Patient-physician-relationship

This kind of relationship and interaction is a central process in the practice of Western medicine. There are many perspectives from which to understand and describe it.

An idealized physician’s perspective, such as is taught in medical school, sees the core aspects of the process as the physician learning the patient’s symptoms, concerns and values; in response the physician examines the patient, interprets the symptoms, and formulates a diagnosis to explain the symptoms and their cause to the patient and to propose a treatment. The job of a physician is similar to a human biologist: that is, to know the human frame and situation in terms of normality. Once the physician knows what is normal and can measure the patient against those norms, he or she can then determine the particular departure from the normal and the degree of departure. This is called the diagnosis.

The four great cornerstones of diagnostic medicine are anatomy (structure: what is there), physiology (how the structure/s work), pathology (what goes wrong with the anatomy and physiology) and psychology (mind and behavior). In addition, the physician should consider the patient in their 'well' context rather than simply as a walking medical condition. This means the socio-political context of the patient (family, work, stress, beliefs) should be assessed as it often offers vital clues to the patient's condition and further management.

A patient typically presents a set of complaints (the symptoms) to the physician, who then obtains further information about the patient's symptoms, previous state of health, living conditions, and so forth. The physician then makes a review of systems (ROS) or systems inquiry, which is a set of ordered questions about each major body system in order: general (such as weight loss), endocrine, cardio-respiratory, etc. Next comes the actual physical examination and often laboratory tests; the findings are recorded, leading to a list of possible diagnoses. These will be investigated in order of probability.

The next task is to enlist the patient’s agreement to a management plan, which will include treatment as well as plans for follow-up. Importantly, during this process the healthcare provider educates the patient about the causes, progression, outcomes, and possible treatments of his ailments, as well as often providing advice for maintaining health. This teaching relationship is the basis of calling the physician doctor, which originally meant "teacher" in Latin. The patient-physician relationship is additionally complicated by the patient’s suffering (patient derives from the Latin patior, "suffer") and limited ability to relieve it on his/her own. The physician’s expertise comes from his knowledge of what is healthy and normal contrasted with knowledge and experience of other people who have suffered similar symptoms (unhealthy and abnormal), and the proven ability to relieve it with medicines (pharmacology) or other therapies about which the patient may initially have little knowledge.

The physician-patient relationship can be analyzed from the perspective of ethical concerns, in terms of how well the goals of non-maleficence, beneficence, autonomy, and justice are achieved. Many other values and ethical issues can be added to these. In different societies, periods, and cultures, different values may be assigned different priorities. For example, in the last 30 years medical care in the Western World has increasingly emphasized patient autonomy in decision making.

The relationship and process can also be analyzed in terms of social power relationships (e.g., by Michel Foucault), or economic transactions. Physicians have been accorded gradually higher status and respect over the last century, and they have been entrusted with control of access to prescription medicines as a public health measure. This represents a concentration of power and carries both advantages and disadvantages to particular kinds of patients with particular kinds of conditions. A further twist has occurred in the last 25 years as costs of medical care have risen, and a third party (an insurance company or government agency) now often insists upon a share of decision-making power for a variety of reasons, reducing freedom of choice of healthcare providers and patients in many ways.

The quality of the patient-physician relationship is important to both parties. The better the relationship in terms of mutual respect, knowledge, trust, shared values and perspectives about disease and life, and time available, the better will be the amount and quality of information about the patient's disease transferred in both directions, enhancing accuracy of diagnosis and increasing the patient's knowledge about the disease. Where such a relationship is poor the physician's ability to make a full assessment is compromised and the patient is more likely to distrust the diagnosis and proposed treatment. In these circumstances and also in cases where there is genuine divergence of medical opinions, a second opinion from another physician may be sought or the patient may choose to go to another doctor.

In some settings, e.g. the hospital ward, the patient-physician relationship is much more complex, and many other people are involved when somebody is ill: relatives, neighbors, rescue specialists, nurses, technical personnel, social workers and others.

In non-Western societies, the physician/patient relationship may be couched in different terms. The illness may be seen as a violation of the spiritual realm and the cure will be seen likewise as having to take place in the spiritual realm. Violation of some spiritual rule can result in illness; persons distant to the patient may have caused illness by manoeuvres in the spiritual realm, by cursing or causing another practitioner / shaman / healer to place the curse. Powerful faith in these factors can result in serious illness or cure. Spirits can be part of a culture's usual pantheon, ancestor spirits or arbitrary new spirit forces arising independently or as derived from an existing object in the real world: such as an animist spirit coming from a totem animal, mountain or other thing. As in the scientific West, the practitioner is assumed to have special knowledge or power, and is paid by the patient in some form.

Text “The general practitioner”

Britain has a two-tier system of medical care. A person who is ill goes first to a primary care physician or general practitioner. The general practitioner treats most problems himself, and refers patients with unusual or serious illnesses to specialists for secondary care.

General practice is the “gateway” to specialist health care. But it is also becoming a spe­cialty in its own right. In Britain 99 percent of the population is registered with a general practi­tioner. Two-thirds of the population visits a general practitioner every year and 98 percent do so at least once every five years. The general practitioner can therefore offer preventive medicine and health education to almost everyone in the community. In the past the general practitioner dealt only with “ presenting complaints ”, that is, the symptoms and anxieties which patients brought along to the doctor. This is called reactive medicine, where the doctor does nothing un­til the patient has noticed that something is wrong. Modern general practice involves pro-active medicine, where the doctor makes contact with healthy people and offers medical care to peo­ple who have not asked for it.

Health education is another important aspect of modern general practice. The general practitioner is usually a well-known and respected member of the local community. People are more likely to accept the advice of their own general practitioner than that of a stranger or an “expert” on television. Advice from a general practitioner to stop smoking is the most cost-effective health policy in the developed world. Many general practitioners now organize “lifestyle” clinics, where patients can come for advice about smoking, diet, alcohol, exercise or stress reduction.

Perhaps the most important skill in general practice is communication. Even when a patient has seen a specialist, it is the general practitioner who explains the diagnosis to the patient and supervises the treatment of the illness. If the patient does not understand the problem, or if he finds the treatment painful or tedious, he may not follow the doctor’s advice. It is important to involve the patient in his own care. The days of “doctor’s orders” are gone. Some old-fashioned general practitioners do not like this new system, in which the patient often knows as much about his illness as the doctor, but many general practitioners find it both challenging and rewarding.

In Britain the general practitioner is also known as the family doctor. He provides primary care for patients “ from the cradle to the grave ”. If one member of a family has a serious illness, the general practitioner can give support and advice to the rest of the family. If necessary the general practitioner visits the patient at home. This unique relationship is often envied by other countries. In the United States, for example, each new illness requires a new specialist doctor who has probably never met the patient or the family before. This leads to a very reactive type of health care. The doctor treats the illness but does not – accept overall responsibility for the patient’s health. Most doctors do not see themselves as pro-active health care providers for a whole community. Recently, doctors in the United States have recognized this problem, and “family medicine” is now the fastest-growing medical specialty in that country.

Some specialists still think of general practice as a low-status and uninteresting branch of medicine. They think that the general practitioner does, little more than give out aspirin and weigh babies. But good general practice demands a wide range of skills. The general practitioner should know a little about every branch of medicine, and know when to ask a specialist for advice. To many people in the community, the general practitioner is “my doctor” – healer, adviser, helper and friend.

Дата добавления: 2015-11-16