The+Doctor+Patient+Relationship

Name: Anton Glebov Student Number: n8093415 Tutor: Sophie Miller Tutorial: Thursday 2-3

**The Doctor Patient Relationship: How Culturally ‘Clued-In’ our Primary and Emergency Service Providers?**

Artifact

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This footage from the popular medical comedy show ‘Scrubs’ depicts a patient who subscribes to unsourced internet advice rather than the advice of his physician. The physician becomes frustrated by this and, after getting the patient to give him a high rating on a website, takes the computer away whilst verbalising his true opinion regarding the raw food diet suggested by Wikipedia. (ABC Studios, 2009)

Public Health Issue

“I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.”

-Hippocratic Oath (1964)

The fundamental roles of a doctor outlined in the Hippocratic Oath stipulate the necessity to develop a warm, rewarding, yet professional relationship with patients. Even prior to this 1964 amended version, the history of medical treatment enforces the importance of developing positive relationships in order to help build confidence, trust, and mutual respect (Dugdale, Siegler & Rubin (2008, p. 547). Kuba & Sooriakumaran (2007, p. 63) have observed a generational gap which has begun to emerge where technologically knowledgeable patients have begun to self-diagnose and, as shown in the artefact, potentially undervalue the professional opinion of their physician. More significantly, increasing cultural diversity in Australia due to rising immigration levels (Australian Bureau of Statistics, 2010) have made these cultural barriers more apparent within the doctor-patient relationship. Ferguson & Candib (2002, p. 353) state that ethnic minorities or patients who speak little English are less likely to be engaged in medical decision making, receive less empathy, and overall are less likely to generate a relationship with their practitioner. This can have a devastating effect on the patients outlook regarding treatment, the health system, and the amount of confidence they have in the handling of their most important asset; their health (Anderson, Devitt, Cunningham, Preece & Cass, 2008, p. 499).

Literature review

A common theme among the relevant literature is the value of the doctor-patient relationship and how complex and multifaceted it can truly be. Dugdale et al. (2008, p. 547) argue that the doctor patient relationship is an integral part of medical professionalism, and that ethical practices and a demonstration of a strong commitment to the well-being of the patient are key principles in providing personal treatment and aid in building trust and gratitude. Despite this, often a physician’s medical knowledge or interest in assisting the patient can prove insufficient, and more trivial indicators can take precedence. These indicators may include a physician’s interpersonal skills, shared interests, or the patients ‘gut feeling’ (Skirbekk, Middelthon, Hjortdahl &Finset, 2011, p. 1182). This same study suggests that patients primarily want to feel interested in as a person. The sub context of this can be further explained when matched with Francis Peabody’s observations in 1925, where he noted patients often lose their personal identity after being admitted into hospitals, and are treated with impersonal expertise and superior knowledge rather than compassion, empathy, understanding and patience (Dugdale et al., 2008, p. 547). Therefore the following theory can be formed; while the amount of expertise and medical knowledge a physician possesses is important, a deeper and more rewarding relationship is forged when a physician takes the time to understand their patient’s expectations, fears, and needs.

The World Wide Web provides an immense and immeasurable wealth of information, and the debate rages as to whether this is helpful or damaging in the formation and maintenance of the doctor patient relationship. Marcinkiewicz & Mahboobi (2009, p. 2) state that while patients who seek information online still value their physicians’ input over the information they obtain from the internet, they are more likely to be involved and informed in their treatment regimens resulting in improved commitment to changing lifestyle factors due to their newfound understanding. In addition to this, doctors are more able to engage patients in medical decision making and work with them to develop treatment plans which cater to the patient’s needs, creating an environment where the two parties can openly exchange information and ideas (Tourtier, Mangouka & Auroy, 2011). Here the benefits are clear; the patient can feel more confident and in control of their encounters with their physician, and the physician is able to speak in more straightforward terms and spend less time explaining simple ideas the patient has already obtained for themselves.

