MEDICAL

ETHICS
AND
LEGAL
MEDICINE
DOCTOR – PATIENT RELATIONSHIP
 DOCTOR – PATIENT RELATIONSHIP

Introduction

 Doctor –Patient relationships express the values of

medical profession
 The relationship should not be the fish & fisherman

 It should be always like fish and water

 The doctor-patient relationship has been defined as “a

consensual relationship in which the patient knowingly

seeks the physician’s assistance and in which the
physician knowingly accepts the person as a patient.”
 ROOTS
 The physician-patient relationship has at least three
roots:
1. A root of social contract relying upon a mutual
perception of profession;
2. A root developing out of the historical tradition of
society and profession; and
3. A personal root which gains its strength from the
specific personality of both physician and patient and
from that unique relationship.
 WHY DOES IT MATTER ?
 The patient-physician relationship is essential for
providing
1. Excellent care
2. To the healing process
3. To improve outcomes
 Therefore, it is important to understand what elements

comprise the relationship and identify those that make

it "good."
 SHOCKING FINDINGS FROM RESEARCH
 During interviews between doctor and patient :
 60% of taped interviews showed interruption in first 20

seconds
 In 50 % of the cases: doctors and patients did not agree

on the key problem

 80% of the cases could not adequately repeat the

prescription
DOCTOR-PATIENT RELATIONSHIP IN THE PAST
 Paternalism
 In former days, patients related to their physicians on a

direct one to-one basis in the context of their home and

relatives. Few other caregivers or institutions were
involved.
 Because physicians in the past were people who have

higher social status

 “doctor” is seen as a sacred occupation which saves

people’s lives
 The advices given by doctors are seen as paramount

mandate
DOCTOR-PATIENT RELATIONSHIP AT PRESENT
 Consumerism and mutuality
 Patients nowadays have higher education and better

economic status
 The concept of patient’s autonomy

 The ability to question doctors

 DUTIES OF A GOOD DOCTOR
 Patients must trust doctors with their life and death. To justify
that the Doctor must show respect for human life:
 Knowledge, skills and performance *
 Make the care of your patient the first concern.
 Provide a good standard of practice and care.
 Safety and quality
 Protect and promote the health of patients.
 Take prompt action for patient safety, dignity.

* Skills all doctors should possess : E.g.

1. Recognize when a patient needs to be transferred to
the ICU.
2. Deliver bad news compassionately, yet honestly.
3. Explain a disease or procedure to patients in plain,
understandable terms.
4. Know when to speak, and when to listen
DUTIES OF A GOOD DOCTOR
 Communication, partnership and teamwork
 Treat patients as individuals and respect their dignity.
 Respect patient’s right to confidentiality.
 Work in partnership with patient
 Work with colleagues in the ways that best serve patient’s
interests
 Maintaining trust
 Be honest and open and act with integrity
 Never discriminate unfairly against patients or colleagues
 Never abuse your patient’s trust
 Being a doctor today is not easy!
 too much work
 too much hassle
 too much competition
 too much despair; and
 too little reimbursement ?
 WHAT MAKES A “GOOD” DOCTOR ?
 Listening
 Interest – concern

 Respect

 Flexibility

 Knowledge

 Subject matter

 General examination

 interview techniques
 Symptomatic reading of the patient

 Relationship reading
Dr. Gregory House (of the show House) has a caustic, callous
bedside manner.
However, this is an extension of his normal personality.
 COMMUNICATION SKILLS
 Communication skills in clinical practice: “Its an
art to talk medicine in the language of a non
medical men”!
 Separates successful doctors from unsuccessful

ones!
 Include ability to engage with patients at

emotional level, to listen, to convey information

with clarity & sympathy
 Polish your bedside manner
 Non-verbal communication – SOFTEN
 S - Smile

 O - Open posture

 F - Forward lean

 T - Touch. This is a privilege – use it !

 E - Eye contact

 N – Nod

Communication
• 7% - Spoken words !
• 38% - Voice quality like Tone, Tempo, intonation !
• 55% - Body language !
FOUR MODELS OF THE PHYSICIAN-PATIENT RELATIONSHIP

1) The paternalistic model

2) The informative model
3) The deliberative model
4) The interpretive model
1) THE PATERNALISTIC MODEL
 Similar relationship as father and child , hence
paternalism
 father overriding decision of child .
 Doctor has the patient's best interest in mind , and

overrides the patient's choice

 may be appropriate in emergencies patient cannot
voices wishes .
 This is in contrast to ethical principle of autonomy .

 much in favour of ethical principle of beneficence .

 allows for uncertain patient to " allow the doctor to
decide what's best "
 Doctor seen as a father figure
2) THE INFORMATIVE MODEL
 Doctor provides patient with facts regarding treatment .
 Patient makes decision based upon these facts provided

, and doctor follows through with the patient's plan.

 informed patient decision .
 Increased patient autonomy , potentially decreased
beneficence .
 patients may not make a decision that is in their best
interest .
 opposite of paternalistic model .
 Concept here is that the doctor is an expert
3) THE DELIBERATIVE MODEL
 Discussion of patient values , by doctor , to clarify and
challenge them
 Doctor tries to challenge patient views and attempt to

guide patient towards values doctor believes is in the

patients best interests .
 Concept here is that the doctor is a friend .
4) THE INTERPRETIVE MODEL
 Doctor discusses patient management , in order to clarify
patients values , and promote patient understanding of
the consequence of their decisions .
 Development of deliberative model , respects patient

autonomy by informing patient rather than manipulating

of their views .

