Issue: April-June 2015 (Volume-4, Number-2)
Medicine, law and social values are not static. Re-examining the ethical tenets of medical practice and their application in new circumstances is a necessary and ongoing exercise. Medicine is not a trade to be learned, but a profession to be entered. The practice of medicine has changed drastically in the twenty first century. There have been many positive as well as negative changes in medical sciences. The good age-old doctor-patient relationship ( D P R ) is in doldrums. The communication skills have almost been forgotten. Commercialization is the obvious agenda especially with the development of corporate culture in the health sector. The concept of privatization has added fuel to the fire. The patient who are willing to pay, feel that the life can also be purchased with money. This has resulted in soaring expectations. Because of all these, doctors are not only affected by medico-legal cases but many other legal problems arising out of other related issues of staff, instruments & infrastructure also. We should never forget the fact that despite changing pattern of health care, medicine will always be conducted on a human-to-human basis. The doctor patient relationship is in fact a powerful therapeutic force that acts synergistically with medication. Doctor patient relationship Dynamics are changing because of a number of factors:
- Patient perception about doctors has changed
- Status of doctors as professionals has come down
- Physician is no longer a physician but just a commodity in vast healthcare market
- There are increasing law suits against doctors, hospitals and clinics than in the past
- More and more clinicians are now resorting to defensive practice
- Doctors have to work under stress because of their nature of work, working in situations of life and death, treating critically ill patients with indefinite/unexpected outcome. This tells upon their relationship with patients and their relatives. This leads to a sort of burnout as in ICU workers
- Doctors suffer from compassion fatigue because they have to work with people who are emotionally charged and are anxious.
- Institutional and group practice have blurred individual DPR
- Mobility of patients - Patient is moving from place to place, country to country and finds it difficult to establish rapport with a particular physician and belongs to none
- Changing social trends and values - Consumerism is important these days and has affected the doctors as well. Media is playing a role in making doctor-patient relationship strained and doubtful.
- There is an overall change in attitude towards positions of power and authority.
What is the importance of communication Skills?
Good communications skills are vital to good doctor patient relationship, but unfortunately this aspect is often underestimated by doctors who place more importance on technical part of their profession. In today's times when doctor patient relationship is undergoing severe strain communication skills become all the more important. It improves understanding and enhances reception of information. Doctors who can't communicate are more likely to end up in court. Interestingly, analysis of 45 malpractice cases, it was found that many of the doctors sued, delivered information poorly and devalued patients' views.
Some common Mistakes made by Doctors while communicating:
- Overestimated compliance
- Belief that talk is unimportant “chatter”
- Dependent language
- Talking to many persons including patients simultaneously.
- Yes or no questions(closed ended questions)
- Ignoring patient's questions
How it can be improved:
- Get down on eye level with patients
- Be genuinely interested-smile and add chitchat to medical interview
- Trust patients as reliable narrators of symptoms
- Be sensitive to patients' physical and emotional state
- Monitor use of medical jargon
- Explain actions during physical exam
- Involve patients in decision making
Legislation may not always work effectively in the practice of medicine. It can only work if the medical profession becomes ethical in its use and any misuse is dealt with severely by the professional bodies. So as to maintain purity and sanctity of the art of healing, the Fathers of Medicine had laid down a code of conduct for the physicians. The ethical guidelines were framed keeping in mind that the art of healing is a mission for service in human life. Medicine is a service that can't be governed by “cold” science alone. It must have a human touch. The medical ethics is not a mere academic exercise but affects routine patient care. Doctors need to assess the merits of various competing courses of action, and be able to justify their decisions in ethical terms. The physicians must work with nobility and dignity for the welfare of human beings. Physicians should act in their patients' best interest. The purity in life as well as in medical profession was of utmost importance. The aim was “never do harm to anyone”. The painful paradox is that, in today's lavishing health care, we may also be exposing the patients to a potential hazard. Over the years it has become difficult for the doctors to follow the ethical norms. A wrong done over and over again by a large number of people, and highly educated people at that, soon becomes the order of the day. The medical profession is fast losing its credibility because of the large number of unethical practices. The professionals have to do a lot of soul searching and introspection.
What can be the possible remedy?
REMEDY is 'DOCTOR HEAL THYSELF’
- A sound DPR is the foundation of modern medical ethics and practice
- In this era of brief doctor visits & High-tech medical care - warmth, empathy, trust and good communication make the difference
- Patients must have right forums to redress their grievances in a just manner
- High echelons of medical profession & professional bodies must sit up and take concrete steps to check malpractices
- Doctors must learn good communication skills
- Patients must know their duties and rights and efforts should be made to educate them on these matters
- Introduction of study of behavioral sciences, medical ethics, patient psychology and communication skills in medical colleges
- Continuous education of doctors on these matters in various conferences and workshops
What are the various ways to build a strong DPR?
- Eye contact helps build trust
- While talking to a patient tone of voice should be agreeable, not critical
- Presenting the information to a patient in the right manner is important. A disease may be deadly but certainly telling about it should not be
- Encourage request for information
- Be a patient listener - Even if the diagnosis is written on face of the patient, do listen to the complaints.
- Time of consultation – it should neither be too little nor too long.
- Maintain patient confidentiality.
- Maintain good medical records.
- Refer the patient for second opinion well in time.It helps in managing complex patients.
- If something goes wrong taking the patient and his relatives into confidence helps.
- Recording consent should not be a mere formality but well explained to patients in their own language and own level of understanding.
- Keep your knowledge up-to-date. A doctor must know more than the patient.
- We must set standards for clinical practice and follow them.
- Alternatives choices for patients and encourage their participation in decision making.
- Management protocols must be established, widely circulated and strictly followed.
- The doctor-patient relationship is a personal interaction that transcends ethnic, socio-cultural and economic differences and generates trust and responsibility.
- It is based on the trust and understanding that the doctor puts the needs of patient first.
- For a sound DPR, doctors should not only be well equipped with bio-medical aspects of patient care but understand psychological, social, cultural dimensions of health and illness.
- Patient's participation in decision making is an important component in Doctor-patient relationship.
- Re-examining the ethical tenets of medical practice and their application in new circumstances has become a necessary and ongoing exercise.
- Our future doctors must be sensitized to human rights, ethical considerations and gender issues.
- Restoration of the dignity of noble profession was never more required than it is today. The road of ethical practice is not a journey of dos and don'ts, right and wrong. It is one in which the patient and doctor walk hand in hand.
NIJP : Vol.-4, No.-2