(Test Bank) The Patient-Doctor Relationship Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry

Kaplan,Sadock, 10

Psychology

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Kaplan & Sadoc k's Kaplan & Sadoc k's Synopsis of Synopsis of Psychi atry: Be havior al Psychi atry: Be havior al Sciences/Clinical Sciences/Clinical Psychi atry, 10 th Psychi atry, 10 th EditionEdition EDIT Dr liza 140 366 660 EDIT Dr liza 140 366 660The Patient-D octor The Patient-D octor Relationship Kaplan & Relationship Kaplan & Sadock's Synopsis of Sadock's Synopsis of Psychiatry: Behavioral Psychiatry: Behavioral Scienc es/Clinical Psychiatry, Scienc es/Clinical Psychiatry, 10th Edition 10th Edition EDIT Dr liza 140 366 660 EDIT Dr liza 140 366 660RAPPO RT RAPPO RT An effective rela tionship is characterized by An effective rela tionship is characterized by good rap port. good rap port.  Rapport is the s pontaneous, conscious feeling Rapport is the s pontaneous, conscious feeling of harm onious responsivenes s that promotes of harm onious responsivenes s that promotes the development of a constructive therapeutic the development of a constructive therapeutic alliance. alliance.  It implies an understanding a nd trust between It implies an understanding a nd trust between the doct or and the patient. Frequently, the the doct or and the patient. Frequently, the doctor is the only person to whom the patients doctor is the only person to whom the patients can talk ab out things that they cannot tell can talk ab out things that they cannot tell anyone else. Most patients trust their doctors to anyone else. Most patients trust their doctors to keep secrets, and this confidence must not be keep secrets, and this confidence must not be betrayed. betrayed. Patients who feel that someone knows them, Patients who feel that someone knows them, understands them, and accepts them find t hat understands them, and accepts them find t hat a source of strengt h. In his essay,Caring for the a source of strengt h. In his essay,Caring for the Patient Francis Peabody , M.D. (1881-1927), a Patient Francis Peabody , M.D. (1881-1927), a talented teacher and c linician (Fig. 1-2), wrote: talented teacher and c linician (Fig. 1-2), wrote:6 STRATEGI ES RAPPO RT 6 STRATEGI ES RAPPO RT Ekkehard O thmer and S ieglinde Othme r defined Ekkehard O thmer and S ieglinde Othme r defined the development of rapport as encompassing the development of rapport as encompassing six strategies: (1) putting p atients and six strategies: (1) putting p atients and interviewers at ease; (2) findin g patients' pain interviewers at ease; (2) findin g patients' pain and expressing compassion; (3) ev aluating and expressing compassion; (3) ev aluating patients' insight and be coming a n ally; (4) patients' insight and be coming a n ally; (4) showing expertise; (5) establishing autho rity as showing expertise; (5) establishing autho rity as physicians and therapists; and (6 ) balancing the physicians and therapists; and (6 ) balancing the roles of empathic listener, expert, and roles of empathic listener, expert, and authority. As part of a strategy for in creasing authority. As part of a strategy for in creasing rapport, they developed a check list (Table 1-1) rapport, they developed a check list (Table 1-1) that enab les interviewers to recognize problems that enab les interviewers to recognize problems and refine t heir s kills in establishing ra pport. and refine t heir s kills in establishing ra pport.Empathy Empathy Empathy is a way of increasing rapport. It is an Empathy is a way of increasing rapport. It is an essential character istic of psychiatrists, but it is essential character istic of psychiatrists, but it is not a universal human capacity. An incapacity for not a universal human capacity. An incapacity for normal understanding of what other people are normal understanding of what other people are feeling appears to be centr al to certain feeling appears to be centr al to certain personality distur bances, such as antiso cial and personality distur bances, such as antiso cial and narcissist ic personality disorders. Although narcissist ic personality disorders. Although empathy probably cannot be created, it can be empathy probably cannot be created, it can be focused and deepened through training, focused and deepened through training, observation, and self-reflection. It manifests in observation, and self-reflection. It manifests in clinical work in a variety of ways. An empa thic clinical work in a variety of ways. An empa thic psychiatrist may anticip ate what is felt before it is psychiatrist may anticip ate what is felt before it is spoken and can often help patients a rticulate spoken and can often help patients a rticulate what they are feeling . Nonve rbal cues, such as what they are feeling . Nonve rbal cues, such as body posture and facial expr essio n, are noted. body posture and facial expr essio n, are noted. Patients' reactio ns to the psychiatrist can be Patients' reactio ns to the psychiatrist can be understood and clarified. understood and clarified.Transference Transference Transference is generally defined as the set of Transference is generally defined as the set of expect ations, belief s, and emotional respo nses that a expect ations, belief