The negative effects of the World Wide Web on this relationship arise primarily from misunderstandings. Lo & Parham (2010, p. 17) state that approximately 40% of physicians felt that patients bringing information from the internet with them to a practice resulted in reduced efficiency, particularly if they felt challenged by the patients inappropriate treatment suggestions. Marcinkiewicz & Mahboobi (2009, p. 2) also identify much of the information found on the internet is unreliable or not provided in context, resulting in the patient displaying similar symptoms to a hypochondriac. Lo & Parham (2010, p. 20) confirm this by stating only 25% of patients who seek medical information from the internet check the source. This research shows that properly sourced information can aid in the development of a rewarding relationship, while unsourced medical data can undermine the trust between the two parties.

The parameters in the formation of a rewarding doctor patient relationship are difficult to achieve for two likeminded people of similar backgrounds, but are even further complicated by the inherent difficulties presented by cross-cultural communication. A literature review conducted by Ferguson & Candib (2002, p. 353) found consistent evidence that concluded that differences in ethnicity or language are strong influencing factors in the formation of a doctor patient relationship. Perloff, Bonder, Ray, Ray & Siminoff (2006, p. 836) confirm this by stating the fundamental differences in both verbal and non-verbal communication styles of two different ethnicities can greatly exaggerate the existing difficulties associated with patient to doctor communication and vice-versa. For example, a patient will rarely state openly to the doctor that they trust the physician; it is an unspoken understanding that is either achieved or not (Skirbekk et al., 2011, p. 1183). In a situation where cultural differences can mask fear, misunderstanding, or uncertainty, unspoken connections may be misinterpreted resulting in a false sense of an accomplished relationship being formed. Anderson et al. (2008, p. 499) provide an example of this via a qualitative study of Aboriginal people receiving dialysis treatment, and their experiences with their physicians when they were first informed they were experiencing kidney failure. Their research reports mass dissatisfaction and confusion regarding the information surrounding the biomedical, pathophysiological and treatment details of the patients’ kidney failure. Many Indigenous patients felt confused by the advanced language of their physician, and language barriers along with a cultural distrust prevented them seeking further information (Anderson et al., 2008, p. 499). The physicians involved would often perceive this lack of questioning to equate to satisfaction in the provided medical information, and would not provide further explanation unless prompted, creating an even more intense sense of frustration among the Indigenous patients. This research demonstrates the cultural and social barriers to open communication, resulting in the doctor patient relationship suffering.

The blanket solution for rectifying these short comings in the formation of doctor patient relationship has been increased on the job training, primarily focused on cultural competence. The use of role modelling is the most effective way to do this, however it is the most inconsistent one (Egnew & Wilson, 2011, p. 99). Ferguson & Candib (2002, p. 353) argue that due to the inconsistencies in role modelling the ultimate way to rectify this is to bypass ethnic majority doctors treating ethnic minorities and either introduce the use of a professional interpreter, or provide the option for patients to see a physician who shares their ethnic background. The limitations of these studies coupled with their lack of explanation regarding how these strategies would actually be implemented make it difficult to assess how effective these solutions would really be. Skirbekk et al. (2011, p. 1183) observe that the development of trust is a constantly changing and evolving social construct which is never accurately measurable. Therefor the limitations regarding the methodologies of any study researching doctor patient relationships possess inherent risks associated with examining any non-constant variable. The best that can be achieved is a snapshot of a situation, and even that snapshot is likely to change drastically and over short amount of time. However, the studies throughout this literature review provide consistent data across different cultures and countries which have been gathered over an extended period of time. Even though the scope of some individual studies is limited, the consensus of information helps to build a foundation of certainty.

