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Seminar I: A1 Patient and Doctor

Acting as a Doctor
by

Tram Ho Dac

on 22 May 2017

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Transcript of Seminar I: A1 Patient and Doctor

PART A

Medical Action









Physician-Patient Relationship
MEDICAL PSYCHOLOGY & SOCIOLOGY
course of disease depends on patients' subjective theories of disease, styles of coping and ways of reporting symptoms
definitions of health: ideal, functional, statistical; perspectives on disease: patient, physician, society
specific features of the physician's role and profession include clear responsibilities and ethics, competencies and legal obligations, special conflicts and stresses
Being a doctor requires understanding psychological + social factors and a healthy relation with the patient
Seminar I: Medical Action
Norms of the Patient Role
Social Role
= sum of expectations that the environment directs at a
person’s behaviour; depends on situation and social context
Role of the Patient
(Talcott Parsons)
relief from usual role expectations, esp. family and job
no responsibility for her illness
responsibility to recover
responsibility to get professional help + compliance
Parson describes ideal rights, obligations, and expectations towards a patient;
In reality
stigmatization
and
prejudices
influence how society judges and what they expect;
Understanding the Patient
Subjective Theory of Disease
= the patient's own beliefs and ideas of her illness;
its cause, course, appraisal, treatment, consequences
affects:
the patient's condition and reaction towards symptoms
compliance, cooperation
Coping
handling bodily, functional restrictions, pain, depression...
cognitive: evaluation of disease, belief in own influence
affective: handle emotions, defense mechanisms
behavioral: active or passive (e.g. resignation)
doctor can adress different levels to support coping; might consult expert collegues (e.g. depression)
The Patient's Role and Needs
Norms of the Physician Role
Hippocratic Oath
Declaration of Geneva (1948): life at the service of humanity
conscientious + dignified exercise of profession
medical secrecy
Role of the Doctor
(expectations acc. to Talcott Parsons)
universalism
: patients need to be treated equally
collectivity orientation
: benefit patient and society
affective neutrality
: help independent of sympathy
functional specificity
: focus on your medical tasks
Professionalization
Professionalization
: physician as an expert profession
market monopoly
: conventional orthodox medicine
clear competencies
: prevention, diagnosis, therapy, follow-up care, acute treatment (accident)
legal obligations
: to be member in the
medical association
(federal states and republic)
professional self-administration
determination of guidelines for professional practice
control of professional training
ethics
: Physician's Oath
Deprofessionalization
e.g. public discourse on health, Psychotherapy Act
continuous specialization and effectivity need to be balanced with an integrative, holistic care + quality assurance; e.g. day-care hospital, ambulant, rehab...
The Physician's Role and Profession
Patient-Doctor Relation
Patient needs
information
: on prognosis, treatment; individual; empathic; dependent on patient questions; take time; alone
co-decision
: on diagnosis, therapy; inform about alternatives; seek advice from expert colleques or scientific literature
Placebo Effect
effectiveness of a substance without active medical ingredient
may be due to patient expectations, belief in effectiveness, or earlier conditioning to substances
express that the patient-doctor relation can positively influence the course of disease (the "
doctor drug
")
honest and empathic patient-doctor conversations are essential for recovery
Patient Behavior
Morbid gain
advantages a patient may have from a specific diagnosis; might be psychological motivators in reporting symptoms
primary
: subjective gain; unconscious; reduction of mental tension by avoiding situations with symptoms (e.g. exam)
secondary
: objective gain; (partly) conscious; due to care and relief from usual role expectations
Pension covet
: conscious or unconscious need for/ attachment to own sickness and its benefits (e.g. accident victims)
Reporting symptoms
Simulation
: conscious faking/simulation of false symptoms
Dissimulation
: conscious denial or trivilization of symptoms
Aggravation
: exaggeration of symptoms to gain benefits
Suspicions must be checked carefully (interdisciplinary)
Conflicts and Stress
Examples of
ethical decision
conflicts
choice of medication
euthanasia/ life-prolonging measures: patient's wish to die might be due to pain or depression
abortion
Role conflicts
intra-role
: beween expectations towards the physician's role; e.g. nursing staff <--> patient <--> physician's beliefs
inter-role
: between expectations towards different roles of the person; e.g. physician <--> mother <--> scientist
Psychic stress
higher risk of morbidity, mortality, addiction, suicide
helper syndrome (projection of own need to help)
overload can lead to burn-out, depression (bodily + emotional fatigue, reduced performance, social withdrawal)
Dealing with Conflicts
Clear motivation, reasons to become a physician:
help others; scientific interest
challenging job; independent work, financial security
high social status, parent's expectations
Dealing with conflicts and stress
consciously process conflicts + communicate
be aware of compromises + own mental state
don't ignore and supress own wishes and weeknesses
balance between too little and too large emotional distance
Balint groups
group to exchange with other physicians, often moderated by a psychotherapist
talk about problems, emotions, behaviors (of patient and doctor; get ideas and interpretations
psychic hygiene: reduce psychic stress
Definition of Health
WHO Definition
health is "a state of complete bodily, mental, and social well-being and not only the abscence of disease."
disease is a continuum of different degrees of being restricted in action, well-being, and bodily
homoestasis

