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Building a Doctor Patient's Partnership

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Title: Building a Doctor Patient's Partnership


1
Building a Doctor Patient's Partnership
  • Jaime Correia de Sousa, MD, MPH
  • Horizonte Family Health Unit
  • Matosinhos Health Centre
  • Porto, Portugal

2
Sir Luke Fildes, Tate Gallery, London
3
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

4
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

5
Deciding to see a doctor
6
Deciding to seek help or advice
7
Cultural patterns of access to health care
  • The three sectors of health care
  • The popular sector
  • The folk sector
  • The professional sector

Kleinman (1980)
8
Reasons for consulting a doctor
9
In an average month
New Ecology of Medical Care - 2000
10
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

11
Reasons for encounter (RFE) international study
Lamberts, Wood, Hoffmans-Okkes, 1993
12
Patient's explanations about health and diseases
The explanatory model
13
The explanatory model
  • Illness the patients perspective
  • Disease the doctors perspective
  • Questions to be answered

14
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15
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?

16
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
17
Consultation length and consultation outcomes
18
Length of consultation with general practitioner
Deveugele, Derese, van den BrinkMuinen, Bensing,
De Maeseneer. BMJ. 2002 August 31 325 (7362) 472
19
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

20
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
21
Building Doctor Patient's Partnership
22
Building Doctor Patient's Partnership
  • Consultation Models
  • Pendleton - Doctor's Tasks
  • Levenstein - Patient-Centred Model
  • MacWhinney - Disease-Illness Model
  • Neighbour The inner consultation

23
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)
24
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)
25
Patient-Centred Model
26
Building a Partnership
27
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

28
Building a Partnership
Charles, Whelan, Gafni (1999)
29
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

30
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

31
Some pitfalls in Patient-Physician Relationship
32
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

33
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