What a Patient Brings to the Doctor:

Cultural beliefs

Personality

1. Personal beliefs

2. Transference

3. Defense Mechanisms

4. Stoicism

The Patient’s PERSONAL STORY

Routinely check these areas of personal concern if appropriate

Personal Beliefs

(Core Beliefs*)

1. World:  Safe vs. Unsafe

2. Nature of Self:  Internal (commanding yourself) or External Locus of Control (outside forces command you).

3. Nature of Others: Loving or Hurtful, Honest or Dishonest

4. Purpose of Life: Spiritual Journey vs. Struggle for Survival

                           Service to Others vs. Quest for Power

5. Nature of God: Loving and Forgiving vs. Punishing

6. Family: Source of Love vs. Tension

The Health Belief Model:

Adherence is a function of how much threat the patient perceives.

Moderate fear levels are best for patient adherence.  This follows the Stress – Performance curve paradigm ( Yerkes-Dodson)

Perceived threat is a function of:

  Perceived seriousness

  Perceived susceptibility

External barriers to health care, such a finances and lack of insurance can prevent adherence even if the perceived threat is sufficient as there is a counter-balancing threat.

Patient Culture

Culture affects all stages of illness behavior

Experience of symptoms

Assumption of sick role

Medical care contact

Dependent patient role

Perceived Recovery

the patient will try to hide any reaction to pain, anxiety, stress or confusion. 

The patient believes that he should “just take it on the chin”, be “rational and not emotional”.

Waiting too long to seek treatment

  Not reporting symptoms that would assist in the

  diagnosis and treatment.

  Not asking questions

TRANSFERENCE:

TRANSFERENTIAL ATTITUDES

A patient's attitude toward a physician

A repetition of the attitude he or she has had toward authority figures (physician).

1. Realistic basic trust, with an expectation that the doctor has the patient's best interests at heart (good)

Transference Advice

-Your professional caring is likely to trigger in the patient a need to Give gifts of gratitude.

Don't except it. Clarify your role with the patient and allow the patient to “save face”.

Defense Mechanisms

-Protect us from realities that might cause conflict and anxiety by reducing the potential for anxiety.

-Protect us from anxiety (when ego and id collide).

The need for such protection through a defense mechanism is intensified by the stress of illness.

The Patients who are stressed about being ill may use more immature defense mechanisms!

Unconscious and are designed to protect our “ego” (the part of us that says who we should be) from unacceptable impulses that come from the “Id” (primitive drives for pleasure gratification,

aggression and sex).

Denial:     The patient unconsciously refuses to admit to being ill or to acknowledge the severity of the illness.  Initially it protects us from fear but can be destructive if it prevents us from seeking care. Delusional Denial (deny reality).

Regression:    The patient reverts to a more child-like pattern of behaving that may involve wanting more attention and time from the physician and others.

This male patient is “in denial” about the impact his drinking has had on his life.  He will use this denial to continue the behavior that is causing so much difficulty for him.

There are more pathological forms of denial in which the patient “Denies” the reality right in front of him or her – this form of denial is classically seen in psychosis.

1. Personal Beliefs about Patients

2. Stereotyping

3. Attribution 

We over-estimate the importance of the situation for ourselves.

We over-estimate the importance of internal characteristics (personality) for others.

-When others act bad, they’re Rude, Jerk. When it’s ourselves, it’s the situation.

Counter transference

-Just as patients bring transferential attitudes to doctor–patient relationships,

doctors themselves often have counter-transferential reactions to their patients.

-May take the form of negative feelings disruptive to the doctor–patient relationship

Or may also encompass disproportionately positive, idealizing, or even eroticized reactions.

-Be alert to any change from professional caring to romantic caring.

-Countertransference is an inappropriate reaction. Effective medical care involves being objectively vigilant and monitoring oneself.

Doctors may have problems with the following patients:

  1.  Those who repeatedly defeat attempts to help them

  2.  Those perceived as uncooperative

  3.  Those who request a 2nd opinion

  4.  Those who fail to recover after treatment

  5.  Those who use somatize (manifest mental pain as pain in one's body) their emotional problems

  6.  Those with chronic organic mental syndromes

  7.  Those who are in chronic pain

  8.  Those who are dying

  9.  Those with personality problems

This patient gives little response to our initial inquiries.

Non-focusing, open-ended skills may be ineffective.

-Gives very little information.

-Some students prefer this patient, as they can move “quickly”.  They may not recognize that the patient’s story is not being told. 

The Overly Talkative Patient

-This patient is irritating to those who prefer to control the interview process, and will be considered “easy to interview” by those interviews who are somewhat passive or uncertain about the interview.

-Developing an agenda is difficult.  Respectfully and tactfully interrupt and redirect.  Use firm, clear transition statements

“We need to now change our line of questions so that I can learn more about your constipation, if that is OK.”

-“Those are important details, but how did that make you feel emotionally?”

The Silent Patient

1. Silence is often uncomfortable

2. Silence has many meanings and many uses

3. Patients may use this to collect their thoughts, remember details or decide whether to not they trust you.

4. Be alert for nonverbal clues of distress

5. Silence may be the result of the interviewer’s lack of sensitivity

The Anxious Patient

Anxiety is often a natural response

  Severe anxiety is a cue to further problems

  Be very sensitive to the non-verbal cues the patient gives you

It is tempting to be overly reassuring

  Premature reassurance blocks communication

Angry and hostile patients

Understand that anger and hostility are often natural reactions

Often anger is being DISPLACED onto the clinician

Do not get angry in return

Continue talking normally and checking with the patient

Intoxicated Patients

Be accepting of the condition of intoxication.  You cannot change it.

Do not challenge substance use during intoxication.

Do not attempt to have the patient change symptoms brought on by intoxication, such as a loud voice, cursing or slurring of words, clumsy movements or confusion. 

Treat signs of potential violence as you would in any patient

Depressed Patient

Be alert for signs of depression

Be sure you find out how severe the depression is

Talk about the depression openly and clearly

Crying Patient

Ask about the crying, do not ignore it

Be empathetic

(Don’t go there there, or stop crying, or there is no need to cry)

Sexually attractive or seductive patient

Clinicians and patients may feel sexually attracted to the other

  Be aware of your own feelings and SUBLIMATE the feeling in order to

  care for the patient

  Accept sexual attraction as normal but prevent it from affecting

  your care of the patient

  If a patient becomes seductive or makes sexual advances, frankly but

  firmly make clear that your relationship is one of the health

  care provider not a personal one.

(Always ask 1 question on the USMLE's)

Responding to your patient

Her physician asks about recent stressors, she says that she has been arguing a lot with her parents, who are pressuring her to go to college.  The physician, who is concerned because his own daughter refuses to go to college, begins to feel angry with the patient.  The physician’s anger is an example of which of the following: