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Approach to the patient. The patient-physician relationship. Professional attitude. Behaviour in wards


Title: Approach to the patient. The patient-physician relationship. Professional attitude. Behaviour in wards Author: Szathm ri Mikl s Last modified by – PowerPoint PPT presentation

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Title: Approach to the patient. The patient-physician relationship. Professional attitude. Behaviour in wards

Approach to the patient. The patient-physician
relationship. Professional attitude. Behaviour
in wards
  • Dr. Szathmári Miklós
  • Semmelweis University
  • First Department of Medicine
  • 13. Sept. 2011.

Interactions during the care of patients
Emotional reactions
Course Outcome
Clinical competence
Professional competence
The professional competence of the Doctor (to
maintain the human aspects of medical care)
  • Responsibility
  • The primacy of patient welfare. The willingness
    to take the time to explain all aspects of the
  • Patient autonomy a nonjudgmental attitude when
    dealing with patients whose cultures, lifestyles,
    and values differ from those of the physician.
  • Social justice compassion, the support of
    distressed persons etc.
  • Authority In sense of power to influence people
    because they respect our knowledge and official
    position. Our knowledge and experiences is
    eternally unfinished. The commitment to continued
    learning is an integral part of being a physician
    and must be given highest priority.
  • Self-control Every physician will, at times,
    challenged by patients who evoke strongly
    negative or positive responses. Physicians should
    be alert to their own reactions to such patients
    and situations and should consciously monitor and
    control their behavior so that the patients best
    interest remains the principal motivation for
    their actions at all times.

The clinical competence of the Doctor (to express
the expected understand at bedside)
  • Involvement
  • Acceptance
  • Responsiveness
  • Empathy
  • is a term indicating one persons appreciation,
    understanding, and acceptance of someone elses
    emotional situation. The communication of this
    understanding is one of the most helpful,
    meaningful, and comforting interventions one
    person can have with someone else.

Methods to expression the empathy
  • Reflection
  • The patient begins to look sad
  • Legitimation
  • The phisician should let the patient know that
    his or her feelings are understandable
  • Personal support
  • A statement indicating that the physician is for
    the patient and she or he wants to help
  • Partnership
  • The patients are more satisfied with physicians
    and more likely to adhere to treatment
    recommendation when they feel a sense of
  • Respect
  • Respectful comments can add a great deal to
    building rapport, improving relationship, and
    helping the patient cope with difficult situation
  • I can see this is upsetting to you
  • Your reaction is perfectly normal, or I can
    understand why you are so angry
  • I want to help in any way I can
  • After we have talked some more about your
    problems, perhaps together we can work out some
    solutions that may help.
  • I am impressed by how well you are coping

The patient
Physicians must never forget that patients are
individual human beings with problems that all to
often transcend their physical complaints. The
patient are not cases or admissions or
The patient
  • Illness generates emotional distress. The
    normal emotional reactions to illness are
  • Regression, dependency
  • Denial, suppression, and repression
  • Anxiety
  • Anger
  • Sadness
  • The physician should understand and recognize
    these emotional stages.

Normal emotional reactions to illness
  • Regression increased physical and emotional
    dependency during illness. Limited regression can
    be adaptive, to permit rest and recovery from
    acute illness. Good patient.
  • Denial information received from the physician
    is actually contradicted.
  • If the patient is told he or she has cancer, the
    patient who denies this information will actually
    insist that the physician is wrong.

Emotional reactions to illness
  • Anxiety subjective experience of fear, dread.
    It can be experienced by patients as internal
    states of fearfulness, but it can also have
    somatic manifestations (palpitation, sweating,
    sleeplesness etc) and influence the course of the
    primary physical illness itself.
  • Anger The patient wonder Why me?Many patients
    feel a generalized anger that can not be focused
    on any one particular person. They often lash out
    unexpectedly and seemingly without good reason.
    Physicians are typical targets.
  • Sadness Chronic illness usually leads to many
    losses. Sadness is the most common emotional
    reaction to loss.

