Done by :Haidar Aoofey
1
Is the corner stone of medical practice ,the intervening technique
implies that the understanding &trust exist between them with
rapport …the patient feel that doctor is figure in his life like
teacher ,father & this is called transference ……
Failure of DR-patient good relation establishment account for
ineffectiveness in care of patient
If however the physician cod handle the resentful
patient
with equanimity
,the patient may become loyal
&
cooperative
The reaction of patient to doctor to be a repetition of altitude to
ward parent teacher or other authoritve person Who have figure
importantly in patient past
Both individual experience & cultural attitude affect reaction of
the patient it is desirable for the physician to have as much as
understanding possible of patient culture
The doctor must avoid side stepping issues that are important to
the patient that he or she find boring or difficulty product of
physician ability to establish (empathic & responsive)
Done by :Haidar Aoofey
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To the patient find borders or difficult to deal with
When a therapist can convey (receptive) to the hearing about any
subject –this will facilitate patient to talk fluently at any topic
even embarrassing or disturbance difficult patient can be
managed by physician ability to establish &response relationship
(self-knowledge &interpersonal sensitivity )
The patient &doctor will have expectation of each other ,based
on culture ,prior experience & account each other's these will
determined the initial presentation ,which will be modified by
degree of which the contact fulfill these expectation ,the applies
to all level of interaction like :Posture ,limb movement
,vocbulozy , to mood familiarity , the content of information
Mood level
The course of content of information presented
There is usual socio-cultural between doctor & patient
Research has found that most doctors in western culture are
white ,male & upper –middle class
This inadvertently influence
the manner in which
they relate to patient in mount of information given .questions
asked &overall afford in each area being given to the patient the
more similar the they are
Done by :Haidar Aoofey
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Doctor should treat patient not disease this may be lost in
fascination
of MRI scan
Result or EEG trace ,but forgotten entirely will increase the like
hood of doing harm or at least lessen the potential to benefit a
distinction has been made between disease
The pathological abnormality occurring as result of some
specific noxious
insult
and illness
The subjective interpretation of problem that are perceived as
related to health ,these are related to each other but can occur
independently for example (maligning ,somatization )
hypochondriasis
A distinction also has made between
:action taken by people who see themselves
as healthy in order to prevent or detect it while it is still
asymptomatic
action of people who see themselves as ill,
for the purpose
The first doctor –patient contact may not be this simple
The patient is initiation of contact may for example be to gain
support housing application
The doctor may gaining experience ,being trained ,carrying out
research or working out their time until retirement
The only assumption the doctor can make about the patient that
message :is being transmitted which is combination of :
Done by :Haidar Aoofey
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Informative
(giving information)
Promative
(intend to make doctor do some time)
Evocative
(intend to make doctor feel some time)
the doctor must be carful to pay attention for illness as well as
to disease in order to clear patient perspective
Doctor must feel comfortable with his cloth but should be aware
that jeans and T-shirt give different impression with or without
white coat
doctor should be neat
,tidy
, smart dressed business attitude.
Facilities should be available to psychiatrist will vary in their
level of formality
Provide comfort & informality
Encourage but does not deter the disclosure
of
important information or emotion
Balance must be struck
between (homling &clinical
atmosphere)
In western countries interview can be carried outside the office
setting due to availability of mid house (community psychiatry )
Done by :Haidar Aoofey
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The layout
of all setting should try to ensure that patient &
doctor are at similar height eg :disk
Eye contact is possible but not forced chairs :are similar & at
angle of 90degree with low side table with surface of writing –
light ;should be adequate but not too bright & should not shine
in the patients eyes
The sequence of smile,touch ,question ( where hand shake or
gentle direction to the consulting room) is fine for general
medical consultation
Be careful of excessive touch because it cause flash back of
unpleasant memory of insult
Not taking is a matter of personal preference ,because it may
reduce the potential for observation & amount of attention given
to patient
On other hand patient regards it is as indication of the doctor
taking what say seriously
Looking interested also facilities disclosure
Non-verbal communication is continues & the edge of
conscious
Inconsistency between verbal & nonverbal communication, the
laten take precedence ,nodding , inclining , the head tend to
encourage further disclosure
Done by :Haidar Aoofey
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Patient taking they will not maintence eye contact all the time
but will keep checking that the listener is paying attention &
mainly fix their gaze at important juncture
Question should progress from open to more specific closed
question
Different question will tend to produce different response
Studies have shown that doctor tend to interrupt open statement
from their patient & doctor don't hear mon
Active listening : is an active process that improve the
efficiency of DR-patient relation & communication there are
four skill area:
The skill of attractive listening (active listening)
longer for response before interruption
allowing
increase the amount & quality of information volunteer.
