1. Autonomy and trust
2. Basics
3. Moral responsibility in medicine
4. Characteristics of the physician-patient relationship
5. Models of doctor-patient relationship
6. What is the role of family in the doctor-patient relationship?

By Juan Manuel Carrera – Student of Medicine, Buenos Aires University. Monographs – Read the complete article

Among the aspects that can be analyzed to study the evolution of the doctor-patient relationship in terms of the autonomy of the latter, the following: The establishment of medicine as science. Medicine in the past offered more choice to patients, the coexistence of different systems or medical theories that were outdated in favor of a single model: the Medical Officer. Up to scientific medicine, more focused on the disease and the diagnostic and therapeutic, in the same patient, expressed in a scientific language. Increased distance from the patient and their families regarding the physician. The patient, every time I knew less and less confident in itself, while the doctor, by contrast, increasingly have more data, better diagnostics and therapeutics, thus increasing their ability to make decisions.

Paradoxically, scientific development, as stated Peabody, worsened the patient-physician relationship at a time when medicine has improved significantly. From this point of view, throughout the twentieth century, patients have less autonomy than one hundred years ago. The development of skills and changes in the organization of care that occur over s. XX. Hospital medicine, the consolidation of health insurance and the process of collectivization, as Social Security, they have modified the model of the medical profession and have encouraged the appearance of conflicts of interest arising from having to respond on any action, to-whom-the payor or the patient-client and with different interests.

Considering what has been the evolution of medical practice in relation to medical information, condition for the patient can consent to a clinical performance. This is an area in which apparently by professionals, has not been unanimous, and that gives us an interesting evolution over time. To which we must join a changing society

based on respect for human rights and increasingly interventionist. We are in a time of development of social responsibilities by both physicians and patients and their families. The right to epidemiological information, non-tolerance of irresponsibility to one’s health, smoking, obesity, etc.. and development of preventive medicine, are examples.

An essential aspect in the current debate on patient autonomy is the economic issue, since the rationing in the health conditions the patient’s choice.

Autonomy and trust

Regardless of the issues listed above, having the patient in health care is not new: in the doctor-patient relationship, mutual respect is essential. Neither the patient nor the family can impose a performance criterion that is not professional or going against the opinion of a professional.

With regard to respect the patient, and in 1952, Lain Entralgo stated: “The doctor now has to think with clarity on the intellectual antinomy with their two main events, the treatment and diagnosis, as referring to a be — the sick man that is both sensitive and kind person, principle of operation and course materials rational, patient actions required and the author of free shares. ” That is “the treatment of a disease may be entirely impersonal; the care of a patient must be completely personal.”

Patient care mission, is a paternalistic act? It seems rather a manifestation of the activity in the clinic, “it is not possible to deal in the abstract but concrete and individual.”

The significance of the interplay between physician and patient must be strongly pronounced, and to a large extent, the diagnosis and treatment are directly dependent on it and the physician’s failure to establish this relationship entails a great loss of effectiveness in patient care.

There are many issues that remain open. It’s time to try to answer the questions listed above. It is time to reconsider the patient’s autonomy, which is not new in medical practice, which directly affects the professionals and patients as it is intrinsically linked to the physician-patient relationship.

Basics:

For physician-patient interaction is one that is established between the doctor and patient in order to restore it to health, ease their suffering and prevent disease. So that the doctor can apply their knowledge and expertise to diagnosis and treatment, needs to establish dialogue with the patient which depends heavily on the therapeutic success.

The doctor-patient relationship, is still beyond the technological advances, so important to medical practice and as essential in the training of the physician, as always, or even a bit more, given the deterioration that comes with being subjected this relationship, both hypertrophic use of technical measures, such as overcrowding trends associated with socializing and preventive medicine that has undergone in recent years.

