Doctor–Patient Relationship

The quality of the doctor–patient relationship is very crucial to the practice of psychiatry Opens in new window.

The good doctor–patient relationship helps in better data collection, improves compliance, helps in achieving better therapeutic results, and prevents unnecessary legal hassles.

The doctor–patient relationship can be discussed under the following headings:

Patient-related factors
Treating physician-related factors
The approach toward the patient
Models of interaction between doctor and patients

Patient-Related Factors

The personality of the individual, past experiences, coping mechanisms, and transference are common patient factors.

Transference is defined as the patient’s feelings toward the doctor. This is determined by psychodynamic conflicts. The patient may perceive the doctor as good/bad/caring/hostile/brother/sister/father/mother.

Transference is not based on how the doctor actually behaves but is a repetition of the attitude of the patient toward the authority figures.

Treating Physician-Related Factors

The personality of the doctor, his preconceived notions, and countertransference are common factors.

Doctor’s feelings toward the patient are known as countertransference and it has several psychodynamic components.

Countertransference can be:

negative,
positive,
idealizing,
or even eroticized reactions to the patients.

The Approach Toward the Patient

The doctor should have a nonjudgmental and empathic approach toward the patient. The patient should be given a patient hearing and assured of confidentiality.

Models of Interaction Between Doctor and Patients

An experienced physician uses different approaches with different patients or at times different approaches with the same patients at different times as per need.

4.1 Paternalistic Model

In this model, it is assumed that the doctor knows the best. A patient is supposed to obey the prescribed treatment without asking questions. The doctor can withhold information if it is in the interest of the patient. Paternalistic model is desired in emergencies where the doctor needs to make lifesaving decisions.

4.2 Informative Model

In the informative model, the doctor dispenses information and choice is left wholly up to the patient. In the informative model, the patient may think that the doctor is cold and uncaring.

This model may be appropriate for certain one-time consultations where the patient will return to the regular care of his/her known physician.

4.3 Interpretive Model

In this model, shared decision-making is done. The role of the doctor is to discuss alternatives with the patient and to find the best alternative for a particular patient with his participation.

4.4 Deliberative Model

In the deliberative model, the doctor presents the information and actively advocates a particular course of action. This approach is used when convincing patients to stop smoking or lose weight. In this model, the doctor acts as a counselor to the patient.

Characteristics of Doctor–Patient Relationship

An effective doctor-patient relationship is characterized by good rapport. Empathy increases rapport.

Rapport

Rapport is the spontaneous and conscious feeling of harmonious responsiveness that promotes the development of a constructive therapeutic alliance. It is an understanding and trust between the doctor and the patient.

Empathy

Empathy means “feel into” an object. Carl Rogers defined empathy as

“To perceive the internal frame of reference of another with accuracy, and with emotional components which pertain thereto, as if one were the other person, but without ever losing the ‘as if’ condition.”

Empathy is an essential characteristic of a psychiatrist.

Barrett-Lennard described an empathy cycle in which a therapist listens openly to the patient; the therapist resonates with the experience; the therapist expresses the resonance back and then the patient becomes aware of being understood and continues to express her or himself with a heightened level of comfort.

Empathy correlates with better patient satisfaction and outcomes.

Confidentiality

Confidentiality involves the ethical duty of the clinician not to disclose information about a patient without his/her authorization. Medical professionals are bound to protect the confidentiality of the patients.

Confidentiality helps to build and develop trust in the doctor-patient relationship. It also helps the patient to be truthful during a healthcare visit. If the confidentiality of the information provided by the patient is not protected, trust in the physician-patient relationship would be diminished.

The following are recognized exceptions to the duty of confidentiality:

Consent of the patient or a legally authorized surrogate decision-maker, such as a parent, guardian, or other surrogate designated by an advance directive.
Court order.
Comply with the law, for example, mandatory reporting of child abuse.
Communication of a threat is a well-known Tarasoff exception to confidentiality that involves the clinician’s duty to protect others from violence by a patient.