Authors: Sadock, Benjamin James; Sadock, Virginia Alcott

Title: Kaplan & Sadock's Snopsis o! "schiatr: Beha#ioral Sciences$%linical "schiatr, &'th (dition
%opright )*+'', -ippincott .illiams & .ilkins
/ Ta0le o! %ontents / & 1 The "atient2345octor 6elationship
&
The "atient2345octor 6elationship
The 7ualit o! patient234doctor or patient234therapist relationship is crucial to the practice o! medicine and
pschiatr8 The capacit to de#elop an e!!ecti#e relationship re7uires a solid appreciation o! the comple9ities
o! human 0eha#ior and a rigorous education in the techni7ues o! talking and listening to people8 To
diagnose, manage, and treat an ill person, doctors and therapists must learn to listen8 The need the skills o!
acti#e listening, :hich means listening 0oth to :hat the and the patient are saing and to the undercurrents
o! the unspoken !eelings 0et:een them ;<ig8 &1&=8 A phsician :ho monitors 0oth the content o! the
interaction ;:hat the patient and the doctor actuall sa= and the process ;:hat the patient or the doctor
mean to sa= reali>es that communication 0et:een t:o people occurs on se#eral le#els at once: :hat the
person 0elie#es a0out himsel! or hersel!; :hat he or she :ants others to 0elie#e a0out them; and !inall :ho
the person reall is8
An e!!ecti#e relationship is characteri>ed 0 good rapport8 6apport is the spontaneous, conscious !eeling o!
harmonious responsi#eness that promotes the de#elopment o! a constructi#e therapeutic alliance8 ?t implies
an understanding and trust 0et:een the doctor and the patient8 <re7uentl, the doctor is the onl person to
:hom the patients can talk a0out things that the cannot tell anone else8 @ost patients trust their doctors to
keep secrets, and this con!idence must not 0e 0etraed8 "atients :ho !eel that someone kno:s them,
understands them, and accepts them !ind that a source o! strength8 ?n his essa, 23A%aring !or the
"atient23B <rancis "ea0od, @858 ;&CC&234&D+,=, a talented teacher and clinician ;<ig8 &1+=, :rote:
The good phsician kno:s his patients through and through, and his kno:ledge is 0ought dearl8 Time,
smpath, and understanding must 0e la#ishl dispensed, 0ut the re:ard is to 0e !ound in that personal
0ond :hich !orms the greatest satis!action o! the practice o! medicine8 Ene o! the essential 7ualities o! the
clinician is interest in humanit, !or the secret o! the care o! the patient is in caring !or the patient8
(sta0lishing 6apport
(kkehard Ethmer and Sieglinde Ethmer de!ined the de#elopment o! rapport as encompassing si9
strategies: ;&= putting patients and inter#ie:ers at ease; ;+= !inding patients' pain and e9pressing
compassion; ;F= e#aluating patients' insight and 0ecoming an all; ;G= sho:ing e9pertise; ;H= esta0lishing
authorit as phsicians and therapists; and ;I= 0alancing the roles o! empathic listener, e9pert, and authorit8
As part o! a strateg !or increasing rapport, the de#eloped a checklist ;Ta0le &1&= that ena0les inter#ie:ers
to recogni>e pro0lems and re!ine their skills in esta0lishing rapport8
?n one sur#e o! ,'' patients, patients su0stantiall agreed that man phsicians do not ha#e the time or
inclination to listen and consider their !eelings, that phsicians do not ha#e enough kno:ledge o! the
emotional pro0lems and socioeconomic 0ackground o! their !amilies, and that phsicians increase their !ear
0 gi#ing e9planations in technical language8
(#aluating the pressures in patients' earl li#es helps pschiatrists 0etter understand patients8 (motional
reactions, health or unhealth, are the result o! a constant interpla o! 0iological, sociological, and
pschological !orces8 (ach stress lea#es 0ehind a trace o! its in!luence and continues to mani!est itsel!
throughout li!e in proportion to the intensit o! its e!!ects and the suscepti0ilit o! the human 0eing in#ol#ed8
"ast and current stresses should 0e determined to the !ullest e9tent possi0le8
(mpath
(mpath is a :a o! increasing rapport8 ?t is an essential characteristic o! pschiatrists, 0ut it is not a
uni#ersal human capacit8 An incapacit !or normal understanding o! :hat other people are !eeling appears
to 0e central to certain personalit distur0ances, such as antisocial and narcissistic personalit disorders8
Although empath pro0a0l cannot 0e created, it can 0e !ocused and deepened through training,
o0ser#ation, and sel!1re!lection8 ?t mani!ests in clinical :ork in a #ariet o! :as8 An empathic pschiatrist
ma anticipate :hat is !elt 0e!ore it is spoken and can o!ten help patients articulate :hat the are !eeling8
Jon#er0al cues, such as 0od posture and !acial e9pression, are noted8 "atients' reactions to the
pschiatrist can 0e understood and clari!ied8
"atients sometimes sa, 23AKo: can ou understand me i! ou ha#en't gone through :hat ?'m going
throughL23B %linical pschiatr, ho:e#er, is predicated on the 0elie! that it is not necessar to ha#e other
people's literal e9periences to understand them8 The shared e9perience o! 0eing human is o!ten su!!icient8
.hether in an initial diagnostic setting or in ongoing therap, patients dra: com!ort !rom kno:ing that
pschiatrists are not msti!ied 0 their su!!ering8
Trans!erence
Trans!erence is generall de!ined as the set o! e9pectations, 0elie!s, and emotional responses that a patient
0rings to the patient234doctor relationship8 The are 0ased not necessaril on :ho the doctor is or ho: the
doctor acts in realit 0ut, rather, on repeated e9periences the patient has had :ith other important authorit
!igures throughout li!e8
Trans!erential Attitudes
The patient's attitude to:ard the phsician is apt to 0e a repetition o! the attitude he or she has had to:ard
authorit !igures8 The patient's attitude can range !rom one o! realistic 0asic trust, :ith an e9pectation that
the doctor has
"8+
the patient's 0est interest at heart, through one o! o#erideali>ation and e#en erotici>ed !antas to one o!
0asic mistrust, :ith an e9pectation that the doctor :ill 0e contemptuous and potentiall a0usi#e8
<?MN6( &1& The acti#e listening descri0ed in the te9t is illustrated 0 the therapist's e9pression o! concern
!or :hat the patient is e9periencing8 The pschiatrist Karr Stack Sulli#an re!erred to the therapist as a
participant o0ser#er in the patient's li!e8 ;%ourtes o! %or0is=8
6ole o! the "schiatrist #ersus the Jonpschiatric "hsician
?n man respects, the role o! a pschiatrist di!!ers !rom that o! a nonpschiatric phsician, et man patients
e9pect the same !rom the pschiatrist as the do !rom other phsicians8 ?! the e9pect a doctor to take
action, gi#e ad#ice, and prescri0e medication to cure an illness, the ma :ell e9pect the same interaction
:ith a pschiatrist and 0e disappointed or angr i! it does not occur8 Trans!erential reactions can 0e
strongest :ith pschiatrists !or a num0er o! reasons8 <or e9ample, in intensi#e insight1oriented
pschotherap the encouragement o! trans!erence !eelings is an integral part o! treatment8 ?n some tpes o!
therap, a pschiatrist is more or less neutral8 The more neutral or less kno:n the pschiatrist is, the more a
patient's trans!erential !antasies and concerns are mo0ili>ed and projected onto the doctor8 Ence the
!antasies are stimulated and projected, the pschiatrist can help patients gain insight into ho: those
!antasies and concerns a!!ect all the important relationships in their li#es8 Although a nonpschiatrist does
not use or e#en need to understand trans!erence attitudes in that intensi#e :a, a solid understanding o! the
po:er and the mani!estations o! trans!erence is necessar !or optimal treatment results in an
patient234doctor relationship8
<?MN6( &1+ <rancis .8 "ea0od, @858 ;&CC&234&D+,=8 ;%ourtes o! the Jational -i0rar o!
@edicine8=
The doctor's :ords and deeds ha#e a po:er !ar 0eond the commonplace 0ecause o! his or her uni7ue
authorit and the patient's dependence on the doctor8 Ko: a particular phsician 0eha#es has a direct
0earing on the patient's emotional and e#en phsical reactions8
Ene patient repeatedl had high 0lood pressure readings :hen e9amined 0 a phsician he considered
cold, aloo!, and stern8 Ke had normal 0lood pressure readings, ho:e#er, :hen seen 0 a doctor he
regarded as :arm, understanding, and smpathetic8
%ountertrans!erence
Just as the patient 0rings trans!erential attitudes to the patient234doctor relationship, doctors themsel#es
o!ten ha#e countertrans!erential reactions to their patients8 %ountertrans!erence can take the !orm o!
negati#e !eelings that are disrupti#e to the patient234doctor relationship, 0ut it can also encompass
disproportionatel positi#e, ideali>ing, or e#en erotici>ed reactions to patients8 Just as patients ha#e
e9pectations !or phsicians23O!or e9ample, competence, lack o! e9ploitation,
"8F
o0jecti#it, com!ort, and relie!23Ophsicians o!ten ha#e unconscious or unspoken e9pectations o! patients8
@ost commonl, patients are thought o! as good patients i! their e9pressed se#erit o! smptoms correlates
:ith an o#ertl diagnosa0le 0iological disorder, i! the are compliant :ith treatment, i! the are emotionall
controlled, and i! the are grate!ul8 ?! those e9pectations are not met, the patient ma 0e disappro#ed o! and
e9perienced as unlika0le, un:orka0le, or 0ad8
Table 1-1 Checklist for Clinicians
The !ollo:ing checklist allo:s clinicians to rate their skills in esta0lishing and maintaining rapport8 ?t helps
them detect and eliminate :eaknesses in inter#ie:s that !ailed in some signi!icant :a8 (ach item is rated
23Aes,23B 23Ano,23B or 23Anot applica0le823B
Yes No N/A
&8 ? put the patient at ease8 23O 23O 23O
+8 ? recogni>ed the patient's state o! mind8 23O 23O 23O
F8 ? addressed the patient's distress8 23O 23O 23O
G8 ? helped the patient :arm up8 23O 23O 23O
H8 ? helped the patient o#ercome suspiciousness8 23O 23O 23O
I8 ? cur0ed the patient's intrusi#eness8 23O 23O 23O
,8 ? stimulated the patient's #er0al production8 23O 23O 23O
C8 ? cur0ed the patient's ram0ling8 23O 23O 23O
D8 ? understood the patient's su!!ering8 23O 23O 23O
&'8 ? e9pressed empath !or the patient's su!!ering8 23O 23O 23O
&&8 ? tuned in on the patient's a!!ect8 23O 23O 23O
&+8 ? addressed the patient's a!!ect8 23O 23O 23O
&F8 ? 0ecame a:are o! the patient's le#el o! insight8 23O 23O 23O
&G8 ? assumed the patient's #ie: o! the disorder8 23O 23O 23O
&H8 ? had a clear perception o! the o#ert and the therapeutic goals o! treatment8 23O 23O 23O
&I8 ? stated the o#ert goal o! treatment to the patient8 23O 23O 23O
&,8 ? communicated to the patient that ? am !amiliar :ith the illness8 23O 23O 23O
&C8 @ 7uestions con#inced the patient that ? am !amiliar :ith the smptoms o! the
disorder8
23O 23O 23O
&D8 ? let the patient kno: that he or she is not alone :ith the illness8 23O 23O 23O
+'8 ? e9pressed m intent to help the patient8 23O 23O 23O
+&8 The patient recogni>ed m e9pertise8 23O 23O 23O
++8 The patient respected m authorit8 23O 23O 23O
+F8 The patient appeared !ull cooperati#e8 23O 23O 23O
+G8 ? recogni>ed the patient's attitude to:ard the illness8 23O 23O 23O
+H8 The patient #ie:ed the illness :ith distance8 23O 23O 23O
+I8 The patient presented as a smpath1cra#ing su!!erer8 23O 23O 23O
+,8 The patient presented as a #er important patient8 23O 23O 23O
+C8 The patient competed :ith me !or authorit8 23O 23O 23O
+D8 The patient :as su0missi#e8 23O 23O 23O
F'8 ? adjusted m role to the patient's role8 23O 23O 23O
F&8 The patient thanked me and made another appointment8 23O 23O 23O
6eprinted :ith permission !rom Ethmer (, Ethmer S%8 The Clinical Interview Using DSM-IV. .ashington,
5%: American "schiatric "ress; &DDG8
5isliking a "atient
A phsician :ho acti#el dislikes a patient is apt to 0e ine!!ecti#e in dealing :ith him or her8 (motion 0reeds
counteremotion8 <or e9ample, i! the phsician is hostile, the patient 0ecomes hostile; the phsician then
0ecomes e#en angrier than 0e!ore, and the relationship deteriorates rapidl8 ?! the phsician can rise a0o#e
such emotions and handle a di!!icult patient :ith e7uanimit, the interpersonal relationship ma shi!t !rom
one o! mutual o#ert antagonism to one o! at least increased acceptance and grudging respect8 6ising a0o#e
such emotions in#ol#es 0eing a0le to step 0ack !rom the intense countertrans!erential reactions and
dispassionatel e9plore :h the patient is reacting to the doctor in such an apparentl sel!1de!eating :a8
The patient needs the doctor, and hostilit ensures that the needed help :ill occur in a less e!!ecti#e conte9t8
?! the doctor can understand that the patient's antagonism is in some :as de!ensi#e or sel!1protecti#e and
most likel re!lects trans!erential !ears o! disrespect, a0use, and disappointment, the doctor ma 0e less
angr and more empathic than other:ise8
5octors :ho ha#e strong unconscious needs to 0e all1kno:ing and all1po:er!ul ma ha#e particular
pro0lems :ith certain tpes o! patients8 These patients ma 0e di!!icult !or most phsicians to handle,
0ut23Oi! the phsician is as a:are as possi0le o! his or her o:n needs, capa0ilities, and limitations23Othe
patients :ill not 0e threatening8 Such patients include the !ollo:ing: those :ho repeatedl appear to de!eat
attempts to help themsel#es ;!or e9ample, patients :ith se#ere heart disease :ho continue to smoke or
drink=; those :ho are percei#ed as uncooperati#e ;!or e9ample, patients :ho 7uestion or re!use treatment=;
those :ho re7uest a second opinion; those :ho !ail to reco#er in response to treatment; those :ho use
phsical or somatic complaints to mask emotional pro0lems ;!or e9ample, patients :ith somati>ation
disorder, pain disorder, hpochondriasis, or !actitious disorders=; those :ith chronic cogniti#e disorders ;!or
e9ample, patients :ith dementia o! the Al>heimer's tpe=; and patients :ho represent a pro!essional !ailure
and, thus, are a threat to the phsician's identit and sel!1esteem ;!or e9ample, those :ho are ding or in
chronic pain=8
Se9ualit and the "hsician
"hsicians are 0ound to like some patients more than others8 Ko:e#er, i! the phsician !eels a strong
attraction to a patient and is tempted to act on the attraction, stepping 0ack and assessing the situation are
essential8 ?n some medical specialties in :hich the patient234doctor relationship is not particularl intimate or
intense, the prohi0ition against romantic in#ol#ement :ith patients ma not 0e strong8
"8G
?n other specialties, ho:e#er, especiall pschiatr, the ethical and e#en legal prohi0ition is important8 The
doctor is a po:er!ul !igure in the Nnited States culture and ma trigger man unconscious !antasies o! 0eing
rescued, taken care o!, and lo#ed8 5octors themsel#es ma ha#e their o:n unconscious !antasies o! 0eing
and needing to 0e all1po:er!ul, rescuing, and lo#ing8 Those !antasies are inherentl unrealistic and are
ine#ita0l disappointed8 The disappointments, i! reali>ed in a romantic relationship 0et:een the doctor and
the patient, can 0e destructi#e, especiall !or the patient8 "atient234therapist se9 is discussed !urther in
%hapter HD8
Another aspect o! se9ualit as it pertains to countertrans!erence issues relates to asking patients a0out
se9ual issues and o0taining a se9ual histor8 A reluctance to do so ma re!lect the phsician's o:n an9iet
a0out se9ualit or e#en an unconscious attraction to:ard the patient8 @oreo#er, the omission o! those
7uestions generall tells patients that the doctor is uncom!orta0le :ith the su0ject, thus leading to an
inhi0ition a0out discussing an num0er o! other sensiti#e su0jects8
Sel!1@onitoring o! %ountertrans!erence <eelings
%ountertrans!erence !eelings do not al:as ha#e to 0e percei#ed in negati#e terms8 The also ha#e the
potential, i! recogni>ed and anal>ed, to help the doctor 0etter understand the patient :ho has stimulated
the !eelings8 <or instance, i! a doctor !eels 0ored and restless :hen :ith a particular patient and has
ascertained that the 0oredom is not secondar to his or her o:n preoccupations, the doctor ma surmise
that the patient is speaking a0out tri#ial or insigni!icant concerns to a#oid real and potentiall distur0ing
concerns8