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The patient-physician relationship
In an extraordinary large number of cases both
the diagnosis and treatment are directly
dependent on the intimate relationship between
physician and patient. The ideal
patient-physician relationship is based on
thorough knowledge of the patient, on mutual
trust, and the ability to communicate.
Factors facilitating Communication
  • comfortable supportive physical setting
  • a warm introduction
  • an open initial enquiry, allowing the patient to
    present the problem in his own words
  • a specific invitation to describe any affective
    responses to illness
  • a sequence of selective questions in the search
    for diagnosis
  • concluding open questions

Gathering data to understand the patient
  • Nonverbal skills
  • Attentive and interested body posture
  • Facial expression
  • Appropriate eye contact
  • Touch

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Gathering data to uderstand the patient
  • Open-ended questions
  • Require patients to generate responses other than
    a simple yes or no
  • Invite the patients to describe their problems by
    using their own vocabulary and personal
    experiences of the symptoms
  • Often allows the physician the opportunity to
    learn about the important environmental
    precipitants or stress factors that may influence
    the development of symptoms

What problems brought you to the hospital?
  • I have been having terrible headaches
  • Open-ended question Can you tell me some more
    about the headaches? Answer They come on slowly
    and get worse and worse over several days. They
    seem to only come in the hay fever season when my
    allergies get worse.
  • Closed-ended question Where is the pain? Answer
    The pain is all over.

Gathering data to understand the patient
  • Facilitations Any comment or behavior on the
    interviewers part that encourages the patient to
    keep taking in an open-ended manner can be
    considered facilitative
  • They come on slowly and get worse and worse over
    several days. They seem to only come in the hay
    fever season when my allergies get worse.
  • Phys.You say they only come in hay fever season?
  • Pat. Well, I guess I might get a headache in
    the winter or summer, but this is quite rare.
    Spring and fall tend to be the time the allergies
    and the headaches come.
  • Phys.OK (pause and attentive silence)
  • Pat. This headache now has gone on for 5 days
    and Im having trouble at work.

Gathering data to understand the patient
  • Clarification In order to understand clearly
    what patients mean to convey and to piece
    together a coherent narrative of a patients
    problem, the interviewer must make of clarifying
    and directive questions
  • Phys. Can you help me understand what you mean
    when you talk about your allergies?
  • Pat. Well, every spring and fall I sneeze a
    lot, and my eyes run and itch. My head feels
  • After such a clarification, the physician can
    return to open-ended facilitation.
  • - Phys. So theyve been getting worse in the
    last weeks?

Gathering data to uderstand the patient
  • - Pat. Yes, I got married 3 years ago, changed
    jobs, and had a baby. My life is very dfficult
    now. I just can not seem to get enough rest.
  • The patient introduced new subject. The patient
    seems to be waiting for the physician to make a
    decision about where to direct the interview.
  • Direction The physician can decide to return to
    the physical symptomology, this can be done with
    directing comments
  • Phys. This stress situation could be a problem
    in itself, but talk about the headaches for a few
    more minutes and then come back to the stress

Gathering data to understand the patient
  • Checking It gives the physician the opportunity
    to check the accuracy of what he or she thinks
    the patient actually said. The patient realizes
    that the physician is interested in gaining an
    accurate understanding of the problem.
  • Phys. Let me check to see if I understand what
    you have told me so far. .

The Illness
  • acute
  • subacute
  • chronic
  • Onset
  • abrupt
  • insidious
  • Outcome
  • cure
  • remission relapse
  • relentless

The Communication
  • the key to effectiveness of the doctor as a
  • absolute requirement in obtaining a good history
    from the patient
  • confidence is necessary for the patient to
    respond to the doctors advice
  • Lawsuit is more likely when communication between
    doctor and patient is poor
  • leadership of the medical team

Meeting the patient
  • Learning the interview means learning
  • a new set of difficult and complex skills
  • to assume a new and dramatically different social
  • The student, in putting on the white coat attains
    the social status of physician
  • The student is required to ask intimate questions
    of other people and to tell them to undress and
    be examined
  • These patients usually do what they are told and
    treat the student with great respect
  • The new social role makes most medical students
    quite anxious

