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Physician-patient relationship

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The physician-patient relationship is defined as the "interactions between physician and patient".[1] Patient expectations include active listening from the physician.[2]

A positive relationship is associated with improved health outcomes.[3]

The medical interview

See also: Medical history taking

A qualitative study suggested benefit from the following 8 attributes of the health care provider:[4]

  • "do the little things"
  • "take time"
  • "be open and listen"
  • "find something to like, to love"
  • "remove barriers"
  • "let the patient explain"
  • "share authority"
  • "be committed"

Being an empathetic listener[5] and having a caring (as opposed to a dominant) attitude[6] may help.

A supportive relationship that has "warmth, attention, and confidence" can reduce the pain of irritable bowel.[7]

It is not clear whether the physician should wear traditional attire.[8]

Before the interview

Various methods of helping the patient prepare questions prior to the interview have been studied without strong effect.[9]

Greeting the patient

One study of videotaped physician-patient encounters concluded that "physicians should be encouraged to shake hands with patients but remain sensitive to nonverbal cues that might indicate whether patients are open to this behavior. Given the diversity of opinion regarding the use of names, coupled with national patient safety recommendations concerning patient identification, we suggest that physicians initially use patients' first and last names and introduce themselves using their own first and last names."[10]

Collaborative agenda setting may reduce, "oh by the way," requests by patients at the end of the visit.[11]

Hearing the patient's story

Although physicians frequently (3/4s of interviews) interrupt patients before the patient finishes listing their concerns.[12][13] It is not clear that this interruption is bad.[14][15] Not asking for the patient's concerns at all may lead to more concerns arising late in the interview.[12]

After the patient finishing stating their chief concern, responding with "Is there something else you want to address in the visit today?" rather than "Is there anything else you want to address in the visit today?" may decrease patients' unmet concerns.[16]

Engaging the patient

Encouraging the patient to participate in decisions may increase engagement and patient compliance.[17][18] Using stories to describe medical evidence may help communication.[19]

Patient activation can be measured with the "Patient Activation Measure".[18]

Readiness to change can be measured by the Readiness to Change Ruler[20][21] or by the University of Rhode Island Change Assessment (URICA) questionnaire[22] based on the Transtheoretical Model of Change. The URICA is 23 or 32 items and a 12 item "'Readiness to change" version[23] has been developed. The Ruler correlates with the full questionnaire[24][23] and predicts behavioral intentions[24].

Health literacy

Health literacy can be assessed.

The length of the visit

There is not enough time during the typical doctor-patient visit to cover all concerns[25] in spite of the increasing length of visits[26]. Increased numbers of medical problems[27] or concerns brought by the patient[25] interfere with quality of care. Preventive care alone, if coordinated by the doctor rather than delegated, requires more time than available.[28]

Longer visits are associated with higher quality[29] and satisfactory[30] care. Time restriction reduce satisfaction of physicians.[31]

There is much variety in length of visits.[30] Patient visits should probably be at least 20 minutes.[17]

Facilitating recall of information

Patients (and health care professionals as well[32])have difficulty in recall details of the discussion during the visit.[33][34]

The role of the computer during the interview

The presence of a computer and the electronic health record alters the dynamics of the interview.[35]

Most patients do not mind the physician seeking online information and not appearing to be "all knowing".[36]

Oh, by the way

The "by-the-way” syndrome is the raising of a new problem by the patient at the end of the interview. Starting the interview with careful eliciting of the patient's agenda may avoid this problem.[16] However, when "by-the-way" occurs, the nature of the problem is usually psychosocial whereas the physician usually reponds with a biomedical reply.[37]

Benefits

Higher ratings by patients of patient-provider communication is association with receipt of regular mammography.[38]

Patient-physician confidentiality

In general, communications between patient and physician are privileged and cannot be brought up as part of a court proceeding. There are exceptions for reporting certain contagious diseases, child abuse, and other specific events. In the U.S., privileged information is protected by the the Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA).