"hsicians as "atients
A special e9ample o! countertrans!erence issues occurs :hen the patient 0eing treated is a phsician8
"ro0lems that can arise in that situation include an e9pectation that the phsician1patient :ill take care o! his
or her o:n medications and treatment and the treating phsician's !ear o! criticism o! his or her skills or
competence8 "hsicians are notoriousl poor patients, most likel 0ecause phsicians are trained to 0e in
control o! medical situations and to 0e the masters o! the patient234doctor relationship8 <or a phsician,
0eing a patient ma mean gi#ing up control, 0ecoming dependent, and appearing #ulnera0le and
!rightened23O0eha#iors that most phsicians are pro!essionall trained to suppress8 "hsician1patients ma
0e reluctant to 0ecome :hat the percei#e as 0urdens to o#er:orked colleagues, or the ma 0e
em0arrassed to ask pertinent 7uestions !or !ear o! appearing ignorant or incompetent8 "hsician1patients
ma stimulate !ear in the treating phsicians :ho see themsel#es in the patient, an attitude that can lead to
denial and a#oidance on the part o! the treating phsician8
@odels o! ?nteraction Bet:een 5octor and "atient
The interactions 0et:een a doctor and patient23Othe 7uestions a patient asks, the :a in :hich ne:s is
con#eed and treatment recommendations are made23Ocan take di!!erent shapes8 ?t is help!ul in thinking
a0out the relationship to !ormulate 23Amodels23B o! interaction8 These are !luid concepts, ho:e#er8 A
talented, sensiti#e phsician :ill ha#e di!!erent approaches :ith di!!erent patients and indeed ma ha#e
di!!erent approaches :ith the same patient as time and medical circumstances #ar8
The paternalistic model8 ?n a paternalistic relationship 0et:een the doctor and patient, it is assumed
that the doctor kno:s 0est8 Ke or she :ill prescri0e treatment, and the patient is e9pected to
compl :ithout 7uestioning8 @oreo#er, the doctor ma decide to :ithhold in!ormation :hen it is
0elie#ed to 0e in the patient's 0est interests8 ?n this model, also called the 23Aautocratic
model,23B the phsician asks most o! the 7uestions and generall dominates the inter#ie:8
%ircumstances arise in :hich a paternalistic approach is desira0le8 ?n emergenc situations the
doctor needs to take control and make potentiall li!e1sa#ing decisions :ithout long deli0eration8 ?n
addition, some patients !eel o#er:helmed 0 their illness and are com!orted 0 a doctor :ho can
take charge8 ?n general, ho:e#er, the paternalistic approach risks a clash o! #alues8 A paternalistic
o0stetrician, !or e9ample, might insist on spinal anesthesia !or deli#er :hen the patient :ants to
e9perience natural child0irth8
The in!ormati#e model8 The doctor in this model dispenses in!ormation8 All a#aila0le data are !reel
gi#en, 0ut the choice is le!t :holl up to the patient8 <or e9ample, doctors ma 7uote H1ear sur#i#al
statistics !or #arious treatments o! 0reast cancer and e9pect :omen to make up their o:n minds
:ithout suggestion or inter!erence !rom them8 This model ma 0e appropriate !or certain one1time
consultations :here no esta0lished relationship e9ists and the patient :ill 0e returning to the
regular care o! a kno:n phsician8 At other times, the in!ormati#e model places the patient in an
unrealisticall autonomous role and lea#es him or her !eeling the doctor is cold and uncaring8
The interpreti#e model8 5octors :ho ha#e come to kno: their patients 0etter and understand
something o! the circumstances o! their li#es, their !amilies, their #alues, and their hopes and
aspirations, are 0etter a0le to make recommendations that take into account the uni7ue
characteristics o! an indi#idual patient8 A sense o! shared decision1making is esta0lished as the
doctor presents and discusses alternati#es, :ith the patient's participation, to !ind the one that is
0est !or that particular person8 The doctor in this model does not a0rogate the responsi0ilit !or
making decisions, 0ut is !le9i0le, and is :illing to consider 7uestion and alternati#e suggestions8
The deli0erati#e model8 The phsician in this model acts as a !riend or counselor to the patient, not
just 0 presenting in!ormation, 0ut in acti#el ad#ocating a particular course o! action8 The
deli0erati#e approach is commonl used 0 doctors hoping to modi! injurious 0eha#ior, !or
e9ample, in tring to get their patients to stop smoking or lose :eight8
These models are onl guides !or thinking a0out the doctor234patient relationship8 Ene is not intrinsicall
superior to an other, and a phsician ma use all !our approaches :ith a patient during a single #isit8
5i!!iculties are most likel to arise not !rom the use o! one or another o! the models, 0ut :ith the phsician
:ho is rigidl !i9ed in one approach and cannot s:itch strategies, e#en :hen indicated and desira0le8 The
models do not, moreo#er, descri0e the presence or a0sence o! interpersonal :armth8 ?t is entirel possi0le
!or patients to see a paternalistic or autocratic phsician as persona0le, caring, and concerned8 ?n !act, a
common image o! the small to:n or countr doctor in the earl part o! the +'th centur :as a man ;seldom a
:oman= totall committed to the :el!are o! his patients, :ho :ould come in the middle o! the night and sit at
the 0edside holding the patient's hand, :ho :ould 0e in#ited to Sunda dinner, and :ho e9pected his
instructions to 0e !ollo:ed e9actl and :ithout 7uestion8
?llness Beha#ior
The term illness 0eha#ior descri0es patients' reactions to the e9perience o! 0eing sick8 Aspects o! illness
0eha#ior ha#e sometimes 0een termed the sick role, the role that societ ascri0es to people :hen the are
ill8 The sick role can include 0eing e9cused !rom responsi0ilities and the e9pectation o! :anting to
"8H
o0tain help to get :ell8 ?llness 0eha#ior and the sick role are a!!ected 0 people's pre#ious e9periences :ith
illness and 0 their cultural 0elie!s a0out disease8 The in!luence o! culture on reporting and mani!estation o!
smptoms must 0e e#aluated8 <or some disorders, this #aries little among cultures, :hereas !or others, the
cultural mores ma strongl shape the :a the patient presents the condition8 The relation o! illness to !amil
processes, class status, and ethnic identit is also important8 The attitudes o! peoples and cultures a0out
dependenc and helplessness greatl in!luence :hether and ho: a person asks !or help, as do such
pschological !actors as personalit tpe and the personal meaning the person attri0utes to 0eing ill8 Some
people e9perience illness as o#er:helming loss; others see in the same illness a challenge the must
o#ercome or a punishment the deser#e8 Ta0le &1+ lists essential areas to 0e addressed in assessing illness
0eha#ior and help!ul 7uestions !or making the assessment8
Table 1-2 Assessment of Individual Illness Behavior
"rior illness episodes, especiall illnesses o! standard se#erit ;child0irth, renal stones,
surger=
%ultural degree o! stoicism
%ultural 0elie!s concerning the speci!ic pro0lem
"ersonal meaning o! or 0elie!s a0out the speci!ic pro0lem
"articular 7uestions to ask to elicit the patient's e9planator model:
&8 .hat do ou call our pro0lemL .hat name does it ha#eL
+8 .hat do ou think caused our pro0lemL
F8 .h do ou think it started :hen it didL
G8 .hat does our sickness do to ouL
H8 .hat do ou !ear most a0out our sicknessL
I8 .hat are the chie! pro0lems that our sickness has caused ouL
,8 .hat are the most important results ou hope to recei#e !rom treatmentL
C8 .hat ha#e ou done so !ar to treat our illnessL
%ourtes o! @ack -ipkin, Jr8, @858
"schiatric #ersus @edical1Surgical ?nter#ie:s
@ack -ipkin, Jr8, descri0ed three !unctions o! medical inter#ie:s: to assess the nature o! the pro0lem, to
de#elop and maintain a therapeutic relationship, and to communicate in!ormation and implement a treatment
plan ;Ta0le &1F=8 These !unctions are e9actl the same in pschiatric and surgical inter#ie:s8 Also uni#ersal
are the predominant coping mechanisms used in illness, 0oth adapti#e and maladapti#e8 These
mechanisms include such reactions as an9iet, depression, regression, denial, anger, and dependenc
;Ta0le &1G=8 "hsicians must anticipate, recogni>e, and address such reactions i! treatment and inter#ention
are to 0e e!!ecti#e8
"schiatric inter#ie:s ha#e t:o major technical goals: ;&= recognition o! the pschological determinants o!
0eha#ior and ;+= smptom classi!ication8 These goals are re!lected in t:o stles o! inter#ie:ing: the insight1
oriented, or pschodnamic, stle and the smptom1oriented, or descripti#e, stle8 ?nsight1oriented
inter#ie:ing attempts to elicit unconscious con!licts, an9ieties, and de!enses8 The smptom1oriented
approach emphasi>es the classi!ication o! patients' complaints and ds!unctions as de!ined 0 speci!ic
diagnostic categories8 The approaches are not mutuall e9clusi#e and, in !act, can 0e compati0le8 A
diagnosis can 0e descri0ed as precisel as possi0le 0 eliciting such details as smptoms, course o! illness,
and !amil histor and 0 understanding a patient's personalit, de#elopmental histor, and unconscious
con!licts8
"schiatric patients o!ten contend :ith stresses and pressures that di!!er !rom those o! patients :ho do not
ha#e a pschiatric disorder8 These stresses include the stigma attached to 0eing a pschiatric patient ;it is
more accepta0le to ha#e a medical or surgical pro0lem than a mental pro0lem=; communication di!!icult
0ecause o! disorders o! thinking; oddities o! 0eha#ior; and impairments o! insight and judgment that might
make compliance :ith treatment di!!icult8 Because pschiatric patients o!ten !ind it di!!icult to descri0e !ull
:hat is going on in their li#es, phsicians must 0e prepared to o0tain in!ormation !rom other sources8 <amil
mem0ers, !riends, and spouses can pro#ide critical data such as pre#ious pschiatric histor, responses to
medication, and precipitating stresses that patients ma not 0e a0le to descri0e themsel#es8
"schiatric patients ma not 0e a0le to tolerate a traditional inter#ie: !ormat, especiall in the acute stages
o! a disorder8 <or instance, a patient :ho has increased agitation or depression ma not 0e a0le to sit !or F'
to GH minutes o! discussion or 7uestioning8 ?n such cases, phsicians must 0e prepared to conduct multiple
0rie! interactions o#er time, !or as long as the patient is a0le, stopping and returning :hen the patient
appears a0le to tolerate more8
Studies sho: that a0out I' percent o! all patients :ith mental disorders #isit a nonpschiatric phsician
during an I1month period and that patients :ith mental disorders are t:ice as likel to #isit a primar care
phsician as are other patients8 Jonpschiatric phsicians should 0e kno:ledgea0le a0out the special
pro0lems o! pschiatric patients and the speci!ic techni7ues used to treat them8
Biopschosocial @odel
?n &D,,, Meorge (ngel at the Nni#ersit o! 6ochester, pu0lished a seminal paper that descri0ed the
0iopschosocial model o! disease, :hich stressed an integrated sstems approach to human 0eha#ior and
disease8 The 0iopschosocial model is deri#ed !rom general sstems theor8 The 0iological sstem
emphasi>es the anatomical, structural, and molecular su0strate o! disease and its e!!ects on the patient's
0iological !unctioning; the pschological sstem emphasi>es the e!!ects o! pschodnamic !actors,
moti#ation, and personalit on the e9perience o! illness and the reaction to it; and the social sstem
emphasi>es cultural, en#ironmental, and !amilial in!luences on the e9pression and the e9perience o! illness8
(ngel postulated that each sstem a!!ects, and is a!!ected 0, e#er other sstem8 (ngel's model does not
assert that medical illness is a direct result o! a person's pschological or sociocultural makeup 0ut, rather,
encourages a comprehensi#e understanding o! disease and treatment8
A dramatic e9ample o! (ngel's conception o! the 0iopschosocial model :as a &D,& stud o! the relation
0et:een sudden death and pschological !actors8 A!ter in#estigating &,' sudden deaths o#er a0out I ears,
he o0ser#ed that serious illness or e#en death can 0e associated :ith pschological stress or trauma8
Among the potential triggering e#ents (ngel listed are the !ollo:ing: the death o! a close !riend, grie!,
anni#ersar reactions, loss o! sel!1esteem, personal danger or threat and the letdo:n a!ter the threat has
passed, and reunion or triumphs8
"8I
Table 1-3 Three unctions of the !edical Intervie"
unctions #b$ectives %kills
?8 5etermining the
nature o! the pro0lem
&8 To ena0le the clinician to
esta0lish a diagnosis or
recommend !urther
diagnostic procedures,
suggest a course o!
treatment, and predict the
nature o! the illness
&8 Kno:ledge 0ase o! diseases, disorders,
pro0lems, and clinical hpotheses !rom
multiple conceptual domains:
0iomedical, sociocultural,
pschodnamic, and 0eha#ioral
+8 A0ilit to elicit data !or the a0o#e
conceptual domains ;encouraging the
patient to tell his or her stor: organi>ing
the !lo: o! the inter#ie:, the !orm o!
7uestions, the characteri>ation o!
smptoms, the mental status
e9amination=
F8 A0ilit to percei#e data !rom multiple
sources ;histor, mental status
e9amination, phsician's su0jecti#e
response to the patient, non#er0al
cues, listening at multiple le#els=
G8 Kpothesis generation and testing
H8 5e#eloping a therapeutic relationship
;!unction ??=
??8 5e#eloping and
maintaining a
therapeutic
relationship
&8 The patient's :illingness to
pro#ide diagnostic
in!ormation
+8 6elie! o! phsical and
pschological distress
F8 .illingness to accept a
treatment plan or a process
o! negotiation
G8 "atient satis!action
H8 "hsician satis!action
&8 5e!ining the nature o! the relationship
+8 Allo:ing the patient to tell his or her
stor
F8 Kearing, 0earing, and tolerating the
patient's e9pression o! pain!ul !eelings
G8 Appropriate and genuine interest,
empath, support, and cogniti#e
understanding
H8 Attending to common patient concerns
o#er em0arrassment, shame, and
humiliation
I8 (liciting the patient's perspecti#e
,8 5etermining the nature o! the pro0lem
C8 %ommunicating in!ormation and
recommending treatment ;!unction ???=
???8 %ommunicating
in!ormation and
implementing a
treatment plan
&8 "atient's understanding o!
the illness
+8 "atient's understanding o!
the suggested diagnostic
procedures
F8 "atient's understanding o!
