Name the emotion
• Understand their feeling
• Respect their sufferings
• Offer them Support and
• Keep an Empathetic approach. 

Move to a doctor- centered interview: at this point, briefly summarize the story the patient has just shared, & indicate that both the style & content of the encounter is about to change. 

What do patients want? 

• Humaneness
• Competency/ Accuracy.
• Patient’s involvement in decisions.
• Time for care. 

Patient wants a doctor who listens & who does not hurry them. Patient satisfaction is increased by a patient-centered approach to consultations.

Core family interviewing skills

• Greet & build rapport: physician should greet & establish a rapport with everyone present.
• Identify each person’s agenda: first, the patient’s agenda should be established, & then the family members should be asked if they have any additional concerns.
• Check each person’s perspective: these additional perspectives may broader the physician’s differential diagnosis including those related to family dynamics.
• Allow each person’s to speak.
• Recognize & acknowledge feelings: emotions expressed by the patient or their family members should be acknowledged & legitimized.
• Avoid taking sides: the physician– patient relationship can be negatively impacted by the physician’s agreement with the family member. In these situations acknowledge the family member’s concern & then listen to the patient’s response to that concern.
•  Respect privacy & maintain confidentiality.
•  Interview the patient separately, if needed.
•  Evaluate an agreement with the plan. 

Establishing rapport 

1. Give your full attention
2. Listen carefully & show interest.
3. Appear encouraging.
4. Make reflective comments.
5. Adopt a warm friendly manner.
6. Establish eye contact.
7. Register appropriate response by facial expression (do not appear bored).
8. Make clarifying comments “so you mean that”…
9. Apologies if interruptions occur. 

Communicating with the patient
History taking is a special form of communication. It is necessarily a two way business, involving two people studying each other.

It is usually possible to start the interview with some non- committal remarks. The discovery of a common town of origin or a mutual interest in hobby may work wonders.

 It is important for the doctor to recognize that there is always a reason for difficult behavior. 

Promoting communication 

• Ensure privacy.
• Respect confidentiality.
• Use words the patient will understand.
• Ensure that patients can hear what you are saying.
• Introduce yourself to the patient.
• Strive to remember the patient’s name.
• Identify the treatments that have been or are being given.
• Do not dominate.
• Admit areas of ignorance.
• Avoid leading questions.
• Non verbal communication: eye contact, gestures, & our postures are all relevant.
• Use of body language: doctors will vary in their abilities to usefully modify their inherent body language. Dress plays a part in non-verbal communication.
• Tries to make items of information simple.
• Explain what tests you want to do & what these entail. 

According to Dr. Rajan Saankaran, author of famous books like Spirit of Homoeopathy, Sensation in Homoeopathy & Sensation Refined etc., in a case taking process the Homoeopathic Physician must be 

• Be empty. 
• Look, Listen and Ask. 
• During case taking 
• Gesture is the key.
• Go with the flow, to the deepest level. Avoid leading questions.
• Stop them moving back but with out imparting any sense of direction. 

While taking a new case we should explain to the patient the different approach in Homoeopathic case taking & the importance of Generals, desires & aversions etc in case taking. 

Finally all the above is useful advice. Dr. Hahnemann in aphorism 224 says that “mental diseases of doubtful origin or resulting from faults of education, bad practices, corrupt morals, neglects of mind etc. will be improved by sensible exhortations & consolatory arguments”.

Case taking in chronic cases requires a great deal of experience & training which cannot be acquired from reading books. A well taken case is a valuable experience for the patient as well, because it becomes an opportunity to consciously examine the most crucial & intimate regions of his or her life.

References:

• The Science of Homoeopathy by George Vithoulkas.
• The Spirit of Homoeopathy by Dr. Rajan Sankaran.
• Organon of Medicine.
• Hutchinson’s Clinical Methods.
• Homoeobuzz Magazine- October& November.
• www.google.com

Dr.Sunila
Medical Officer, Department of Homoeopathy
Govt. of Kerala
Email : babuabau@gmail.com