Doctor-Patient Relationship and Initial Patient Interview

1. Doctor-Patient Relationship and Initial Patient Interview Michael Blumenfield, M.D. Professor of Psychiatry - NYMC Director of Medical Student Education in Psychiatry Director of C/L Psychiatry - Westchester Medical Center

3. “...Some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician.” Hippocrates Precepts, Chapter I

4. Placebo Effect • Placebo Effect is a combination of a psychological expectation blended with a neurochemical response that transforms an anticipated effect into a real effect

5. Placebo Effect • The Placebo Effect can positively or negatively effect pain, swelling, GI, CV, GU responses, mental state and side effects of treatment

6. Placebo Response • At least 20-30 % of patients have been shown to respond to treatment with placebo • Placebo pain response can be blocked by naloxone which suggests it is mediated by the endogenous opioid system

7. Transference • Expectation, beliefs and emotional responses that the patient brings to the doctor-patient relationship based on important relationships in the patient’s past

8. Positive Transference • Patient views doctor as good and has confidence in his or her ability • Can lead to over idealization and tremendous disappointment when doctor can’t solve all problems or is not always available

9. Positive Transference • Idealization of the the doctor can lead to having sexual feelings toward the doctor

10. Negative Transference • Patient views doctor as harsh punitive parent or authoritative figure who doesn’t care about well being and patient may be non-compliant

11. Negative Transference • Patient with experience with untrustworthy parent may seek many consultations and may be provocative to doctors

12. Countertransference • Refers to doctor’s reaction towards patient based on their own earlier experience

13. Countertransference • Doctors can feel guilty when they are unable to help patient • Doctor may have feelings towards patient who remind them of close relative or friend • Doctor may minimize the severity of another physician’s illness

14. Models of Doctor Patient Relationship

16. Doctor-Patient RelationshipAlternative Models

19. Empathy • The ability to momentarily experience the the feelings of another person ( put yourself in another person’s place)

20. Empathy -Components • Transiently experience feelings of the patient and use those feelings to gain understanding of the the patient’s subjective experience • Communication of that understanding to the patient

21. Empathy-Techniques of Learning • Intuitive - Reflect on emotions when with patient • Cognitive - Ask self how would I feel in patient’s situation • Cognitive- Relate to similar situation in own life ( ie. threat to you or a parent)

22. Empathy- Examples of empathic responses • You seem understandably upset with how things are going • It must have been very painful after the injury until you received pain medication • I am sorry (when learning of death of family member or friend of patient)

23. The Interview Process The Interview Process INE HRAA-VF- WAY5 To MAV WE mvF- WAY5TOMA14F- ~ WE RA.VF- Clinical Interview

24. Clinical Interview • Be Polite • Introduce yourself to patient • Make the patient comfortable • Initial Question-Invite the patient to tell you how he or she came to be in the hospital (chief complaint )

25. Clinical Interview • Listen to patient- Don’t interrupt patient especially at the beginning of the interview • Begin each topic with open ended question and close with detailed specific question

26. Clinical Interview • Pay attention to patient’s associations so you can return later to get more information • Be empathic- Respond to patient’s emotional reactions

27. Usual Order of Interview • Chief Complaint • History of Present Illness- • Elaborate all aspects of symptoms • Aggravating factors • Alleviating factors • Associated manifestations • Past Illness • Review of Systems

28. Usual Order of Interview • Mental Status Exam ( especially in psychiatric patients )

30. Let’s Go To The Video Tape !!!

31. Doctor-Patient Relationship and Initial Patient Interview Michael Blumenfield, M.D. Professor of Psychiatry - NYMC Director of Medical Student Education in Psychiatry Director of C/L Psychiatry - Westchester Medical Center