The Physician–Patient Relationship

Abstract

The relationship between a physician and his or her patient is the heart of medicine. The quality of this relationship is strongly influenced by the doctor’s communication skills and in turn has an impact on patient outcomes as well as on physician factors such as satisfaction, burnout, and malpractice risk. This chapter also explores the importance of patient education and ensuring understanding and reviews how to deliver bad news using the SPIKES model. Vignettes that highlight these learning issues will be presented, and readers will be invited to apply the problem-based approach to work through these vignettes.

“The good physician treats the disease; the great physician treats the patient who has the disease.”—Osler

*Co-first editor of the book

Appendices

Appendix A: Tables with Possible Answers to the Vignettes

Vignette 8.1: Mark Taylor

Table 8.1.1

Facts	Hypotheses	Information needed	Learning issues
Mr. Taylor has a CHF exacerbation	Mr. Taylor is not adherent to medications, possibly due to	What does the patient understand about his disease?	What are the factors that affect the doctor–patient relationship?
Mr. Taylor has frequent ER visits and clinic no-shows
	Financial difficulties	Is he taking his medications? Why not?	How does the doctor–patient relationship affect patient outcomes?
Mr. Taylor’s medication doses are increased and new medications are added at each visit	Lack of understanding of disease	Why is he not making clinic appointments?
You notice that your alliance with Mr. Taylor is poor	Improving the doctor–patient relationship may improve Mr. Taylor’s outcomes

Table 8.1.2

Facts	Hypotheses	Information needed	Learning issues
Mr. Taylor is not compliant with medications due to complexity of medication regimen and contextual factors	Medication compliance could be increased by simplifying the medication regimen and by using less costly medications	How can Mr. Taylor’s medication regimen be simplified?	What can physicians do to maximize patient adherence?
		What can Mr. Taylor afford? Can any of his medications be changed to generics so they are more affordable?	How can contextual factors affect patient outcomes?
Financial constraints limit Mr. Taylor’s ability to pay for medications	If nothing changes, Mr. Taylor will end up in the ED and hospital again soon		How can contextual factors be addressed?
Mr. Taylor is not following up due to lack of insurance

Table 8.1.3

Facts	Hypotheses	Information needed	Learning issues
The medication regimen is simplified by cutting the number of medications needed to half	The strong communication skills you used with Mr. Taylor have improved your doctor–patient relationship, which will increase the likelihood of Mr. Taylor’s adherence	Does Mr. Taylor take his medications and show up for clinic appointments now?	How does a strong doctor–patient relationship affect the physician?
The remaining medications are switched to generics and the new cost is US$16/month, which Mr. Taylor can afford	More affordable medications are likely to increase adherence	How does taking the time to understand Mr. Taylor’s situation and help him affect your judgments about this patient, how you feel about being a doctor, and your level of burnout?
The next appointment is set up through a local outreach clinic, which Mr. Taylor can afford	Simplified medication regimens are likely to increase adherence
	Having a follow-up appointment made through a more affordable clinic is likely to increase adherence

Vignette 8.2: Mrs. Gebreselassie

Table 8.2.1

Facts	Hypotheses	Information needed	Learning issues
Mrs. Gebreselassie is a 73-year-old Eritean woman who speaks Arabic only	Patient may not be aware of her diagnosis or treatment options due to language or cultural barriers	What does the patient understand about her disease?	How does the patient’s cultural and religious background affect her treatment considerations?
She is not aware of her cancer diagnosis, and you need to tell her the bad news	Patient may have good reasons for declining surgery, but you have not explored them	Are language or cultural barriers interfering with the patient’s understanding?	How should the provider deliver the bad news about the patient’s diagnosis?
Her cancer has not spread, and it can be cured by surgery		Why has the patient declined surgery? Are there other forms of treatment she may accept?
Patient declines surgery without offering an explanation

Table 8.2.2

Facts	Hypotheses	Information needed	Learning issues
The cancer has spread, possibly as a result of declining surgery	You made a medical error by not exploring the patient’s reasons for declining surgery and not offering other treatment options	What was Mrs. Gebreselassie’s reason for declining surgery, and is she open to any treatment options?	What questions should the physician ask to understand the patient’s explanatory model?
The oncologist wants to know why Mrs. Gebreselassie refused the surgery, and you are now being held accountable by a colleague	Patient may have been open to surgery or other treatment options if you had explored her explanatory model	Does Mrs. Gebreselassie understand her treatment options?	What model could the physician have used to guide a culturally sensitive encounter?
			How can the teach-back method be used to ensure patient understanding?

Table 8.2.3

Facts	Hypotheses	Information needed	Learning issues
You failed to address Mrs. Gebreselassie’s refusal in your last visit, and you did not offer alternative treatment options	Mrs. Gebreselassie would have likely agreed to surgery sooner if her concerns had been addressed	Will patient and her family sue you?	Should physicians apologize after a medical error?
		Will an apology affect your risk of being sued?
The patient had religious reasons for not pursuing the surgery			How should physicians offer an apology?
You made a medical error and are at risk for being sued			How does the doctor–patient relationship affect malpractice risk?
You are not sure whether you should apologize for your medical error

Appendix B: Answers to Review Questions

• 1. D

• 2. B

• 3. C