Cultural and Social Research Based Analysis

To understand this health issue social and cultural groups experiencing the most difficulty forming a positive doctor patient relationship need to be identified and researched accordingly. Ferguson & Candib (2002, p. 353) not only identify that race, ethnicity and language are influencing factors in the relationship between a physician and his patient, but that ethnic minorities are underrepresented in research. Only 25% of studies take into account non-English speaking people, and only a small minority of these have scarce references regarding socioeconomic status (Ferguson & Candib, 2002, p. 353). With little research in understanding the most affected groups, the real social and cultural issues have not been effectively identified. Therefore the ability to develop and monitor solutions for these groups is greatly diminished. Current role model based solutions aren’t meeting the needs of the patients, and the sheer amount of variables involved in teaching a physician communication skills to develop relationships across of the vast scope of different cultures poses a daunting challenge (Egnew & Wilson, 2011, p. 99).

In Australia, the primary cultural group experiencing severe repercussions of poor communication and relationship development are Indigenous Australians. Anderson et al. (2008, p. 499) states that language and cultural barriers prevent the open exchange of medical information, and recommends increasing the use of interpreters to optimise the information given to Aboriginal patients. At Royal Darwin Hospital the necessity and cultural push for increased communication channels has resulted in Aboriginal Research and Development Services (ARDS) employing interpreters to improve patient understanding of their conditions, as well as helping patients to feel more comfortable in their surroundings (ARDSInc YouTube video, 2007). The success of this program can be perceived as confirming the idea presented by Ferguson & Candib (2002, p. 353); the problematic and inconsistent process of training physicians to communicate with cultural minorities is best bypassed in favour of providing the option of interpreters or ethnic minority physicians.

Analysis of Artefact and Learning Reflections

The Artefact represents the potential volatility of the doctor patient relationship. The clip shows technology and the World Wide Web fuelling the dispute due to the patients’ disregard for the physician’s professional opinion in favour of a Wikipedia article. This doesn’t just have to reflect the effect technology has on the doctor patient relationship, this also symbolises how a doctor might react if a patient had a cultural belief in an alternative therapy or had the desire to deviate from the treatment plan the doctor had developed. The sarcastic manner in which the doctor treats the patient at the end of the clip is a perfect example of a doctor feeling challenged and unappreciated, while the patient might be feeling unhappy because he is unable to have any input in his own treatment plan. To protect the relationship the physician could have calmly explained the medical reasons a raw food diet would be ineffective, and why something like chemotherapy would have been a superior option.

Reflecting on this assessment piece I find it incredible that people often don’t have the patience and tolerance to help another human being from another culture understand their condition better and to help ease them through a confusing and terrifying time. There is no doubt that in the past I have overlooked someone who didn’t fully understand what I was saying and needed clarification, but when a physician is in the position of power that superior medical knowledge gives him or her, one would hope they would be hypersensitive to such a patient.

Further Information

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References


 * ABC Studios. (2009, May 15). Scrubs Cox's Patient Uses Wikipedia [Video file]. Retrieved from http://www.youtube.com/watch?v=RK8dMRLVWvg


 * Anderson, K., Devitt, J., Cunningham, J., Preece, C. & Cass, A. (2008). “All they said was my kidneys were dead”: Indigenous Australian patients’ understanding of their chronic kidney disease. Medical Journal of Australia, 189(9), 499-503. Retrieved from http://www.mja.com.au.ezp01.library.qut.edu.au/public/issues/189_09_031108/and10359_fm.html


 * Australian Bureau of Statistics. (2010). Migration, Australia, 2008-09. Retrieved from http://www.abs.gov.au/ausstats/abs@.nsf/Products/295BCEA8A2132BECCA25776E0017733C?opendocument


 * ARDSInc. (2007, June 26). Royal Darwin Hospital Patient Educators [Video file]. Retrieved from http://www.youtube.com/watch?v=6FeKbDdFoTs


 * Dugdale, L., Siegler M. & Rubin, D. (2008). Medical professionalism and the doctor-patient relationship. //Johns Hopkins University Press, 51//, 547. Retrieved from http://find.galegroup.com.ezp01.library.qut.edu.au/gtx/infomark.do?&contentSet=IAC-Documents&type=retrieve&tabID=T002&prodId=HRCA&docId=A188583303&source=gale&srcprod=HRCA&userGroupName=qut&version=1.0


