When patients develop this trust, they are more likely to comply with doctors And, I talked about developing a “relationship” with your doctor so you can effectively communicate. Keep track of your care (participate in your care). . Delivery Mode (CME/CE) · Quiz Time: Just How Many Teens Are Vaping?. Open, honest communication is the foundation of a strong doctor-patient relationship. But when you're in pain—and in pain every day—it can. Changes in the structure of the health care system have placed unprecedented stress on the surgeon-patient relationship. The essential trust placed in the.
While improved anesthetic techniques and minimally invasive procedures have allowed many more operations to be performed with shorter inpatient stays or even on an outpatient basis, the overall economic cost of surgical care is increasing.
By using capitation, among other cost control strategies, managed care insurers often shift the financial risk of health services use to physicians and facilities as a means to encourage cost-effective care. This linkage between the financing and provision of services has many patients and physicians concerned that appropriate and effective services could be withheld, creating tension between a physician's financial interest and a patient's health interest.
This conflict can undermine patients' trust in their physician's decisions, and represents a serious threat to the physician-patient relationship. Although most patients continue to have faith in their surgeons, public sentiment has largely turned against physicians and surgeons in general. Within this milieu, it behooves surgeons to reflect on the moral underpinnings of the surgeon-patient relationship. This article will draw on the extensive literature on the physician-patient relationship, emphasize its particular application to surgeons, and further define the moral obligations and responsibilities surgeons have to their patients.
Using an ethical framework grounded in patient trust, we will examine the impact of the recent changes in health care financing and provision and suggest ethical responses the surgical community should consider. Ethical underpinnings Until the midth century, Western codes of medical ethics were largely derived from the Hippocratic oath. While the original oath offered a set of specific behavior guides to the ancient followers of Pythagorus eg, it forbade sex with patientsthe Hippocratic corpus has been refined through the centuries to provide a moral framework for medical decision making.
The ethical precepts arising from the ancient tradition include beneficence the obligation to help the patientnonmaleficence the obligation to do no harm through negligence or designand confidentiality.
Absent from the precepts espoused by the ancient Greeks and their Stoic and later Roman interpreters, however, was a recognition of individual patient rights.
The Seductive Patient - Curbside Consultation - American Family Physician
Their code of ethics explicitly valued a paternalistic medicine in which the physician's responsibility to act in the best interests of the patient was valued above the rights of his patient. The AMA code enumerated many of the values of the ancient physicians, including a prohibition against abandoning patients, and the obligation to place patient interests first. In keeping with classical tradition, in its section on "Obligations of Patients to Their Physicians," the original AMA code called for total patient obedience.
Critics further charged that the focus of the initial AMA code was too heavily focused on physicians' rights and responsibilities to other physicians rather than on their duties to patients.
It was not until its final revision in that the AMA code explicitly prescribed respect for patients' rights and autonomy. Most prominent is Beauchamp and Childress' Principles of Biomedical Ethics, 9 which describes 4 prima facie principles: Prima facie principles are ethical precepts that must always be respected, unless there is a compelling, usually competing ethical reason to override them.
The first 2 principles, beneficence and nonmaleficence, reaffirm the ancient ethical tenets to act in the patient's best interests and to do no harm. The last 2 principles, autonomy and justice, reflect modern theories of moral obligations not found in the Hippocratic tradition. The principle of respect for autonomy requires that physicians recognize the right of individual patients to make their own health care decisions.
This represents a clear departure from the Hippocratic corpus and can seem to conflict with the principle of beneficence.Reaffirming the Doctor-Patient Relationship - Stephen Sanders - TEDxSaintLouisUniversity
For example, faced with a patient with severe leg ischemia and gangrene who refuses an amputation, a surgeon finds the need to respect patients autonomy by allowing him to refuse the procedure at odds with the physician's perception of what is in the patient's best interest assuming the patient prefers to continue living. In this case, the prima facie principles conflict and thus they provide the physician with no clear way to resolve this dilemma.
Although widely used, principle-based theories have been criticized for, among other things, the lack of a defined hierarchy that can be used to resolve conflicting ethical obligations ie, between the obligation of curing the patient through amputation and the obligation to respect the patient's right to refuse an operation. The fourth principle, justice, has received increased attention owing to rising costs and a growing proportion of uninsured citizens.
The progress of medical science and reliance on the market to allocate health care resources has placed issues of distributive justice in the spotlight of modern ethical thought. Physicians are being asked to participate, like others in the health care system, in efforts to control costs. These pressures are perhaps most dramatic for surgeons who control high-cost, limited resources such as organ transplantation and gamma knife neurosurgery, but are faced by almost all surgeons on a daily basis as they interact with insurers, utilization reviewers, case managers, and administrators.
The reality of limited resources and the influence some would contend interference of third-party payers in clinical medicine has placed increasing strains on the surgeon-patient relationship, to which we will now turn our attention. The surgeon-patient relationship The invasive and potentially life-threatening nature of surgical therapy fundamentally shapes the relationship between a surgeon and his patient and requires an extraordinary degree of trust from the patient and, correspondingly, ethical action by the surgeon.
Through the evaluation and therapy of a patient's condition, the power and control of the clinical encounter is gradually transferred from the patient to the surgeon. Initially, it is the patient who controls the relationship by choosing to visit the physician and to enter into treatment. Ideally, the surgeon and patient discuss therapeutic options and decide together how to proceed. Eventually, it is the surgeon and her operating team who assume total control during the operation.
This transfer of power and control differs substantively from the power dynamics between patients and practitioners in most other fields of medicine. Medical patients, in general, retain a substantial degree of control over their care. A patient with hypertension, for instance, may listen to her internist explain the risks and benefits of controlling her blood pressure with a variety of medications, but ultimately it is she who chooses to take her antihypertensive medication or modify her diet.