References

  1. Anonymous (2020), physician-patient relationships (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Bertakis KD, Roter D, Putnam SM (1991). "The relationship of physician medical interview style to patient satisfaction.". J Fam Pract 32 (2): 175-81. PMID 1990046[e] Review in: J Fam Pract. 1991 Feb;32(2):135-6
  3. Owens DM, Nelson DK, Talley NJ (1995). "The irritable bowel syndrome: long-term prognosis and the physician-patient interaction.". Ann Intern Med 122 (2): 107-12. PMID 7992984[e]
  4. Churchill LR, Schenck D (November 2008). "Healing skills for medical practice". Ann. Intern. Med. 149 (10): 720–4. PMID 19017590[e]
  5. Epstein RM, Hadee T, Carroll J, Meldrum SC, Lardner J, Shields CG (2007). ""Could this Be Something Serious?" : Reassurance, Uncertainty, and Empathy in Response to Patients' Expressions of Worry". DOI:10.1007/s11606-007-0416-9. PMID 17972141. Research Blogging.
  6. Schmid Mast, M., Hall, J., & Roter, D. (2008). Caring and Dominance Affect Participants’ Perceptions and Behaviors During a Virtual Medical Visit. Journal of General Internal Medicine, 23(5), 523-527. DOI:10.1007/s11606-008-0512-5.
  7. Spiegel and Harrington. What is the placebo worth?.
  8. Bianchi MT (May 2008). "Desiderata or dogma: what the evidence reveals about physician attire". J Gen Intern Med 23 (5): 641–3. DOI:10.1007/s11606-008-0546-8. PMID 18286342. Research Blogging.
  9. Kinnersley P, Edwards A, Hood K, et al (2008). "Interventions before consultations to help patients address their information needs by encouraging question asking: systematic review". BMJ 337: a485. PMID 18632672[e]
  10. Makoul G, Zick A, Green M (2007). "An evidence-based perspective on greetings in medical encounters". Arch. Intern. Med. 167 (11): 1172–6. DOI:10.1001/archinte.167.11.1172. PMID 17563026. Research Blogging.
  11. Brock DM, Mauksch LB, Witteborn S, Hummel J, Nagasawa P, Robins LS (2011). "Effectiveness of intensive physician training in upfront agenda setting.". J Gen Intern Med 26 (11): 1317-23. DOI:10.1007/s11606-011-1773-y. PMID 21735348. Research Blogging.
  12. 12.0 12.1 Marvel MK, Epstein RM, Flowers K, Beckman HB (1999). "Soliciting the patient's agenda: have we improved?". JAMA 281 (3): 283–7. PMID 9918487[e]
  13. Beckman HB, Frankel RM (1984). "The effect of physician behavior on the collection of data". Ann. Intern. Med. 101 (5): 692–6. PMID 6486600[e]
  14. Dyche L, Swiderski D (2005). "The effect of physician solicitation approaches on ability to identify patient concerns". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 20 (3): 267–70. DOI:10.1111/j.1525-1497.2005.40266.x. PMID 15836531. Research Blogging.
  15. Thomas Mordekhai Laurence (2004). Extreme Clinic -- An Outpatient Doctor's Guide to the Perfect 7 Minute Visit. Philadelphia: Hanley & Belfus. ISBN 1-56053-603-9. 
  16. 16.0 16.1 Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M (2007). "Reducing patients' unmet concerns in primary care: the difference one word can make". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 22 (10): 1429–33. DOI:10.1007/s11606-007-0279-0. PMID 17674111. Research Blogging.
  17. 17.0 17.1 Bodenheimer T (2007). "A 63-year-old man with multiple cardiovascular risk factors and poor adherence to treatment plans". JAMA 298 (17): 2048–55. DOI:10.1001/jama.298.16.jrr70000. PMID 17986698. Research Blogging.
  18. 18.0 18.1 Greene, Jessica; Judith Hibbard (2012). "Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes". Journal of General Internal Medicine 27 (5): 520-526. DOI:10.1007/s11606-011-1931-2. ISSN 0884-8734. Retrieved on 2012-04-26. Research Blogging.
  19. Steiner JF (2007). "Using stories to disseminate research: the attributes of representative stories". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 22 (11): 1603–7. DOI:10.1007/s11606-007-0335-9. PMID 17763914. Research Blogging.
  20. Readiness-to-Change Ruler Adult Mededucation