Short nonverbal cues that encourage continued response from
patient if more effective the beginning of meeting
The most important is eye contact
Done by :Haidar Aoofey
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These are verbal & non verbal hints of other information that are
seen more at beginning of the interview & need knowledge
appropriate knowledge
Empathy
:understanding of patient feels especially
(unspoken language)
Non possive:warmth
This does not meet agreement with patient already always but it
emphasize the need for patient attitude of truthfulness
Is not the same as bluntness?
Hearing: good doctor is good listener
Sight: ready of non-verbal signs &clinical signs
Smell: to detect diabetic ketoacidosis on the breath ,breath T.fever
Touch : fine palpable liver-abdomen
Taste : taste a cup of tea in patient with D.M
Done by :Haidar Aoofey
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Other vital sense should be proposed emotional response evoked in
doctor by attitude & bearing of patient most experienced
psychiatrist will dx report rather than quizzically
the
psychology or organ psychiatric disorder, which amount to more
than confluence of the signs & symptoms
Trainees:
would be well to cultivate such feeling;
Perhaps more straight for worldly the emotion of anger, depression
,anxiety , admiration
,& sexual arousal may arise in the
context
of doctor patient relationship & influence the action
particularly refer on .
Essential to provide safety & familiarity with best made
introductory phase (good gllabration setting
(
Time availability & limitation appointment should be noted
The outcome & interview should be consider at the end of
interview
Done by :Haidar Aoofey
9
Type
Example
A-key Response
Open
How are you feel?
any
Multiple choice
Do you feel happy
\sad?
Happy\
sad or
confused
Yes \no
Do you feel sad ?
Yes \no
Leading
How sad do you
feel?
What do you mean
or confused
Type question in order of decreasing openness & increasing chance of
limited illness
Clarification
explantation & planning for interview
expected & not expected behavior should be laydown
boundaries should be respected & patient should know its
Done by :Haidar Aoofey
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no alcoholic ,no smocking ,no intoxication
no mobile for both ,no physical violence
if these boundaries breached is high failure rate for treatment &
outcome
it is important characteristic of the Dr- patient relationship & all
interaction between patient health professional (Dr.nurse ,other
staff)
will lose their job professional regiment see the figures below
doctor specifically psychiatrist are responsible for enacting M.H
legislation according to the law
M.H legislation make medical power explicit enhance safe
ground to pleasant abuse& the power
SZASZ & LOING: have different daughter hypothesized that
mental illness is response to society illness & psychiatrist
responsibility
Done by :Haidar Aoofey
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Done by :Haidar Aoofey
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The psychiatrist is responsible especially for prepetition the
myth of mental illness & devising cursive treatment that
perpetuate this approach although (antipsychiatry) movement
responsible for atltelly society the potential for psychiatrist
abuse & build management guideline & also denied needly
people effective relief Of their distressing symptoms
The doctor in relatively to patient carries responsibility to
society to reflect current attitude & more (e;g: putting forward
health education)
It is inherent in Dr-Patient relation ship the Dr wishes to
encourage more healthy behavior (compliance)
The patient wishes for effective health (are this phenomena
something like a barter
it is recommended that Dr
professional skills & knowledge are place at disposal of the
patient
Dr should resist temptation
to prove oneself all-powerful
&all knowledge especially since heioneithen but is asked to be
knows everything ,but he comment
Done by :Haidar Aoofey
13
Balint referred to the (apostolic function) of the doctor in his
classic treatise (the doctor ,his patient & the illness) by that
mean in 1
st
place every doctor has vague ,almost unshakably of
how patient must to behave as if he had sacred duty to convert to
his faith all the ignorant & unbelieving among his patient
The psychiatrist & patient usually only meet following the
intervention of third party, it is useful it is useful for doctor to
consider why how has this patient been referral at this time.
Illness iceberg :to refer to the fact that majority of illness
symptoms are ignored or receive non-medical intervention
In one study :medical consultation occur in 18 illness episode
Similarity most psychiatrist & psychological symptoms are not
refer to the special service
The decision to refer is a key point in illness process &
determined is the many factors other than severity of disorder
Done by :Haidar Aoofey
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Is consequence of rapport
between Dr & patient
It gives significant clue about Dr-patient relationship & interaction
When to stop:
Important boundary
Good listing ….long intention
Balance between patient understood & zelia