the treatment possi0ilities
G8 %onsensus 0et:een
phsician and patient a0out
the a0o#e items & to F
H8 ?n!ormed consent
I8 ?mpro#e coping
mechanisms
,8 -i!estle changes
&8 5etermining the nature o! the pro0lem
;!unction ?=
+8 5e#eloping a therapeutic relationship
;!unction ??=
F8 (sta0lishing the di!!erences in
perspecti#e 0et:een phsician and
patient
G8 (ducational strategies
H8 %linical negotiations !or con!lict
resolution
6eprinted :ith permission !rom -a>are A, Bird J, -ipkin @ Jr, "utnam S8 Three !unctions o! the medical
inter#ie:: An integrati#e conceptual !rame:ork8 ?n: -ipkin Jr @, "utnam S, -a>are A, eds8 The @edical
?nter#ie:8 Je: Pork: Springer; &DCD:&'F8
The patient234doctor relationship is a critical component o! the 0iopschosocial model8 "hsicians must
ha#e 0oth a :orking kno:ledge o! the patient's medical status and 0e !amiliar :ith ho: the patient's
indi#idual pscholog and sociocultural milieu a!!ect the medical condition8
Table 1-& 'redictable (eactions to Illness
Intra)s*chic Clinical
-o:ered sel! image 2QR loss 2QR grie! An9iet or depression
Threat to homeostasis 2QR !ear 5enial or an9iet
<ailure o! ;sel!= care 2QR helplessness,
hopelessness
5epression
Bargaining and
0laming
Sense o! loss o! control 2QR shame ;guilt= 6egression
?solation
5ependenc
Anger
Acceptance
%ourtes o! @ack -ipkin, Jr, @858
Spiritualit
The role o! spiritualit and religion in sickness and health has gained ascendanc in recent ears, :ith some
suggesting that it 0ecome part o! the 0iopschosocial model8 Some e#idence suggests that strong religious
0elie!s, spiritual earnings, praer, and de#otional acts ha#e positi#e in!luences on a person's mental and
phsical health8 These issues are 0etter attended to 0 theologians than 0 phsicians; ho:e#er, doctors
need to 0e a:are o! spiritualit in their patients' li#es and sensiti#e to their patients' religious 0elie!s8 ?n some
instances, 0elie!s can impede medical care, such as the re!usal o! some religious groups to accept 0lood
trans!usions8 ?n most cases, ho:e#er, :hen treating patients :ith strong religious 0elie!s, the :ise phsician
:ill :elcome the colla0oration o! the pastoral counselor8
?nter#ie:ing (!!ecti#el
Ene o! the phsician's most important tools is the a0ilit to inter#ie: e!!ecti#el8 Through a skilled inter#ie:,
phsicians can gather the data necessar to understand and treat patients
"8,
and, in the process, to increase patients' understanding o!, and compliance :ith, the phsicians' ad#ice8
@an !actors in!luence 0oth the content and the process o! inter#ie:s8 "atients' personalities and character
stles signi!icantl in!luence reactions as :ell as the emotional conte9t in :hich inter#ie:s un!old8 Various
clinical situations23Oincluding :hether patients are seen on a general hospital :ard, on a pschiatric :ard, in
an emergenc room, or as outpatients23Oshape the 7uestions asked and the recommendations o!!ered8
Technical !actors such as telephone interruptions, the use o! an interpreter, note taking, and the patient's
illness itsel!23O:hether in an acute stage or in remission23Oin!luence the content and process o! the
inter#ie:8 ?nter#ie:ers' stles, e9periences, and theoretical orientations also ha#e a signi!icant impact8 (#en
the timing o! interjections such as 23Auh huh23B can in!luence :hen patients speak and :hat the do or
do not sa as the unconsciousl tr to !ollo: the su0tle leads and cues pro#ided 0 the doctor8
Beginning the ?nter#ie:
Ko: a phsician 0egins an inter#ie: pro#ides a po:er!ul !irst impression to patients, :hich can a!!ect the
:a the remainder o! the inter#ie: proceeds8 "atients are o!ten an9ious on !irst encounters :ith phsicians
and !eel 0oth #ulnera0le and intimidated8 A phsician :ho can esta0lish rapport 7uickl, put the patient at
ease, and sho: respect is :ell on the :a to conducting a producti#e e9change o! in!ormation8 This
e9change is critical to making a correct diagnosis and to esta0lishing treatment goals8
"hsicians should initiall make sure that the kno: a patient's name and that the patient kno:s the
phsician's name8 "hsicians should introduce themsel#es to other people :ho ha#e come :ith the patient
and should !ind out i! the patient :ants another person present during the initial inter#ie:8 The re7uest !or
the presence o! another person should 0e granted, 0ut the phsician should also attempt to speak :ith
patients pri#atel to determine i! there is anthing that the :ant the doctor to kno: 0ut :ould 0e reluctant to
sa in !ront o! someone else8
"atients ha#e a right to kno: the position and pro!essional status o! persons in#ol#ed in their care8 <or
e9ample, medical students should introduce themsel#es as such and not as doctors, and phsicians should
make it clear :hether the are consultants ;called in 0 another phsician to see the patient=, are co#ering
!or another phsician, or are in#ol#ed in the inter#ie: to teach students rather than to treat the patient8
A!ter the introductions and other initial assessments ha#e 0een made, use!ul and appropriate opening
remarks are as !ollo:s: 23A%an ou tell me a0out the trou0les that 0ring ou in todaL23B or 23ATell me
a0out the pro0lems ou ha#e 0een ha#ing823B <ollo:ing up :ith a second one such as 23A.hat other
pro0lems ha#e ou 0een e9periencingL23B o!ten elicits in!ormation that patients :ere reluctant to gi#e
initiall8 ?t also indicates to the patient that the doctor is interested in hearing as much as a patient :ants to
sa8
A less directi#e approach is to ask a patient 23A.here shall :e startL23B or 23A.here :ould ou pre!er
to 0eginL23B ?! a patient has 0een re!erred 0 another doctor !or consultation, the initial remarks can
indicate that the consulting doctor alread kno:s something a0out the patient8 <or instance, the consulting
doctor might sa, 23APour doctor has told me something a0out :hat has 0een trou0ling ou 0ut ?'d like to
hear !rom ou in our o:n :ords :hat ou'#e 0een e9periencing823B
@ost patients do not speak !reel unless the ha#e pri#ac and are sure that their con#ersations cannot 0e
o#erheard8 "hsicians :ho ha#e attended to such !actors as pri#ac, 7uiet, and a lack o! interruptions 0e!ore
the inter#ie: con#e to patients that :hat the sa is important and :orth o! serious consideration8
Sometimes a patient :ill appear !rightened at the 0eginning o! an inter#ie: and ma not :ant to ans:er
7uestions8 ?! this seems to 0e the case, the phsician ma comment on this impression directl in a gentle
and supporti#e :a and encourage the patient to talk a0out his or her !eelings a0out the inter#ie: itsel!8
Ackno:ledging a patient's an9iet is the !irst step in understanding and reducing it8 An e9ample o! :hat
could 0e said is 23A? notice that ou seem to 0e !eeling an9ious a0out talking :ith me8 ?s there anthing ?
can do or an 7uestions ? can ans:er that :ill make it easierL23B or 23A? kno: it can 0e !rightening to talk
to a doctor, especiall one ou'#e ne#er met 0e!ore, 0ut ?'d like to make it as com!orta0le !or ou as possi0le8
?s there anthing ou can put our !inger on that's making it tough !or ou to talk :ith meL23B
Another important initial 7uestion is 23A.h no:L23B A phsician should 0e clear a0out :h a patient has
chosen that particular time to ask !or help8 The reason ma 0e as simple as that it :as the !irst a#aila0le
appointment hour8 Ver o!ten, ho:e#er, people seek out doctors as the result o! particular e#ents that ha#e
increased stress8 These stress!ul e#ents ma 0e thought o! as precipitants, and the o!ten contri0ute
signi!icantl to patients' current pro0lems8 (9amples o! stress!ul precipitants include real or sm0olic losses,
such as deaths or separations; milestone e#ents ;!or e9ample, 0irthdas or anni#ersaries=; and phsical
changes, such as the presence or intensi!ication o! smptoms8
The ?nter#ie: "roper
?n the inter#ie: proper, phsicians disco#er in detail :hat is trou0ling patients8 The must do so in a
sstematic :a that !acilitates the identi!ication o! rele#ant pro0lems in the conte9t o! an ongoing empathic
:orking alliance :ith patients8
The content o! an inter#ie: is literall :hat is said 0et:een doctor and patient: the topics discussed, the
su0jects mentioned8 The process o! the inter#ie: is :hat occurs non#er0all 0et:een doctor and patient,
that is, :hat is happening in the inter#ie: 0eneath the sur!ace8 "rocess in#ol#es !eelings and reactions that
are unackno:ledged or unconscious8 "atients ma use 0od language to e9press !eelings the cannot
e9press #er0all, !or e9ample, a clenched !ist or ner#ous tearing at a tissue 0 a patient :ith an apparentl
calm out:ard demeanor8 "atients ma shi!t the inter#ie: a:a !rom an an9iet1pro#oking su0ject onto a
neutral topic :ithout reali>ing that the are doing so8 "atients ma return again and again to a particular
topic, regardless o! :hat direction the inter#ie: appears to 0e taking8 Tri#ial remarks and apparentl casual
asides can re#eal serious underling concerns, !or e9ample, 23AEh, 0 the :a, a neigh0or o! mine tells
me that he kno:s someone :ith the same smptoms as m son, and that person has cancer823B
Speci!ic Techni7ues
Ta0le &1H lists some common inter#ie: techni7ues8 Ethers are discussed 0elo: :ith e9amples8
"8C
Table 1-+ Common Intervie" Techni,ues
&8 (sta0lish rapport as earl in the inter#ie: as possi0le8
+8 5etermine the patient's chie! complaint8
F8 Nse the chie! complaint to de#elop a pro#isional di!!erential diagnosis8
G8 6ule the #arious diagnostic possi0ilities out or in 0 using !ocused and detailed 7uestions8
H8 <ollo: up on #ague or o0scure replies :ith enough persistence to accuratel determine the ans:er
to the 7uestion8
I8 -et the patient talk !reel enough to o0ser#e ho: tightl the thoughts are connected8
,8 Nse a mi9ture o! open1ended and closed1ended 7uestions8
C8 5on't 0e a!raid to ask a0out topics that ou or the patient ma !ind di!!icult or em0arrassing8
D8 Ask a0out suicidal thoughts8
&'8 Mi#e the patient a chance to ask 7uestions at the end o! the inter#ie:8
&&8 %onclude the initial inter#ie: 0 con#eing a sense o! con!idence and, i! possi0le, o! hope8
6eprinted :ith permission !rom Andreasen J%, Black 5.8 ?ntroduction Te9t0ook o! "schiatr8 .ashington,
5%: American "schiatric Association, &DD&8
Epen1(nded Versus %losed1(nded Suestions
?nter#ie:ing an patient in#ol#es a !ine 0alance 0et:een allo:ing the patient's stor to un!old at :ill and
o0taining the necessar data !or diagnosis and treatment8 @ost e9perts agree that an ideal inter#ie: 0egins
:ith 0road, open1ended 7uestioning, continues 0 0ecoming speci!ic, and closes :ith detailed direct
7uestioning8
An e9ample o! an open1ended 7uestion is 23A%an ou tell me more a0out thatL23B A closed1ended
7uestion :ould 0e 23AKo: long ha#e ou 0een taking the medicationL23B %losed1ended 7uestions can 0e
e!!ecti#e in generating speci!ic and 7uick responses a0out a clearl delineated topic8 %losed1ended
7uestions ha#e also 0een !ound e!!ecti#e in assessing such !actors as the presence or a0sence, !re7uenc,
se#erit, and duration o! smptoms8 Ta0le &1I summari>es some o! the pros and cons o! open1 and closed1
ended 7uestions8
6e!lection
?n the techni7ue o! re!lection, a doctor repeats to a patient, in a supporti#e manner, something that the
patient has said8 The goal o! re!lection is t:o!old: to assure the doctor that he or she has correctl
understood :hat the patient is tring to sa and to let the patient kno: that the doctor is percei#ing :hat is
0eing said8 The response is meant to let the patient kno: that the doctor is 0oth listening to the patient's
concerns and understanding them8 <or e9ample, i! a patient is speaking a0out !ears o! ding and the e!!ects
o! talking a0out these !ears :ith his or her !amil, the doctor might sa, 23A?t seems that ou are concerned
:ith 0ecoming a 0urden to our !amil823B This re!lection is not an e9act repetition o! :hat the patient has
said, 0ut rather a paraphrase that indicates the doctor has percei#ed the essential meaning8
Table 1-- 'ros and Cons of #)en-.nded and Closed-.nded /uestions
As)ect Broad0 #)en-.nded /uestions Narro"0 Closed-.nded /uestions
Menuineness Kigh
The produce spontaneous !ormulations8
-o:
The lead the patient8
6elia0ilit -o:
The ma lead to nonreproduci0le
ans:ers8
Kigh
Jarro: !ocus, 0ut the ma suggest
ans:ers8
"recision -o: Kigh
?ntent o! 7uestion is #ague8 ?ntent o! 7uestion is clear8
Time e!!icienc -o:
%ircumstantial ela0orations8
Kigh
@a in#ite es or no ans:ers8
%ompleteness o!
