Doctor-Patient Relationship and Initial Patient Interview

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Doctor-Patient Relationship and Initial Patient
Interview

• Michael Blumenfield, M.D.
• Professor of Psychiatry - NYMC
• Director of Medical Student Education in
  Psychiatry
• Director of C/L Psychiatry - Westchester Medical
  Center

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...Some patients, though conscious that their
condition is perilous, recover their health
simply through their contentment with the
goodness of the physician. Hippocrates Precepts,
Chapter I
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Placebo Effect

• Placebo Effect is a combination of a
  psychological expectation blended with a
  neurochemical response that transforms an
  anticipated effect into a real effect

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Placebo Effect

• The Placebo Effect can positively or negatively
  effect pain, swelling, GI, CV, GU responses,
  mental state and side effects of treatment

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Placebo Response

• At least 20-30 of patients have been shown to
  respond to treatment with placebo
• Placebo pain response can be blocked by naloxone
  which suggests it is mediated by the endogenous
  opioid system

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Transference

• Expectation, beliefs and emotional responses that
  the patient brings to the doctor-patient
  relationship based on important relationships in
  the patients past

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Positive Transference

• Patient views doctor as good and has confidence
  in his or her ability
• Can lead to over idealization and tremendous
  disappointment when doctor cant solve all
  problems or is not always available

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Positive Transference

• Idealization of the the doctor can lead to having
  sexual feelings toward the doctor

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Negative Transference

• Patient views doctor as harsh punitive parent or
  authoritative figure who doesnt care about well
  being and patient may be non-compliant

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Negative Transference

• Patient with experience with untrustworthy parent
  may seek many consultations and may be
  provocative to doctors

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Countertransference

• Refers to doctors reaction towards patient based
  on their own earlier experience

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Countertransference

• Doctors can feel guilty when they are unable to
  help patient
• Doctor may have feelings towards patient who
  remind them of close relative or friend
• Doctor may minimize the severity of another
  physicians illness

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Models of Doctor Patient Relationship
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Doctor-Patient RelationshipAlternative Models
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Empathy

• The ability to momentarily experience the the
  feelings of another person ( put yourself in
  another persons place)

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Empathy -Components

• Transiently experience feelings of the patient
  and use those feelings to gain understanding of
  the the patients subjective experience
• Communication of that understanding to the
  patient

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Empathy-Techniques of Learning

• Intuitive - Reflect on emotions when with patient
• Cognitive - Ask self how would I feel in
  patients situation
• Cognitive- Relate to similar situation in own
  life ( ie. threat to you or a parent)

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Empathy- Examples of empathic responses

• You seem understandably upset with how things are
  going
• It must have been very painful after the injury
  until you received pain medication
• I am sorry (when learning of death of family
  member or friend of patient)

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Clinical Interview
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Clinical Interview

• Be Polite
• Introduce yourself to patient
• Make the patient comfortable
• Initial Question-Invite the patient to tell you
  how he or she came to be in the hospital (chief
  complaint )

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Clinical Interview

• Listen to patient- Dont interrupt patient
  especially at the beginning of the interview
• Begin each topic with open ended question and
  close with detailed specific question

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Clinical Interview

• Pay attention to patients associations so you
  can return later to get more information
• Be empathic- Respond to patients emotional
  reactions

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Usual Order of Interview

• Chief Complaint
• History of Present Illness-
• Elaborate all aspects of symptoms
• Aggravating factors
• Alleviating factors
• Associated manifestations
• Past Illness
• Review of Systems

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Usual Order of Interview

• Mental Status Exam ( especially in psychiatric
  patients )

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Lets Go To The Video Tape !!!
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Doctor-Patient Relationship and Initial Patient
Interview

• Michael Blumenfield, M.D.
• Professor of Psychiatry - NYMC
• Director of Medical Student Education in
  Psychiatry
• Director of C/L Psychiatry - Westchester Medical
  Center