s, and emotional respo nses that a patient bring s to the p atient doctor relationshi p. patient bring s to the p atient doctor relationshi p. They a re based not nece ssarily on who the doctor is or They a re based not nece ssarily on who the doctor is or how the doctor acts in reality but, rather, on repea ted how the doctor acts in reality but, rather, on repea ted experiences the patient has had with other important experiences the patient has had with other important authority figures throughout life. authority figures throughout life. Transferential Attitudes Transferential Attitudes The patient's attitude toward the physician is apt to be The patient's attitude toward the physician is apt to be a repetition of the attitude he or she has had toward a repetition of the attitude he or she has had toward authority figures. The p atient's attitude can range from authority figures. The p atient's attitude can range from one of realistic b asic trust, with an expectation that the one of realistic b asic trust, with an expectation that the doctor has P.2 doctor has P.2 the patient' s best interest at heart, through one of the patient' s best interest at heart, through one of overidea lization and even eroticized fantasy to one of overidea lization and even eroticized fantasy to one of basic m istrust, with an expect ation that the doctor will basic m istrust, with an expect ation that the doctor will be contem ptuous and potentially abusive. be contem ptuous and potentially abusive.Countertransference Countertransference Just as the patient brings transf erential Just as the patient brings transf erential attitudes to the patient-doct or attitudes to the patient-doct or relationship, d octors themselves often relationship, d octors themselves often have cou ntertransferential reac tions to have cou ntertransferential reac tions to their patients. Countertransference can their patients. Countertransference can take the form of negative feelings that are take the form of negative feelings that are disrupt ive to the patient-d octor disrupt ive to the patient-d octor relationship, b ut it can also encompass relationship, b ut it can also encompass disproportion ately positive, idealizing, or disproportion ately positive, idealizing, or even e roticized reactions to patients. Just even e roticized reactions to patients. Just as patients have expectations for as patients have expectations for physicians for example, competence, lack physicians for example, competence, lack of exploitation, of exploitation, Models of Interaction Betw een Models of Interaction Betw een Doctor an d Patient Doctor an d Patient The paternalist ic model The paternalist ic model. In a paternalistic . In a paternalistic relationship b etween t he doct or and patient, relationship b etween t he doct or and patient, it is assumed that the doctor knows best. He it is assumed that the doctor knows best. He or she will prescribe treatment, and t he or she will prescribe treatment, and t he patient is expected to comp ly wit hout patient is expected to comp ly wit hout questioning. Moreove r, the doctor may questioning. Moreove r, the doctor may decide to withh old infor mation when it is decide to withh old infor mation when it is believed to be in t he patient's best interests. believed to be in t he patient's best interests. In this model, also called the autocrat ic In this model, also called the autocrat ic model, the physician asks mos t of the model, the physician asks mos t of the questions and g enerally dominat es the questions and g enerally dominat es the interview. interview.The informative model. The informative model. The d octor in The d octor in this model dispens es information. All this model dispens es information. All available data are freely given, but t he available data are freely given, but t he choice is left wholly up to the patient. For choice is left wholly up to the patient. For example, doctors m ay quote 5-year example, doctors m ay quote 5-year survival statistics for variou s treatments of survival statistics for variou s treatments of breast cancer and expect wome n to ma ke breast cancer and expect wome n to ma ke up their o wn minds without suggestion or up their o wn minds without suggestion or interference from them. This model m ay interference from them. This model m ay be appropriat e for certain one-time be appropriat e for certain one-time consultations where no established consultations where no established relationship e xists and the patient will b e relationship e xists and the patient will b e returning to the regular care of a known returning to the regular care of a known physician. At other t imes, the informative physician. At other t imes, the informative model places the patient in an model places the patient in an unrealistically auton omous role and lea ves unrealistically auton omous role and lea ves him or h er feeling t he doct or is cold and him or h er feeling t he doct or is cold and uncaring. uncaring. The interpre tive mo del The interpre tive mo del. Doctors who have . Doctors who have come to know their p atients better and come to know their p atients better and understand som ething of the circ umstances of understand som ething of the circ umstances of their live s, their