diagnostic co#erage
-o:
"atient selects topic8
Kigh
?nter#ie:er selects topic8
Acceptance 0 patient Varies
@ost patients pre!er e9pressing
themsel#es !reel; others !eel guarded and
insecure8
Varies
Some patients enjo clear1cut checks;
others hate to 0e pressed into a es or
no !ormat8
6eprinted :ith permission !rom Ethmer (, Ethmer S%8 The %linical ?nter#ie: Nsing 5S@1?V8 .ashington,
5%: American "schiatric "ress; &DDG8
<acilitation
5octors help patients continue in the inter#ie: 0 pro#iding 0oth #er0al and non#er0al cues that encourage
patients to keep talking8 Jodding one's head, leaning !or:ard in the chair, and saing, 23APes, and then
23T L23B or 23ANh1huh, go on,23B are all e9amples o! !acilitation8
Silence
Silence can 0e used in man :as in normal con#ersations, e#en to indicate disappro#al or disinterest8 ?n
the doctor234patient relationship, ho:e#er, silence can 0e constructi#e and, in certain situations, allo:
patients to contemplate, to cr, or just to sit in an accepting, supporti#e en#ironment in :hich the doctor
makes it clear that not e#er moment must 0e !illed :ith talk8
%on!rontation
The techni7ue o! con!rontation is meant to point out to a patient something to :hich the doctor thinks the
patient is not paing attention, is missing, or is in some :a dening8 The con!rontation is meant to help
patients !ace :hate#er needs to 0e !aced in a direct 0ut respect!ul :a8 <or e9ample, a patient :ho has just
made a suicidal gesture 0ut is telling the doctor that it :as not serious ma 0e con!ronted :ith the !ollo:ing
statement: 23A.hat ou ha#e done ma not ha#e killed ou, 0ut it's telling me that ou are in serious
trou0le right no: and that ou need help so that ou don't tr suicide again823B
%lari!ication
?n clari!ication, doctors attempt to get details !rom patients a0out :hat the ha#e alread said8 <or e9ample,
a doctor ma sa, 23APou are !eeling depressed8 .hen do ou !eel most depressedL23B
?nterpretation
The techni7ue o! interpretation is most o!ten used :hen a doctor states something a0out a patient's
0eha#ior or thinking o! :hich the patient ma not 0e a:are8 The techni7ue re7uires the doctor's care!ul
listening !or underling themes and patterns in the patient's stor8 ?nterpretations usuall help clari!
interrelationships that the patient ma not see8 ?t is a sophisticated techni7ue and should generall 0e used
onl a!ter the doctor has esta0lished some rapport :ith the patient and has a reasona0l good idea o! :hat
some interrelationships are8 <or e9ample, a doctor ma sa, 23A.hen ou talk a0out ho: angr ou are
that our !amil has not 0een supporti#e, ? think ou're also telling me ho: :orried ou are that ? :on't 0e
there !or ou either8 .hat do ou thinkL23B
"8D
Summation
"eriodicall during the inter#ie:, a doctor can take a moment and 0rie!l summari>e :hat a patient has said
thus !ar8 5oing so assures 0oth the patient and doctor that the doctor has heard the same in!ormation that
the patient has actuall con#eed8 <or e9ample, the doctor ma sa, 23AEK, ? just :ant to make sure that
?'#e got e#erthing right up to this point823B
(9planation
5octors e9plain treatment plans to patients in easil understanda0le language and allo: patients to respond
and ask 7uestions8 <or e9ample, a doctor ma sa, 23A?t is essential that ou come into the hospital no:
0ecause o! the seriousness o! our condition8 Pou :ill 0e admitted tonight through the emergenc room, and
? :ill 0e there to make all the arrangements8 Pou :ill 0e gi#en a small dose o! medication that :ill make ou
sleep8 The medication is called lora>epam, and the dose ou :ill 0e getting is '8+H mg8 ? :ill see ou again
!irst thing in the morning, and :e'll go o#er all the procedures that :ill 0e re7uired 0e!ore anthing else
happens8 Jo:, :hat are our 7uestionsL ? kno: ou must ha#e some823B Jote that :hen prescri0ing
medication, the patient should 0e ad#ised o! common ad#erse e!!ects8
Transition
The techni7ue o! transition allo:s doctors to con#e the idea that su!!icient in!ormation has 0een o0tained
on one su0ject; the doctor's :ords encourage patients to continue on to another su0ject8 <or e9ample, a
doctor ma sa, 23APou'#e gi#en me a good sense o! that particular time in our li!e8 "erhaps no: ou
could tell me a 0it more a0out an e#en earlier time in our li!e823B
Sel!16e#elation
-imited, discreet sel!1disclosure 0 phsicians ma 0e use!ul in certain situations i! phsicians !eel at ease
and can communicate a sense o! sel!1com!ort8 %on#eing this sense ma in#ol#e ans:ering a patient's
7uestions a0out :hether a phsician is married and :here he or she comes !rom8 A doctor :ho practices
sel!1re#elation e9cessi#el, ho:e#er, is using a patient to grati! un!ul!illed needs in his or her o:n li!e and is
a0using the role o! phsician8 ?! a doctor thinks that a piece o! in!ormation :ill help a particular patient 0e
more com!orta0le, the doctor can decide to 0e sel!1re#ealing8 The decision depends on :hether the
in!ormation :ill !urther a patient's care or i! it :ill pro#ide nothing use!ul8 (#en i! the doctor decides that sel!1
re#elation is not :arranted, he or she should 0e care!ul not to make the patient !eel em0arrassed !or asking
a 7uestion8 <or e9ample, the doctor ma sa, 23A? :ill 0e happ to tell ou :hether or not ? am married, 0ut
!irst let's talk a little a0out :h it is important !or ou to kno: that8 ?! :e talk a0out it, ?'ll ha#e a 0it more
in!ormation a0out :ho ou are and :hat our concerns are regarding me and m in#ol#ement in our
care823B 5o not take patients' 7uestions at !ace #alue alone8 @an 7uestions, especiall personal ones,
con#e not just natural curiosit 0ut also hidden concerns a0out the doctor that should not 0e ignored8
"ositi#e 6ein!orcement
The techni7ue o! positi#e rein!orcement allo:s patients to !eel com!orta0le telling a doctor anthing, e#en
a0out such things as noncompliance :ith treatment8 (ncouraging a patient to !eel that the doctor is not
upset 0 :hate#er the patient has to sa !acilitates an open e9change8 <or e9ample, a doctor might sa,
23A? appreciate our telling me that ou ha#e stopped taking our medication8 %an ou tell me :hat the
pro0lem :asL23B An e9perienced pschiatrist, in response to patients :ho :ere a!raid o! re#ealing
23Ashocking23B material in the initial inter#ie:, ma respond in the !ollo:ing manner: 23AA!ter all these
ears in practice ? don't think ? ha#e heard anthing that could shock me823B The implied acceptance o! all
things human usuall puts patients at ease8
6eassurance
Truth!ul reassurance o! a patient can lead to increased trust and compliance and can 0e e9perienced as an
empathic response o! a concerned phsician8 <alse reassurance, ho:e#er, is essentiall ling to a patient
and can 0adl impair the patient's trust and compliance8 <alse reassurance is o!ten gi#en !rom a desire to
make a patient !eel 0etter, 0ut once a patient kno:s that a doctor has not told the truth, the patient is unlikel
to accept or 0elie#e truth!ul reassurance8 ?n an e9ample o! !alse reassurance, a patient :ith a terminal
illness asks, 23AAm ? going to 0e all right, 5octorL23B and the doctor responds, 23AE! course ou're
going to 0e all right8 (#erthing's !ine823B An e9ample o! truth!ul reassurance is 23A?'m going to do
e#erthing possi0le to make ou com!orta0le, and part o! 0eing com!orta0le is !or ou to kno: as much as ?
