Building a Doctor Patient's Partnership

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Building a Doctor Patient's Partnership

• Jaime Correia de Sousa, MD, MPH
• Horizonte Family Health Unit
• Matosinhos Health Centre
• Porto, Portugal

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Sir Luke Fildes, Tate Gallery, London
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Learning objectives

• By the end of the session, participants should
• Be aware of the different cultural patterns of
  access to health care
• Understand why patients decide to seek help or
  advice
• Know the main reasons for consulting a doctor
• Be familiar with patient's explanations about
  health and diseases
• Know the main consultation models used in family
  practice
• Be able to build an effective Doctor Patient's
  Partnership

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Summary

• Deciding to seek help or advice
• Deciding to see a doctor
• Cultural patterns of access to health care
• Reasons for consulting a doctor
• Patient's explanations about health and diseases
• Consultation length and consultation outcomes
• Building Doctor Patient's Partnership
• Consultation Models
• Some pitfalls in Patient-Physician Relationship

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Deciding to see a doctor
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Deciding to seek help or advice
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Cultural patterns of access to health care

• The three sectors of health care
• The popular sector
• The folk sector
• The professional sector

Kleinman (1980)
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Reasons for consulting a doctor
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In an average month
New Ecology of Medical Care - 2000
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Reasons for consulting (or not consulting) a
doctor

• Factors that influence the decision to consult
• The availability of medical care
• Whether the patient can afford it
• The failure or success of treatments within the
  popular or folk sectors
• How the patient perceives the problem
• How others around him or her perceive the problem

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Reasons for encounter (RFE) international study
Lamberts, Wood, Hoffmans-Okkes, 1993
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Patient's explanations about health and diseases
The explanatory model
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The explanatory model

• Illness the patients perspective
• Disease the doctors perspective
• Questions to be answered

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Patients expectations of consultations

• Different phrasing is required to ask questions
  about patients expectations examples
• What are you concerned that it might be?
• What were you hoping we might be able to do for
  this?
• What do you think might be the best plan of
  action?
• How might I best help you with this?
• Youve obviously given this some thought, what
  were you thinking would be the best way of
  tackling this?

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The purpose of the general practice consultation

• The term is suggested to denote what patients
  have on their mind when waiting to see the doctor
• Purposes of an actual consultation
• Several consultation purposes exist
• Wishes, what is perceived by the patient as
  desirable
• The focus is directed towards the patient's
  wishes prior to a consultation
• Emphasis on the specific processes and outcomes.

Thorsen, Witt, Hollnagel, Malterud, 2001
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Consultation length and consultation outcomes
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Length of consultation with general practitioner
Deveugele, Derese, van den BrinkMuinen, Bensing,
De Maeseneer. BMJ. 2002 August 31 325 (7362) 472
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Consultation length in general practice

• Patients are satisfied with care from general
  practice but often say that consultations are too
  short
• Consultation length varies from country to
  country
• Important factors for consultation length are
  list size, characteristics of doctors and
  patients, and character of the problem.
• Characteristics of patients have as much effect
  on consultation length as the characteristics of
  countries and doctors combined

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Consultation length in general practice

• Longer consultations are associated with a range
  of better patient outcomes
• Modern consultations in general practice deal
  with patients with more serious and chronic
  conditions.
• Increasing patient participation means more
  complex interaction, which demands extra time.
• Difficulties with access and with loss of
  continuity lead to further pressure on time.
• Longer consultations should be a professional
  priority, with increased use of technology and
  more flexible practice management to maximise
  interpersonal continuity.

Freeman, Horder, Shah, Howie, 2002
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Building Doctor Patient's Partnership
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Building Doctor Patient's Partnership

• Consultation Models
• Pendleton - Doctor's Tasks
• Levenstein - Patient-Centred Model
• MacWhinney - Disease-Illness Model
• Neighbour The inner consultation

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Pendletons Doctor's Tasks

• Define the reason for the patient's attendance
• Consider other problems
• Together choose an appropriate action for each
  problem
• Achieve a shared understanding of problems
• Involve the patient in the management of problems
  and encourage acceptance of appropriate
  responsibility
• Use time and resources appropriately
• Establish and maintain a relationship with the
  patient which helps to achieve the other tasks

Pendleton (1984)
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Patient-Centred Model

• 1. Exploring both the disease and the illness
  experience
• 2. Understanding the whole person
• 3. Finding common ground regarding management
• 4. Incorporating prevention and health promotion
• 5. Enhancing the Doctor-Patient relationship
• 6. Being realistic

Levenstein (1984)
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Patient-Centred Model
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Building a Partnership
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Building a Partnership

• Doctorpatient partnerships in making decisions
  about treatment can take different forms
• Three theoretical treatment decision making
  models are the paternalistic, the shared, and the
  informed
• Most clinical consultations use elements of these
  theoretical models, and these may change as the
  interaction unfolds
• Doctors need to be aware of and be able to
  identify and explain the treatment options
  available
• If doctorpatient partnerships are to be promoted
  in clinical practice, current disincentives such
  as time and funding constraints will need to be
  restructured

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Building a Partnership
Charles, Whelan, Gafni (1999)
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Stages and competencies of involving patients in
healthcare decisions

• Implicit or explicit involvement of patients in
  decision-making process
• Explore ideas, fears, and expectations of the
  problem and possible treatments
• Portrayal of options
• Identify preferred format and provide tailor made
  information

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Stages and competencies of involving patients in
healthcare decisions

• Checking process understanding of information
  and reactionsfor example, ideas, fears, and
  expectations of possible options
• Acceptance of process and preferred role in
  decision-making
• Make, discuss, or defer decisions
• Arrange follow up

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Some pitfalls in Patient-Physician Relationship
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Some pitfalls in Patient-Physician Relationship

• Boundaries to the Patient-Physician Relationship
• Gifts From Patients
• Patients we dont like
• Dealing with Celebrity Patients and VIPs
• Use of Chaperones During Physical Exams

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