families , their v alues, and their their live s, their families , their v alues, and their hopes and a spirations, are better able to make hopes and a spirations, are better able to make recommendations that take into account the recommendations that take into account the unique c haracteristics of an individual pa tient. unique c haracteristics of an individual pa tient. A sense of shared decision-making is A sense of shared decision-making is established as the doctor pres ents and established as the doctor pres ents and discusses alternatives, with the patient's discusses alternatives, with the patient's participation, to find the one that is best for participation, to find the one that is best for that particular person. The doctor in this mode l that particular person. The doctor in this mode l does not abrogate the res ponsibility for making does not abrogate the res ponsibility for making decisions, but is flexible, and is willin g to decisions, but is flexible, and is willin g to consider question and a lternative sugge stions. consider question and a lternative sugge stions. The deliberative model The deliberative model . The . The physician in t his model acts as a physician in t his model acts as a friend o r counse lor to the patient, not friend o r counse lor to the patient, not just by presen ting in forma tion, but in just by presen ting in forma tion, but in actively advocating a particular actively advocating a particular course of ac tion. The deli berative course of ac tion. The deli berative approac h is commonly use d by approac h is commonly use d by doctors ho ping to modi fy injurious doctors ho ping to modi fy injurious behavior, fo r example, in tr ying to behavior, fo r example, in tr ying to get their p atients to stop smok ing or get their p atients to stop smok ing or lose w eight. lose w eight.Table 1-2 As sessmen t of In dividual Illness Table 1-2 As sessmen t of In dividual Illness BehaviorBehavior Prior illness episo des, especially illnesses of standard Prior illness episo des, especially illnesses of standard severity (childbirth, renal stones, surgery) severity (childbirth, renal stones, surgery) Cultural degree of stoicism Cultural degree of stoicism Cultural beliefs concerning the specif ic problem Cultural beliefs concerning the specif ic problem Personal mean ing of or beliefs about the specific Personal mean ing of or beliefs about the specific problemproblem Particular questions to a sk to elic it the patient's Particular questions to a sk to elic it the patient's explanatory model: explanatory model: What do yo u call your problem? What name does it What do yo u call your problem? What name does it have? have? What do yo u think caused your problem? What do yo u think caused your problem? Why do you think it started when it did? Why do you think it started when it did? What does your sickn ess do to yo u? What does your sickn ess do to yo u? What do yo u fear most about your sick ness? What do yo u fear most about your sick ness? What are the chief problems tha t your sickn ess has What are the chief problems tha t your sickn ess has caused you? caused you? What are the most important results you hope to What are the most important results you hope to receive fr om treatment? receive fr om treatment? What have you done so far to treat your illness ? What have you done so far to treat your illness ? Courtesy of Mack Lipkin, Jr., M.D. Courtesy of Mack Lipkin, Jr., M.D.1. Fun ctions 1. Fun ctions Determining the nature of the problem Determining the nature of the problem Objectives Objectives To enable the clinician to est ablish a To enable the clinician to est ablish a diagnosis or recomme nd further diagnost ic procedures, diagnosis or recomme nd further diagnost ic procedures, suggest a course of treatment, and predict the nature suggest a course of treatment, and predict the nature of the illness of the illness SKILLSSKILLS Know ledge base of disea ses, disorders, Know ledge base of disea ses, disorders, problems, and clinical hypotheses from multiple problems, and clinical hypotheses from multiple conceptual domains: biomedica l, sociocultural, conceptual domains: biomedica l, sociocultural, psychodynamic , and behavioral psychodynamic , and behavioral Ability to elicit data for the a bove conceptual domains Ability to elicit data for the a bove conceptual domains (encour aging the patient to tell his or her story: (encour aging the patient to tell his or her story: organizing the flow of the interview, the form of organizing the flow of the interview, the form of quest ions, the character ization of sympto ms, the quest ions, the character ization of sympto ms, the mental status examin ation) mental status examin ation) Ability to perceive data from multip le sources (histo ry, Ability to perceive data from multip le sources (histo ry, mental status examin ation, physicia n's subjective mental status examin ation, physicia n's subjective response to the patient, nonver bal cues, listening at response to the patient, nonver bal cues, listening at multipl e levels) multipl e levels) Hypothesis generation and testing Hypothesis generation and testing Developing a therapeutic relationship (function II) Developing a therapeutic relationship (function II)2. 