kno: a0out :hat is going on :ith ou8 .e 0oth kno: that :hat ou ha#e is serious8 ?'d like to kno: e9actl
:hat ou think is happening to ou and to clari! an 7uestions ou ha#e823B The patient ma then 0e a0le
to talk openl a0out his or her !ear o! ding8
Ad#ice
?n man situations it is not onl accepta0le 0ut desira0le !or doctors to gi#e patients ad#ice8 To 0e e!!ecti#e
and to 0e percei#ed as empathic rather than inappropriate or intrusi#e, the ad#ice should 0e gi#en onl a!ter
patients are allo:ed to talk !reel a0out their pro0lems so that phsicians ha#e an ade7uate in!ormation
0ase !rom :hich to make suggestions8 At times, a!ter a doctor has listened care!ull to a patient, it 0ecomes
clear that the patient does not, in !act, :ant ad#ice as much as an o0jecti#e, caring, nonjudgmental ear8
Mi#ing ad#ice too 7uickl can lead a patient to !eel that the doctor is not reall listening 0ut, rather, is
responding, either out o! an9iet or !rom the 0elie! that the doctor inherentl kno:s 0etter than the patient
:hat should 0e done in a particular situation8 ?n an e9ample o! ad#ice gi#en too 7uickl, a patient sas, 23A?
can't take this medication8 ?t's 0othering me,23B and the phsician responds, 23A<ine8 ? think ou should
stop taking it, and ?'ll prescri0e something di!!erent823B A more appropriate response is 23A?'m sorr to
hear that8 Tell me :hat a0out the medication has 0een 0othering ou, and ?'ll ha#e a 0etter idea :hat :e
should do to make ou more com!orta0le823B ?n another e9ample, the patient sas, 23A?'#e reall 0een
!eeling do:n latel,23B and the doctor replies, 23A.ell in that case, ? think it's important that ou go out
and do some things that are !un, such as going to a mo#ie or taking a :alk in the park823B ?n this case, a
more appropriate and help!ul response could 0e 23ATell me more a0out :hat ou mean 0 23U!eeling
do:n23V823B
(nding the ?nter#ie:
"hsicians :ant patients to lea#e an inter#ie: !eeling understood and respected and 0elie#ing that all the
pertinent and important in!ormation has 0een con#eed to an in!ormed, empathic listener8 To this end,
doctors should gi#e patients a chance to ask 7uestions and should let patients kno: as much as possi0le
a0out !uture plans8 5octors should thank patients !or sharing the necessar in!ormation and let patients
kno: that the in!ormation con#eed has 0een help!ul in clari!ing the ne9t steps8 An prescription o!
medication should 0e spelled out clearl and simpl, and doctors should ascertain :hether patients
understand the prescription and ho: to take it8 5octors should make another appointment or gi#e a re!erral
and some indication a0out ho: patients can reach help 7uickl i! it is necessar 0e!ore the ne9t
appointment8
Speci!ic ?ssues in "schiatr
<ees
Be!ore clinicians can esta0lish an ongoing relationship :ith patients, the must address certain issues8 <or
instance, the must openl discuss pament o! !ees8 5iscussing these issues and an other 7uestions a0out
!ees !rom the 0eginning o! the relationship can minimi>e misunderstanding later8 @ost patients ha#e medical
insurance through health maintenance organi>ations ;K@Es= or @edicare8 K@Es pa !or doctors' #isits in
:hole or in part, 0ut onl i! the doctor is a mem0er ;or pro#ider= in the patient's plan8 Some plans ;called
point o! ser#ice plans= o!!er partial paments e#en i! the doctor is not a mem0er ;i8e8, he or she is called
23Aout1o!1net:ork23B=8 That should 0e clari!ied; other:ise, the patient ma ha#e to pa out1o!1pocket,
:hich he or she ma 0e un:illing or una0le to do8
"8&'
%on!identialit
"schiatrists and mental health pro!essionals should discuss the e9tent and limitations o! con!identialit :ith
patients, so that patients are clear a0out :hat can and cannot remain con!idential8 As much as phsicians
must legall and ethicall respect patients' con!identialit, it ma 0e :holl or partiall 0roken in some
speci!ic situations8 <or e9ample, i! a patient makes clear that he or she intends to harm someone, the doctor
has a responsi0ilit to noti! the intended #ictim8 Ether issues related to con!identialit include :ho has
access to the patient's medical record, in!ormation re7uired 0 insurance companies ;:hich ma 0e
e9tensi#e=, and the degree to :hich the patient's case :ill 0e used !or teaching purposes8 ?n all such
situations, the patient must gi#e permission !or the use o! medical records8 ;See %hapter HC !or a discussion
o! con!identialit8=
Super#ision
?t is 0oth commonplace and necessar !or doctors in training to recei#e super#ision !rom e9perienced
phsicians8 This practice is the norm in large teaching hospitals, and most patients are a:are o! it8 .hen
oung doctors are recei#ing super#ision !rom senior phsicians, patients should kno: !rom the 0eginning8
?n!orming patients is particularl important in pschiatr, in :hich the super#ision o! indi#idual pschotherap
cases is a routine and esta0lished practice and in :hich the pschiatric resident is re7uired to present
#er0atim accounts o! an entire therap session ;process notes= to a senior super#isor8 ?! a patient is curious
a0out the le#el o! the treating doctor's e9perience, the doctor or medical student should respond honestl
and not mislead the patient8 ?! the doctor is less than truth!ul and the patient later disco#ers this, the
relationship 0et:een doctor and patient ma 0ecome untena0le8
@issed Appointments and -ength o! Sessions
"atients need to 0e in!ormed a0out a doctor's policies !or missed appointments and length o! sessions8
"schiatrists generall see patients in regularl scheduled 0locks o! time ranging !rom &H to GH minutes8 At
the end o! this time, pschiatrists e9pect patients to accept the !act that the session is o#er8 Jonpschiatric
phsicians ma schedule some:hat di!!erentl, 0 putting aside F' minutes to an hour !or an initial #isit and
then perhaps scheduling patient #isits e#er &H to +' minutes !or !ollo:1up appointments8 "schiatrists :ho
are treating pschotic inpatients ma determine that a patient cannot tolerate a length session and ma
decide to see the patient in a series o! &'1minute sessions throughout the :eek8 .hate#er the policies,
patients must 0e made a:are o! them to pre#ent misunderstandings8
The same can 0e said a0out policies !or missed appointments8 Some doctors ask patients to gi#e +G hours'
notice to a#oid 0eing 0illed !or a missed session8 Ethers 0ill !or missed sessions regardless o! ad#ance
noti!ication8 Still others decide on a case101case 0asis or perhaps state a +G1hour rule, 0ut make
e9ceptions :hen :arranted8 Some doctors state that i! the recei#e ad#ance notice and can !ill the
appointment time, the :ill not charge !or missed sessions; others do not charge !or missed appointments at
all8 The choice is up to the indi#idual phsician, 0ut patients must kno: in ad#ance to make an in!ormed
decision a0out :hether to accept the doctor's polic or to choose another doctor8
A#aila0ilit o! 5octor
.hat are a doctor's o0ligations to 0e a#aila0le 0et:een scheduled appointmentsL ?s it incum0ent on
phsicians to 0e a#aila0le +G hours a daL Ence a patient enters into a contract to recei#e care !rom a
particular phsician, the doctor is responsi0le !or ha#ing a mechanism in place !or pro#iding emergenc
ser#ice outside scheduled appointment times8 "atients should 0e told :hat the mechanism is, :hether it is
an emergenc phone num0er or a co#ering phsician8 ?! the phsician is going to 0e a:a !or a period o!