 * Egnew, T.R., Wilson, H.J. (2011). Role modeling the doctor-patient relationship in the clinical curriculum. Family medicine, 43(2), 99-105. Retrieved from http://www.stfm.org/fmhub/fm2011/February/Thomas99.pdf


 * Ferguson, W., Candib, L. (2002). Culture, Language, and the Doctor-Patient Relationship. //Family// //Medicine, 34(5)//, 353-361. Retrieved from http://www.stfm.org/fmhub/fm2002/may02/mcappc.pdf


 * Kabaa, R., Sooriakumaranb, P. (2007). The evolution of the doctor-patient relationship. //International// //Journal of Surgery, 5(1)//, 57-65. doi: 10.1016/j.ijsu.2006.01.005


 * Lo, B., Parham, L. (2010). The Impact of Web 2.0 on the Doctor Patient Relationship. Journal of Law, Medicine, and Ethics, 38(1), 17-26. doi: 10.1111/j.1748-720X.2010.00462.x


 * Marcinkiewicz, M., Mahboobi, H. (2009). The Impact of the Internet on the Doctor-Patient Relationship. //Australasian Medical Journal, 5(1)//, 1-6. Doi: 10.4066/AMJ.2009.69


 * Perloff, R.M., Bonder, B., Ray, G.B., Ray, E.B., Siminoff, L.A. (2006). Doctor-Patient Communication, Cultural Competence, and Minority Health. American Behavioural Scientist, 49(6), 835-852. doi: 10.1177/0002764205283804


 * Skirbekk, H., Middelthon, A.L., Hjortdahl, P., Finset, A. (2011). Mandates of Trust in the Doctor Patient Relationship. Qualitative Health Research, 21(9), 1182-1190. doi: 10.1177/1049732311405685


 * Tourtier, J.P., Mangouka, L., Auroy, Y. (2011). The Computer and the Doctor-Patient Relationship. //Birth, 38(1),// 93-94. doi: 10.1111/j.1523-536X.2010.00455.x

Reflective Task RESPONSE 1 Wiki: Doctors and Patients - Are We From Different Planets? Link: http://healthculturesociety.wikispaces.com/Doctors+and+Patients+-+Are+We+From+Different+Planets%3F Post: Your wiki is very informative and clearly presented. Congratulations on a really good job! I particularly found the study by Nguyen, Barg, Armstrong, Holmes and Hornik (2007) interesting because in my research the primary recommendation among the literature was to bypass increased cross cultural training due to its inconsistencies and provide increase in cultural minority doctors (Ferguson & Candib 2002, p. 353). Also, the mastectomy versus the BCT treatment was really a great example of how someone with a very personal decision to make can be almost bullied into a choice they will later regret by a poor doctor patient relationship.

Thankyou for a well written and informative article!

RESPONSE 2 Wiki: On a scale of 1 to 10 how Culturally ‘Clued-In’ are our Primary and Emergency Service Providers when it comes to Pain? Link: http://healthculturesociety.wikispaces.com/On+a+scale+of+1+to+10+how+Culturally+%E2%80%98Clued-In%E2%80%99+are+our+Primary+and+Emergency+Service+Providers+when+it+comes+to+Pain%3F Post: Thank you for posting your research on Pain across different cultures. The topic of doctor patient relationships links in with this very closely because my research indicates communication is the key to ascertaining the patients' real experiences and feelings, particularly across different cultures (Dugdale, Siegler & Rubin 2008, p. 547). The study conducted by Bjorn-Ove (2005) is also really interesting, pain assessment is such a complicated variable across people from similar cultures let alone those from different ethnicities it is difficult to imagine an accurate and sufficiently time efficient method of assessing pain at a time critical scene.

I appreciate the informative read!