The complete, unavoidable, albeit temporary transfer of autonomy to the physician inherent in surgical therapy makes it imperative that surgeons fully appreciate moral obligations implicit in the surgeon-patient relationship.
Of course, these are generalizations, and the medical patient under heavy sedation for a colonoscopy or the surgical patient awake for a cystoscopy also require the patient to cede some control to his or her physician. Much empirical and ethical examination of the relationship between physicians and their patients has concentrated on the balance between 2 of the prima facie principles, autonomy and beneficence.
Prominent physician-ethicists Emanuel and Emanuel, 10 for instance, define 4 models of physician-patient relationships based on the primacy of either autonomy or beneficence. On one end of their spectrum, the paternalistic model, the physician asserts control of the clinical encounter by diagnosing and implementing treatment based on his interpretation of what is "best" for the patient.
For the patient with gangrene who refuses surgery, for instance, a paternalistic physician would insist on surgery, perhaps by threatening to withdraw services unless the patient complied. At the other extreme, the informative model, the physician merely lays out the medical options without judgment and allows the patient to choose.
This physician would merely state the risks and benefits of surgery compared with nonsurgical "treatment" of gangrene and passively accept the patient's decision. Their preferred model, the "deliberative" model, lies in the middle. The physician helps the patient to identify pertinent health values and to choose among medical alternatives within a personal context.
How to Communicate to Gain Your Doctor’s Trust
Thus, the physician should encourage the patient with the gangrenous leg to understand the risks of surgery and to try to overcome the fear of anesthesia. Furthermore, one should educate the patient about the potential of life after amputation, and the potential to return to a healthy, productive life. Through this process of education and discussion, the surgeon is able to establish or enhance the patient's trust in the physician and his or her surgical judgment.
When a patient presents with a health problem to the surgeon, either emergently or electively, he seeks the skills and advice of an expert who possesses the knowledge and skills inaccessible to the nonsurgeon. The patient thus trusts the surgeon with his life, well-being, and private information. Moral obligations of the surgeon stem from the establishment of this trust-based relationship.
The Doctor-Patient Relationship — Truth Prescriptions with Dr. Errin Weisman
A better understanding of trust-based relationships can serve as a practical guide for behavior in practice.
In fact, most physicians-in-training are unable to identify seductive behavior in their patients. Furthermore, many physicians recall little specific training about the appropriate boundaries to maintain with patients. In Maryland, all new physician licensees attend an orientation session that focuses on boundary issues. It seems apparent that many of these new doctors feel that they have not previously been provided with information on how to successfully navigate these uncharted waters.
The preclusion against becoming socially intimate with patients stems from two basic assumptions. The first is that the physician holds the greater power in the doctor-patient relationship by virtue of his or her training and position. Because of this disparity, patients might be exploited by their physicians. The onus, therefore, remains with the physician to act always in the patient's best interest. The second assumption is that when a dual relationship exists with a patient such as being both physician and loverobjectivity is lost.
As a result, subsequent treatment may be compromised. In addition, a large body of literature suggests that when physicians become intimate with their patients, the patients often suffer significant and lasting emotional harm.
The code of ethics of the American Psychiatric Association instructs psychiatrists that the doctor-patient relationship is an enduring one, which precludes them from pursuing a personal, social or sexual relationship even if the patient is no longer under their care.
Because patients may need to return for further therapy, personal involvement remains inadvisable. The codes of the American Medical Association and the American Osteopathic Association warn physicians of their duty to act in their patients' best interests and not to exploit the doctor-patient relationship. Beginning a personal relationship with a key third party might jeopardize the care of the patient. When instructing new licensees in the orientation sessions, I encourage them to terminate their doctor-patient relationship before pursuing a social relationship with a patient.
I also warn them that if their doctor-patient relationship included counseling or intimate examination of the patient, or if it was a long-term association, the risk remains that a subsequent personal relationship may be considered patient exploitation. Physicians often do not realize the enduring nature of the doctor-patient relationship and do not appreciate that the transference phenomenon is not limited to psychiatric care.
Even a brief association with the physician can significantly affect the patient. In these orientation sessions, someone always asks about the rural physician who has everyone in town for a patient.
In nine years serving on the Maryland Board of Physician Quality Assurance, that scenario never presented to me. The typical physician who is disciplined for having sex with patients is married and has been involved with multiple patients. The patient most often makes complaints about physical impropriety after the sexual relationship has ended or when a subsequent treating therapist supports the patient in making a complaint.
Often, the complaints come from the patient's spouse or even the physician's spouse. Licensing boards look at every complaint regarding physician impropriety and adjudicate it on the individual merits of the case.
The physician in this case scenario acted swiftly and appropriately to avoid becoming entangled in an inappropriate relationship. However, physicians must realize that, especially when they are personally stressed, they are vulnerable to becoming involved with their patients.
Many physicians who are disciplined for unprofessional conduct with patients become involved when they are in the midst of a divorce, are stressed by overwork, have a family member who is ill or have recently suffered a significant loss. During such times, a compassionate patient may end up hearing a lot about a doctor's troubles rather than having his or her own health needs addressed.
Physicians should realize that they can and should seek support and help from their colleagues when their personal troubles, rather than the patient's problems, become the focus of an office visit. Other warning signs indicating that the doctor-patient relationship may be becoming too intimate include scheduling favorite patients for the end of the day, offering free care, exchanging gifts and making arrangements to see the patient outside the office.
Finally, let's talk a bit about the seductive patient described in this case scenario. After one visit, she targeted the physician to be her next husband and supporter, and father to her child.