 Doctor is seen as an advisor .

 Patient Autonomy
 Autonomy = freedom to decide !
 Doctors need to :
 1. present the options to the patients and
 2. allow patients to choose for themselves
 Informed choice means patients need

 Educating patients
 Most doctors do not spend much time educating their
patients!
 Primary role of a doctor should not be merely
treating an illness, but helping people remain healthy
 Patients are the practice !
PATIENT EDUCATION
 Key component of informed consent
 Don’t tell the patient what to do

 Present the information and the treatment options – and

allow them to make up their own mind !

 Empower patients with information – they will respect

you for this !

 Information therapy - “ Prescribing the Right Information

to the Right Person at the Right Time” is the best way of

bridging the doctor-patient communication gap today !
 Benefits of patient education :
 Happier patients practice promoter
 Increase patient compliance
 Improve public health
 Overall :Helps to improve empathy
 Reduce risk of complications
 PATIENTS EXPECTATIONS FROM THEIR
DOCTORS ?
 Expertise ( be well-informed and uptodate)!
 Professionalism – look out for the patient’s best
interests!
 Accountability – be answerable; say Sorry ( if there is a
mistake)!
 Transparency – no unnecessary tests and referrals!
 Respect their desires and their time!
 Treat them as intelligent human beings
 Patients’ Expectations
Experience + Needs + Communication = Expectation !

 If Perception exceeds expectations: Satisfaction!

 If Expectations are less than perception: Dissatisfaction!
 Patient Bill of Rights
 Right to access care
 Equal treatment
 Demand information
 Right to choose doctor and institution
 Confidentiality
 Informed consent
 Security
 Religious respect
 Human values
 Access to visitors
 WHAT DO DOCTORS EXPECT FROM THEIR
PATIENTS ?
 Patient’s will :
 Deal with Doctor with respect
 Will say “Thank You” when things go well
 Will have realistic expectations of treatment
 Will not unfairly blame doctor anytime there is a
problem
 Will pay their professional fees promptly and
gracefully
 Many patients, furthermore, are not ill: they see
physicians to have their health evaluated or certified, to
be examined for employment, or to meet a number of
other requirements not directly associated with illness.
 In the last 50 years, the patient-physician relationship

has become complicated beyond imagination.

 And yet, there remains that unavoidably deeply private

relationship still reflecting a slowly evolving traditional

vision, the patient-physician relationship remains
inevitably based on trust, fear, and hope.
 Physicians are capable of acting unprofessionally, but
cannot act unethically, as ethical standards are part of
their profession.
 Therefore, it behooves all patients to educate

themselves on what constitutes “professional” and

“unprofessional” behaviour for those involved in health
care.
 CONSULTATION STYLES
1. Doctor centered
 Paternalistic - doctor is the expert and patient expected
to cooperate
 Tightly controlled interviewing style aimed at reaching
an organic diagnosis.
 Closed questions
 ‘Voice of medicine’- focus on biomedical diagnosis and
treatment as quickly as possible
 CONSULTATION STYLES
2. Patient centered
 Mutuality
 Less authoritarian - encourages patient to their own
feelings and concerns
 Open questions
 ‘Voice of the patient’ - communication of patients beliefs,
feelings & psychosocial context (bio psychosocial)
INFLUENCES ON THE DOCTOR–PATIENT
RELATIONSHIP

I. Influence of time
 Average 6 minutes (average 2-20 min)
 Pressures of time- doctor centered consultation
 However, doctors own style and approach influences more
than the time available.
 Patient centered approach needs more time but overall
reduces the number of return visits and thus the total
consultation time .
II. Patient characteristics and behaviours
 The patient’s ability to exercise and control depends on a
number of factors:
 Age

 Social and educational level

 Sex

 Different languages

III. Influence of structural context

 Hospital situation/ Ward
 Fee-for service
 BARRIERS IN COMMUNICATION

A. Doctor’s barrier to effective communication

Lack of specific knowledge
Lack of counseling skills
Lack of time
Lack of appropriate resources
B. Patient’s barrier to effective communication
Sex
Social and educational level
Different languages
Membership of an ethnic minority
 PROOF OF NEGLIGENCE
 The essentials of negligence are four "D"s:

 1. There was a Duty towards patients

 2. There was Deficiency in duty

 3. This Directly resulted in the problem

 4. Damage which may be physical, mental or

financial loss to patient or relatives