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. Tolerance threshold Symptom Symptom Symptom Intensity Time 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: 1000 people 800 have symptoms 327consider care 217 physician’s office 113 visit primary care 65 CAM provider 21hospital outpatient clinic 14 home health 13 emergency department 8 hospitalized <1 in an academic hospital 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 patient’s perspective • Disease – the doctor’s perspective • Questions to be answered

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? • You’ve 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 todenote what patients have on their mind when waiting to seethe doctor • Purposes of an actual consultation • Several consultation purposesexist • Wishes, what is perceived by the patientas desirable • The focusis directed towards the patient's wishes prior toa consultation • Emphasis on the specificprocesses 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. Pendleton’s 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 reactions—for 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 don’t like • Dealing with Celebrity Patients and VIP’s • Use of Chaperones During Physical Exams