Meeting the patient common concerns
  • Why should patients want to talk to or be
    examined by a student?
  • Most patients are willing to be interviewed and
    examined by students. Such patients feel that
    they are making an active contribution by
    assisting in the training of the physicians.
    Moreover, the feeling of uselessness that are
    associated with illness can be meaningfully
    counteracted in some patients by their sense of
    contribution to the education of future
  • Students need to ask their patient, before
    beginning, if they are willing to be interviewed.
    If the patient indicates that she or he does not
    want to be interviewed, this wish must be
  • Introducing and touch the patient
  • The student should clearly introduce himself or
    herself as a student doctor This should help
    ensure that patients will not be deceived.
  • Touch is a very powerful and supportive
    technique. In situation of great distress it is
    common and appropriate for physicians to hold a
    parientss hand or put an arm around a patientss
    shoulder. If the student feels uncomfortable in
    touching a patient (other than the physical
    examination), this should not be done.

Meeting the patient common concerns
  • If a patient asks me questions, should I answer
  • In general, the student should avoid answering
    any questions about a patients individual
  • Students have incomplete understanding of the
    medical issues, and the findings of his or her
    physical examination are uncertain.
  • What should I do if the patient tells me some
    secret if I agree to maintain his or her
  • If the patient asks for confidentiality, the
    student should indicate that his or her student
    status makes it impossible to give an absolute
    promise of confidentiality. The student may have
    to share this information with a supervisor.
  • If the patient is in pain or emotional distress,
    should I continue with the interview?
  • First of all, the pain or distress must be
    acknowledged, and the student has to offer of
    assistance. The student should ask the patient
    whether the interview can be conducted or should
    be postponed, Often the patient will appreciate a
    glass of water, a change of the position of the
    bed, or some other small intervention. Most
    oftens the patient will want to continue the
    interview or examination.

Taking the temperature. Fever
"Maximum" thermometer Measuring -
axillary 36.5C 8-10 min - oral 37.0C
0.5C 4-5 min - rectal 37.5C 1-2
min Conditions - normal ambient temperature -
no hot or cold drinks 15 min before - patient
resting, no chills Diurnal variations of
temperature ("fever curve") - early afternoon
peaks - lowest in the night Subfebrility
below 38C (axillary) Hyperpyrexia higher
than 41.0C (rectal) Hypothermia below 35C
Types (patterns) of fever 1.
1. Subfebrility Peaks of temperature do not
exceed 38C Causes - "vegetative" (usually
below 37.5C) - hyperthyroidism (in part
metabolic) - hyperkinetic syndrome
(circulatory) - "functional" subfebrility
(psychogenic?) - hypermotility (children, -
agitated pts) - "organic - chronic
infections - tbc - pyogenous foci
(abscesses) dental, tonsillo, pharyngeal,
biliary gynaecological, prostatic, etc. -
malignancies solid tumours, leukaemias,
lymphomas - haemolysis - immune reactions
rheumatic fever, autoimmune diseases
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Types (patterns) of fever 2.
2. Continuous fever (Variations of temperature lt
1C) Incremental phase (chills) - decremental
phase (sweating) Variations of temperature lt
1C Typical illnesses typhoid fever pneumonia
Types (patterns) of fever 3.
3. Biphasic fever Two consecutive periods of
continuous fever Typical for viral infections
(influenza) 4. Remittent fever Variations of
temperature gt 1C Lowest values remain higher
than 37C 5. Intermittent fever Variations of
temperature gt 1C Lowest values go below 37C
Types (patterns) of fever 4.
6. Septic fever Combination of remittent and
intermittent patterns Rise of temperature is
caused by bacteriaemia arising from pyogenous
(micro) abscess(es). Associated usually with
chills. 7. Recurrent lever Non-periodic
retention and occasional emptying (drainage) of
infected secretion, urine, bile etc. Periodic
malaria, brucellosis, Hodgkin's disease