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Special Issues in the Physician–Patient Relationship
The treatment phase – early, middle, or late (Table 4.4) – affects the structure of the physician–patient relationship in terms of both the issues to be addressed and the task to be accomplished by the physician and the patient. The early stage of treatment involves developing a rapport, forming shared initial goals, and initiating the working alliance. Education of the patient is important to the success of the physician–patient relationship in this stage, so that the patient learns what he or she can expect. In the middle stage of treatment, the physician and patient continuously refine their shared goals, and various interventions are tried. While this takes place, transference and countertransference are likely to emerge. How these are recognized and managed is critical to whether the relationship continues and is therapeutic.
In the later phase of treatment, the assessment of the out-come and plans for the future are the primary focus. The phy-sician and the patient discuss the end of their relationship in a process known as termination. Successes and disappointments associated with the treatment are reviewed. The physician must be willing to acknowledge the patient’s disappointments, as well as recognize her or his own disappointments in the treatment. The therapeutic alliance is strengthened in this stage when the physician accepts expressions of the patient’s disappointments, encourages such expressions when they are not forthcoming,
and prepares the patient for the future. Such preparations in-clude orienting the patient as to when he or she might seek fur-ther treatment (Ursano and Silberman, 2002). Solidifying the physician–patient relationship at the end of the treatment can be critical to the patient’s self-esteem and willingness to return if symptoms reappear (Table 4.5).
As a part of the termination process the physician and the patient must review what has been learned, discuss what changes have taken place in the patient and the patient’s life, and acknowledge together the sadness and joy of their leave-taking. The termination involves a mourning process even when treatment has been brief or unpleasant. Of course, when the physician–patient relationship has been rewarding, and both physician and patient are satisfied with what they have accom-plished, mourning is more intense and often characterized by a bittersweet sadness.
The physician–patient relationship takes place in a variety of treatment settings. These include the private office, community clinic, emergency room, inpatient psychiatric ward and general hospital ward. Psychiatrists treating patients in a private office may find that the relative privacy of this setting enhances the early establishment of trust related to confidentiality. In addi-tion, the psychiatrist’s personality is more evident in the private office where personal factors influencing choice of decor, room arrangement and location play a role. However, in contrast to the hospital or community setting, the private office generally lacks other evidence of the physician’s competence and humanness. In hospital and community settings, when a colleague greets the physician and the patient in the hall, or the physician receives a call for a consultation by a colleague or for a meeting, it indicates to the patient that the physician is qualified, skilled and humane.
On the other hand, therapeutic work conducted in the com-munity clinic, emergency room and general hospital ward often requires the psychiatrist and patient to adapt rapidly to meeting one another, assessing the problem, establishing treatment goals, and ensuring the appropriate interventions and follow-up. The importance of protecting the patient’s needs for time, predictabil-ity and structure can run counter to the demands of a busy serv-ice and unexpected clinical and administrative requirements. The psychiatrist must stay alert to the patient’s perspective but not all interruptions can be avoided. The patient can be informed and accommodated as much as possible, and any feelings of hurt, disappointment, or anger can be listened for by the physician and responded to empathically. At times, patients, particularly those with borderline personality disorder, may require transfer to an-other psychiatrist whose schedule can accommodate the patient’s exquisite needs for stability.
The boundaries of confidentiality are necessarily extended in hospital and community settings to include consultation withother physicians, nursing staff and often family members (Wise and Rundell, 2002). Particular attention must always be given to the patient’s need for and right to respect and privacy. Regardless of the setting, patients receiving medication must be fully informed about the potential risks and benefits of and alternatives to the recommended pharmacological treatment (Kessler, 1991). Patients must be educated about the risks and benefits of receiv-ing prescribed treatment and of not receiving treatment. This is an important component of maintaining the physician–patient relationship. Patients who are informed about and involved in de-cisions about medication respect the physician’s role and interest in their welfare. Psychiatrists must also pay particular attention to the meaning a patient attaches to any prescribed medication, particularly when the time comes to alter or discontinue its use (Ursano et al., 1991).
The change from inpatient to outpatient therapy involves the resumption of a greater degree of autonomy by the patient in the physician–patient dyad. The physician must actively encour-age this separation and its hope for the future. This transition is delicate for any therapeutic pair.
Managed care, broadly defined as any care of patients that is not determined solely by the provider, currently focuses on the economic aspects of delivering medical care, with little atten-tion thus far to its potential effects on the physician–patient relationship (Goodman et al., 1992). Discontinuity of care and the creation of unrealistic expectations on the part of patients have been raised as likely deleterious effects on that relation-ship (Emanuel and Brett, 1993). Other issues that can affect the physician–patient relationship include the erosion of con-fidentiality, shrinkage of the types of reimbursable services, and diminished autonomy of the patient and the physician in medical decision-making. Additionally, many managed care systems dictate a split treatment model, with the psychiatrist prescribing psychopharmacologic treatment and a separate clinician providing psychotherapy. In such a system, there are complicated challenges faced both by clinicians and patients. With neither party in complete control of decisions, the physi-cian–patient relationship can become increasingly adversarial and subservient to external issues such as cost, quality of life, political expediency and social efficiency (Siegler, 1993).
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