Challenges
medical diagnosis vs. subjective state of health
"healthy" ill people + "ill" healthy people
Somatization
: reported symptoms of a somatic illness, but no sufficient diagnosis of bodily causes
false pseudodiagnoses can lead to chronification
treatment: conversation, trustful relation, psychotherapy
Three Perspectives on Disease
1. Patient Perspective
different
symptom awareness
~ own bodily awareness, emotional, cognitve factors, education, social expectations
e.g. negelcted homeless person vs. anxious business man
Health and Disease
Three Perspectives on Disease
2. Physicist/ Medical Perspective
diagnosis is often a dichotomous decision: healthy/ill
phases to make a diagnosis: exploration / anamnesis / behavior observation / bodily examination / technical examination / tentative diagnosis, working hypothesis / differential diagnosis / expert council
Different disease
classification systems
ICD-10
: International Classification of Diseases (WHO)
chapter 5 (F)
: mental and behavioral disorders
ICF
: Intern. Class. of Functioning, Disability & Health (WHO)
DSM-V
: Diagnostic and Statistical Manual of Mental Disorders (APA); 5 axes to describe the patient
OPD
: operationalized psycho-dynamic diagnostic for therapy
Three Perspectives on Disease
3. Society's Perspective
social norms regulate behavior through evaluations, expectations, and claims towards behavior
being sick means deviating from the norm --> patient role
laws of the social and health system reflect the norms
Influences on disease
social + cultural norms may influence the occurrence of diseases; e.g. bulimia, anoraxia
social class, age, gender influence reporting, occurrence, handling, and care of diseases
stigmatization and discrimination influence how sick people are treated ; e.g. AIDS, psychic diseases, schizophrenia
anti-stigmatization programs try to educate and counteract prejudices towards sick people
German Social Code (law)
physician's actions must be efficient (economically), effective (recovery, health), and necessary (appropriate)
treatment must not be guided by monetary considerations
Different norms of disease
ideal
: set value, corresponding to the WHO definition
functional
: patient's capabilty to function in daily life
statistic
: value is pathological if it is extreme (~data set)
Special medical cases of symptom perception
Somatic Symptom Disorder
(Somatoform Disorder):
Somatization:
experience psychological distress as somatic symptoms + seek medical help
Hypochondria
: belief to be severely ill + preocupation with bodily symptoms + claim for medical examination
Affective Disorder (Anxiety, Depression)
: side effects like psychosomatic symptoms, problems of self-esteem, guilt
need to consider and improve
subjective health:
life quality
~ bodily, state, psychic state, and social role
descriptive systems
that define operational criteria for diagnosis (number, intensity, duration, frequency of symptoms) -->
Evidence-Based Medicine
(EBM)
PART B


Life Span and Development



PART C


Theoretical Principles







Methods
PART D

Disease and Society




Prevention




Special Medical Situations
The Patient – Social role & Needs
The Physician – Social role & Profession
Definition of Health and Disease
Full transcript