2. Functions Functions Developing and mai ntaining a therapeutic relationship Developing and mai ntaining a therapeutic relationship Objectives Objectives The patient's willingne ss to provide diagnostic The patient's willingne ss to provide diagnostic information information Relief of physical and psychological distress Relief of physical and psychological distress Willingness to accept a treatment plan or a process of nego tiation Willingness to accept a treatment plan or a process of nego tiation Patient sati sfaction Patient sati sfaction Physician satisfaction Physician satisfaction SKILLSSKILLS Defining the natur e of the relationship Defining the natur e of the relationship Allowing the patient to tell his or her story Allowing the patient to tell his or her story Hearing, bearing, and tol erating the patient's expression of painful Hearing, bearing, and tol erating the patient's expression of painful feelings feelings Appropriate a nd genuine interest, empathy , support, and co gnitive Appropriate a nd genuine interest, empathy , support, and co gnitive unde rstandi ng unde rstandi ng Attending to co mmon pa tient concerns over embarrassment, Attending to co mmon pa tient concerns over embarrassment, shame , and humiliation shame , and humiliation Eliciting the patient's perspective Eliciting the patient's perspective Determining the natur e of the problem Determining the natur e of the problem Communicating information and re commending treatment Communicating information and re commending treatment (function (function 3.FUNGTIO NS Communicating information and 3.FUNGTIO NS Communicating information and implementing a treatme nt plan implementing a treatme nt plan OBJECTIVE OBJECTIVE Patient's u nderst anding of the i llness Patient's u nderst anding of the i llness Patient's u nderstand ing of the s uggested Patient's u nderstand ing of the s uggested diagnostic proc edures diagnostic proc edures Patient's u nderstand ing of the tr eatmen t Patient's u nderstand ing of the tr eatmen t possibilities possibilities Consen sus betwee n physician an d patient abo ut Consen sus betwee n physician an d patient abo ut the above items 1 to 3 the above items 1 to 3 Informed consent Informed consent Improve c oping mechan isms Improve c oping mechan isms Lifestyle changes Lifestyle changes SKILLSSKILLS Dete rmining the n ature of the problem (function Dete rmining the n ature of the problem (function I) I) Devel oping a th erapeutic relationship (function Devel oping a th erapeutic relationship (function II) II) Establi shing the dif ferences in per spective Establi shing the dif ferences in per spective between physician and patient between physician and patient Educational strategies Educational strategies Clinical nego tiations for c onflict resolution Clinical nego tiations for c onflict resolution Predictable Reac tions to Predictable Reac tions to Illness Illness Intrapsychic Intrapsychic Lowered self image Lowered self image loss loss Threat to homeostasis Threat to homeostasis fear fear Failure of (self) care Failure of (self) care helplessness , helplessness , hopelessness hopelessness Sense of loss of Sense of loss of control sham e (guilt) control sham e (guilt) Clinical Clinical Anxiety or depression Anxiety or depression Denial or anxiety Denial or anxiety Depression Depression Bargaining and Bargaining and blamin g blamin g RegressionRegression IsolationIsolation DependencyDependency AngerAnger Accepta nce Accepta nce Common Interview Tech niques Common Interview Tech niques Establ ish rappo rt as early in the interview as pos sible. Establ ish rappo rt as early in the interview as pos sible. Determine the pati ent's ch ief complaint. Determine the pati ent's ch ief complaint. Use the c hief complaint to de velop a provisional differential Use the c hief complaint to de velop a provisional differential diagnosis. diagnosis. Rule the various di agnostic pos sibilities out or in by using Rule the various di agnostic pos sibilities out or in by using focused and de tailed que stions. focused and de tailed que stions. Follow up on vague or obscure replies with enough pe rsistence Follow up on vague or obscure replies with enough pe rsistence to accurately determine the answ er to the question. to accurately determine the answ er to the question. Let the patient talk freely enoug h to obse rve how tightly the Let the patient talk freely enoug h to obse rve how tightly the thoug hts a re connected. thoug hts a re connected. Use a mixture of open-ended a nd closed-ended que stions. Use a mixture of open-ended a nd closed-ended que stions. Don't be afraid to a sk about topics that you or the pa tient may Don't be afraid to a sk about topics that you or the pa tient may find di fficult or embarrassing. find di fficult or embarrassing. Ask a bout sui cidal though ts. Ask a bout sui cidal though ts. Give the pati ent a chance to ask que stions at the end of the Give the pati ent a chance to ask que stions at the end of the interview. interview. Conclude the initial interview by conveying a sense of Conclude the initial interview by conveying a sense of confidence and, if pos sible, of hope . confidence and, if pos sible, of hope . Reprinted with per mission from Andreasen NC, Black D W. Reprinted with per mission