time, co#erage 0 another phsician is necessar, and patients must 0e in!ormed ho: to reach the co#ering
doctor8 The should kno: that their doctor :ill 0e a#aila0le 0et:een appointments to ans:er pressing
7uestions and that e9tra appointments can 0e scheduled i! necessar8
.ithin these general parameters, ho:e#er, phsicians must make their o:n decisions a0out their a#aila0ilit
to speci!ic patients8 ?n some cases, doctors ma ha#e to place !irm limits on a#aila0ilit 0et:een sessions8
<or instance, patients :ho repeatedl call at all hours :ith concerns that are 0est addressed during
scheduled appointments should 0e respect!ull 0ut !irml discouraged !rom calling unnecessaril8 The can
0e reassured that all concerns :ill 0e addressed and i! insu!!icient time e9ists during the regular
appointment, another appointment can 0e made, 0ut the should 0e told that all nonemergenc concerns
:ill 0e postponed until the ne9t session8
<ollo:1Np
@an e#ents can disrupt the continuit o! the patient234doctor relationship8 Some o! these e#ents are
routine, such as residents ending their training and mo#ing on to another hospital; others are out o! the
ordinar and thus unpredicta0le, !or e9ample, :hen phsicians 0ecome ill and can no longer take care o!
their patients8 "atients must 0e assured that regardless o! :hat occurs in the course o! a particular
patient234doctor relationship, their care :ill 0e ongoing8
A comple9 situation arises :hen phsicians 0ecome ill and are una0le to continue caring !or patients8 .hen
the kno: in ad#ance that the :ill ha#e to interrupt therap, clear arrangements !or re!erral to other doctors
can 0e made8 Although arguments e9ist 0oth !or and against phsicians re#ealing their illnesses to patients,
it seems 0est to err on the side o! truth8 The in!ormation should 0e con#eed in as calm and nonthreatening
a :a as possi0le8 The reason !or telling the truth is that patients :ill !antasi>e reasons a0out :h the doctor
has stopped seeing them and ma !ear that something a0out them has made the doctor lea#e8
Nntruth!ulness in this situation also encourages the #ie: that 0eing ill is shame!ul or !rightening8 ?t is not the
role o! patients, ho:e#er, to take care o! their doctors; in!orming patients should not carr :ith it an sense
that a doctor's illness is a patient's 0urden8
Sualities o! the "hsician
"hsicians are dra:n to the !ield o! medicine !or man reasons8 These include a desire to help people, to
cure illness, to
"8&&
0e part o! a respected pro!ession or to hold a position o! authorit, and to e9ert some control o#er li!e and
death8 @an people :ho choose to 0ecome phsicians are per!ectionistic, demanding o! themsel#es, and
attenti#e to details8 These 7ualities can 0e adapti#e23Oin !act, are pro0a0l necessar23O0ut need to 0e
0alanced :ith health doses o! sel!1kno:ledge, humilit, humor, and kindness8 .illiam Esler, @858
;&C&G234&D&D=, phsician and teacher, discussed the characteristics and 7ualit o! the phsician in his 0ook
Ae7uanimitas, :hich are summari>ed in Ta0le &1,8 The are ideals to 0e stri#ed !or, 0ut the are rarel
reached8 "hsicians ;and other health care pro#iders= must 0e tolerant a0out the limits on :hat the can
realisticall and honestl accomplish8
Table 1-1 Character and /ualities of the 'h*sician2
?mpertur0a0ilit The a0ilit to maintain e9treme calm and steadiness
"resence o! mind Sel!1control in an emergenc or em0arrassing situation so that one can sa or do
the right thing
%lear judgment The a0ilit to make an in!ormed opinion that is intelligi0le and !ree o! am0iguit
A0ilit to endure
!rustration
The capacit to remain !irm and deal :ith insecurit and dissatis!action
?n!inite patience The unlimited a0ilit to hear pain or trial calml
%harit to:ard others To 0e generous and help!ul, especiall to:ard the need and su!!ering
The search !or a0solute
truth
To in#estigate !acts and pursue realit
%omposure %almness o! mind, 0earing, and appearance
Bra#er The capacit to !ace or endure e#ents :ith courage
Tenacit To 0e persistent in attaining a goal or adhering to something #alued
?dealism <orming standards and ideals and li#ing under their in!luence
(7uanimit The a0ilit to handle stress!ul situations :ith an undistur0ed, e#en temper
WA!ter .illiam Esler, @858
The demands on a phsician can 0e daunting8 ?n addition to the #ast amount o! kno:ledge and the skills
re7uired to practice medicine, the doctor must also de#elop the capacit o! 0alancing compassionate
concern :ith dispassionate o0jecti#it, the :ish to relie#e pain :ith the a0ilit to make pain!ul decisions, and
the desire to cure and control :ith an acceptance o! one's human limitations8 The lack o! these capacities
can lead a phsician to !eel o#er:helmed and depressed8 -earning to 0alance these interrelated aspects o!
the phsician's role allo:s the doctor to cope producti#el :ithin dail :ork that in#ol#es illness, pain,
sadness, su!!ering, and death8
6e!erences
Ale9ander M%, -antos J58 The doctor1patient relationship in the post1managed care era8 American Journal
o! Bioethics8 +''I;I;&=:+D234F+8
Balint J8 Should con!identialit in medicine 0e a0soluteL American Journal o! Bioethics8 +''I;I;+=:&D234+'8
Brod K8 <amil medicine, the phsician234patient relationship, and patient1centered care8 American Journal
o! Bioethics8 +''I;I;&=:FC234FD8
Broom A8 @edical specialists' accounts o! the impact o! the ?nternet on the doctor$ patient relationship8
Kealth8 +''H;D;F=:F&D234FFC8
<adlon J, "essach ?, Toker A8 Teaching medical students :hat the think the alread kno:8 (ducation !or
Kealth8 +''G;&,;&=:FH234G&8
<an VS, Burman @, @c5onell @B, <ihn S58 %ontinuit o! care and other determinants o! patient satis!action
:ith primar care8 J Men ?ntern @ed8 +''H; +';F=:++I234+FF8
<redericks @, Ediet JA, @iller S?, <redericks J8 To:ard a conceptual ree9amination o! the patient1phsician
relationship in the healthcare institution !or the ne: millennium8 J Jatl @ed Assoc8 +''I;DC;F=:F,C234FCH8
Ksu J, Kuang J, <ung V, 6o0ertson J, Jimison K, <rankel 68 Kealth in!ormation technolog and phsician1
patient interactions: ?mpact o! computers on communication during outpatient primar care #isits8 J Am @ed
?n!orm Assoc8 +''H; &+:G,G234GC'8
Jotko:it> AB, %lar!ield @8 The phsician as com!orter8 (ur J ?ntern @ed8 +''H; &I;+=:DH234DI8
-arson (B, Pao X8 %linical empath as emotional la0or in the patient1phsician relationship8 JA@A8
+''H;+DF:&&''234&&'I8
@anard 5., Keritage J8 %on#ersation analsis, doctor1patient interaction and medical communication8
@ed (duc8 +''H;FD;G=:G+C234GFH8
"iette J5, Keisler @, Krein S, Kerr (A8 The role o! patient1phsician trust in moderating medication
nonadherence due to cost pressures8 Arch ?ntern @ed8 +''H;&IH:&,GD234&,HH8
Tra#aline J@, 6uchinskas 6, 5'Alon>o M( Jr8 "atient1phsician communication: .h and ho:8 J Am
Esteopath Assoc8 +''H;&'H;&=:&F234&C8
.einer @, Biondich "8 The in!luence o! in!ormation technolog on patient1phsician relationships8 J Men
?ntern @ed8 +''I; +&;s&=:SFH8
.erner A, @alterud K8 ?t is hard :ork 0eha#ing as a credi0le patient: (ncounters 0et:een :omen :ith
chronic pain and their doctors8 Social Science & @edicine8 +''F;H,;C=:&G'D234&G&D8