  21. Zimmerman GL, Olsen CG, Bosworth MF (2000). "A 'stages of change' approach to helping patients change behavior.". Am Fam Physician 61 (5): 1409-16. PMID 10735346[e]
  22. DiClemente CC, Hughes SO (1990). "Stages of change profiles in outpatient alcoholism treatment.". J Subst Abuse 2 (2): 217-35. PMID 2136111[e]
  23. 23.0 23.1 Rollnick S, Heather N, Gold R, Hall W (1992). "Development of a short 'readiness to change' questionnaire for use in brief, opportunistic interventions among excessive drinkers.". Br J Addict 87 (5): 743-54. PMID 1591525[e]
  24. 24.0 24.1 LaBrie JW, Quinlan T, Schiffman JE, Earleywine ME (2005). "Performance of alcohol and safer sex change rulers compared with readiness to change questionnaires.". Psychol Addict Behav 19 (1): 112-5. DOI:10.1037/0893-164X.19.1.112. PMID 15783287. Research Blogging.
  25. 25.0 25.1 Parchman ML, Pugh JA, Romero RL, Bowers KW (2007). "Competing demands or clinical inertia: the case of elevated glycosylated hemoglobin". Annals of family medicine 5 (3): 196–201. DOI:10.1370/afm.679. PMID 17548846. Research Blogging.
  26. Chen, Lena M.; Wildon R. Farwell, Ashish K. Jha (2009-11-09). "Primary Care Visit Duration and Quality: Does Good Care Take Longer?". Arch Intern Med 169 (20): 1866-1872. DOI:10.1001/archinternmed.2009.341. Retrieved on 2009-11-10. Research Blogging.
  27. Redelmeier DA, Tan SH, Booth GL (1998). "The treatment of unrelated disorders in patients with chronic medical diseases". N. Engl. J. Med. 338 (21): 1516–20. PMID 9593791[e]
  28. Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL (2003). "Primary care: is there enough time for prevention?". American journal of public health 93 (4): 635–41. PMID 12660210[e]
  29. Wilson A, Childs S (2002). "The relationship between consultation length, process and outcomes in general practice: a systematic review". The British journal of general practice : the journal of the Royal College of General Practitioners 52 (485): 1012–20. PMID 12528590[e]
  30. 30.0 30.1 Geraghty EM, Franks P, Kravitz RL (2007). "Primary care visit length, quality, and satisfaction for standardized patients with depression". J Gen Intern Med 22 (12): 1641–7. DOI:10.1007/s11606-007-0371-5. PMID 17922171. Research Blogging.
  31. Solomon J (2008). "How Strategies for Managing Patient Visit Time Affect Physician Job Satisfaction: A Qualitative Analysis". J Gen Intern Med. DOI:10.1007/s11606-008-0596-y. PMID 18365288. Research Blogging.
  32. Skinner TC, Barnard K, Cradock S, Parkin T (May 2007). "Patient and professional accuracy of recalled treatment decisions in out-patient consultations". Diabet. Med. 24 (5): 557–60. DOI:10.1111/j.1464-5491.2007.02129.x. PMID 17367303. Research Blogging.
  33. Kessels RP (May 2003). "Patients' memory for medical information". J R Soc Med 96 (5): 219–22. PMID 12724430[e]
  34. Jansen J, van Weert J, van der Meulen N, van Dulmen S, Heeren T, Bensing J (April 2008). "Recall in older cancer patients: measuring memory for medical information". Gerontologist 48 (2): 149–57. PMID 18483427[e]
  35. Pearce C, Trumble S, Arnold M, Dwan K, Phillips C (May 2008). "Computers in the new consultation: within the first minute". Fam Pract. DOI:10.1093/fampra/cmn018. PMID 18504254. Research Blogging.
  36. Kahane S, Stutz E, Aliarzadeh B (2011). "Must we appear to be all-knowing?: patients' and family physicians' perspectives on information seeking during consultations.". Can Fam Physician 57 (6): e228-36. PMID 21673199. PMC PMC3114694[e]
  37. Rodondi, Pierre-Yves; Julia Maillefer, Francesca Suardi, Nicolas Rodondi, Jacques Cornuz, Marco Vannotti (2009-06-01). "Physician Response to “By-the-Way” Syndrome in Primary Care". Journal of General Internal Medicine 24 (6): 739-741. DOI:10.1007/s11606-009-0980-2. Retrieved on 2009-06-01. Research Blogging.
  38. Villani J, Mortensen K (2013). "Patient-provider communication and timely receipt of preventive services.". Prev Med 57 (5): 658-63. DOI:10.1016/j.ypmed.2013.08.034. PMID 24021993. Research Blogging.