from Andreasen NC, Black D W. Introduction Textbook of Psychiatry. Washington, DC: American Introduction Textbook of Psychiatry. Washington, DC: American Psychiatric Association, 1991. Psychiatric Association, 1991.Character and Qualities of the Character and Qualities of the Physician Physician Imper turbab ility The Imper turbab ility The ability to maintain ability to maintain extreme calm and extreme calm and steadinesssteadiness Presence of mind Self- Presence of mind Self- control in an control in an emergency or emergency or embarrassing embarrassing situation so that one situation so that one can say or do the right can say or do the right thingthing Clear j udgment The Clear j udgment The ability to make an ability to make an informed opinion that informed opinion that is intelligible a nd free is intelligible a nd free of ambiguity of ambiguityAbility to endure Ability to endure frustratio n The capacity to frustratio n The capacity to remain firm and deal with remain firm and deal with insecurit y and insecurit y and dissatisfaction dissatisfaction Infinite patienceThe Infinite patienceThe unlimited ability to hear unlimited ability to hear pain or trial calmly pain or trial calmly Charity toward othe rsTo Charity toward othe rsTo be gener ous a nd helpf ul, be gener ous a nd helpf ul, especially toward the especially toward the needy and suffering needy and sufferingCharacter and Qualities of the Character and Qualities of the Physician Physician The search for The search for absolute truth To absolute truth To inves tigate facts and inves tigate facts and pursue reality pursue reality Composure Calmness Composure Calmness of mind, bearing , and of mind, bearing , and appearan ce appearan ce Bravery The capacity Bravery The capacity to face or endu re to face or endu re events with courage events with courage  Tenacity To be Tenacity To be persistent in attaining persistent in attaining a goal or adhering to a goal or adhering to somet hing valued somet hing valuedIdeali sm Forming Ideali sm Forming standards and ideals standards and ideals and living under their and living under their influenceinfluence Equanimity The a bility Equanimity The a bility to handle stressful to handle stressful situations w ith an situations w ith an undisturbed, even undisturbed, even tempertemper Thank you Thank youDEMENSI A, DELI RIUM, DEMENSI A, DELI RIUM, AMNESTI C DISOR DER AMNESTI C DISOR DER EDIT DR LIZA EDIT DR LIZADeliriumDelirium Delirium is marked by shor t-term Delirium is marked by shor t-term confusion and changes in cognition. confusion and changes in cognition. There a re four subca tegories b ased There a re four subca tegories b ased on severa l causes: (1) ge neral on severa l causes: (1) ge neral medical condition ( e.g., infe ction); medical condition ( e.g., infe ction); (2) substa nce induced ( e.g., coca ine, (2) substa nce induced ( e.g., coca ine, opioids, ph ency clidine [PC P]); (3) opioids, ph ency clidine [PC P]); (3) multiple causes (e .g., hea d trauma multiple causes (e .g., hea d trauma and k idney disease); and (4) and k idney disease); and (4) delirium not otherwis e specif ied delirium not otherwis e specif ied (e.g., sle ep depri vation). (e.g., sle ep depri vation).Dementia Dementia Dementia is marked by severe impairm ent Dementia is marked by severe impairm ent in me mory, judg ment, orientation, and in me mory, judg ment, orientation, and cognition. The six subcategories are (1) cognition. The six subcategories are (1) dementia of the Alzheimer's type, which dementia of the Alzheimer's type, which usually occurs in pe rsons over 6 5 years of usually occurs in pe rsons over 6 5 years of age and is manifested by progres sive age and is manifested by progres sive intellectual disorientation and de mentia, intellectual disorientation and de mentia, delusions, or dep ression; (2) va scular delusions, or dep ression; (2) va scular dementia, caused by vessel thrombosis or dementia, caused by vessel thrombosis or hemorrhage; (3) other medical conditions hemorrhage; (3) other medical conditions (e.g., human im munodeficiency virus [HIV] (e.g., human im munodeficiency virus [HIV] disease, head trauma, Pick's disease, disease, head trauma, Pick's disease, Creutzfeldt-Jakob disease, which is cause d Creutzfeldt-Jakob disease, which is cause d by a slow-growing transmittable virus); (4) by a slow-growing transmittable virus); (4) substance indu ced, caused by toxin or substance indu ced, caused by toxin or medication (e.g., gasoline fume s, medication (e.g., gasoline fume s, atropin e); (5) m ultiple etiologies; and (6 ) atropin e); (5) m ultiple etiologies; and (6 ) not otherwis e specified (if cause is not otherwis e specified (if cause is unknown). unknown).Amnest ic Disorder Amnest ic Disorder Amnest ic disorder is ma rked by Amnest ic disorder is ma rked by memo ry impairment a nd memo ry impairment a nd forgetfulness . forgetfulness . The t hree subca tegories are (1) The t hree subca tegories are (1) caused by m edical condi tion caused by m edical condi tion (hypoxia); (2) ca used by toxin or (hypoxia); (2) ca used by toxin or medication (e.g., ma rijuana, medication (e.g., ma rijuana, diazepa m); and (3 ) not otherwi se diazepa m); and (3 ) not otherwi se specified.specified.