Moral responsibility in medicine:

Morality is a par value and includes an integrated human activity. No other discipline can prioritize both human values and morality. All science is autonomous, but at the same time, any human activity as science is, by and for men in a historical existence, can not escape the limits of morality. That is because the goal of morality is the man, which, as a subject of transcendent and immanent purpose, is a supreme value, superior to any value that can provide scientific or technical. Some argue that medicine, like science, may lie outside the proper ethical, moral and / or religious. But being outside does not mean being against or otherwise. The scientist must respect the laws and moral duties, must possess a moral orientation. When we speak of moral guidance in medicine we do not refer specifically to medical science as such but to their representatives and farmers, and therefore hold that the person’s doctor and his entire scientific activity is moving in the field of morality. It is not logical to speak of opposition between medicine and Moral; that no hazards or obstacles in the interest of science.

Medical Morality is not concerned with the possibilities and limits of knowledge and skills but to the limits of the rights and duties of the scientist as a person, referring to how they are achieved and used this knowledge.

The physician must learn the moral dramas are as real as the physical phenomena and their importance is much greater. The moral authority of the physician is the key to therapeutic success. The technique alone can never penetrate to the deep root of this mysterious being called the man who has needs that neither the technical nor science can meet.

The moral law tells us that health is just the hierarchy of the individual and man as a person, has an existential project with an eternal destiny with a creative awareness that is not referring only to the biological world but also the moral world that he can glimpse into the experiences of his life. Unfortunately we see too often doctors who live trapped in a single dimension in which the prevailing material, making the worship dinerolatría, becoming merchants of health, real oppressors of the sick

Characteristics of the physician-patient relationship:

Medical care is a specific form of assistance, technical assistance interhumana. Its specificity is determined by the particular characteristics of the “object” to remedy that is a subject, a human being, for some of the characteristics of the technique involved in the repair as the same personality of another human being. In both cases, what to “fix” and that “fixes” are human beings and the relationship interhumana is part of the same technique. Kollar with words: “it is expected that the physician is concerned not only the sick body, but, also, the state of the whole body of man as a whole, because it is actually against a person rather than an isolated organ nor to an abstract psyche.

Like any relationship interhumana implies, ultimately, an attitude of solidarity with others attitudes of others, as indicated by Barcia and grandchildren who need assistance, but aid and solidarity especially important because the disease poses a necessity, a suffering that involves the body, privacy of the individual. Hence the most suitable instrument for the relationship, whether the verbal and nonverbal communication and the link most appropriate empathy or ability to get in the place of another tune with their experiences.

Like any interpersonal relationship of support has unique characteristics, motivation and attitude of dependence and need, altruism and selfless support, trust, similar to those of other natural relations of care, unequal and asymmetrical: parent-child, teacher-students. Therefore tends to be configured according to those relational models that favor spontaneous attitudes of trust and altruism in the relationship, accounting also technically the best vehicle for the most technical.

Like any relationship has the technical formality of a contract by which the expert, the technician provides services or benefits to the user as a health, not being just like all individual and private property, but also social and public takes on the character of social fact. From this point of view the doctor-patient “socially institutionalized,” would be defined by the expectations that society has of the roles, the roles of doctor and patient. Both are expected to conduct a series of rights and duties, for which both technical and user agrees to manage, care for and restore where appropriate, for health.

But the contract, the special nature of the asset is at stake, involves, in addition to the altruistic and attitudes such as confidence, without which the contract would have no operation, acceptance, more or less implicitly, the limitations of the technique and the risk of failure and, if the service provided. This is due to the inability to control all the variables of natural processes and thus to the condition not only means and results of medical care

Would be foolish to forget that a good doctor – patient avoids most of the questioning of the patient to receive treatment or received. The patient (even less legal) demands to know.

Sometimes called partial reports, often asked for details and clarifications to many doubts. Many of their fears demand of our understanding and support. It is not enough to tell you what you have and what we do (or have decided to do) but that our understanding. In some cases you are interested in our “complicity” or our prudence in the report to their families. Sometimes these are seeking our silence. Each patient is an individual, a person can not be compared to another, each requiring individual attention from his illness and always claim that it is comprehensive.

Physical care, but also the possible consequences of our actions or omissions. Its present and future are visible at every medical consultation. Your mind accepts or rejects the evil that afflicts not react as it wants, but as you can and you do not always work with the needs of their search for help in your relationship with us.

Often escapes conscious or not in a state of insecurity and helplessness that mimics a conviction is far from feeling.

Their requests for help can be masked under a dubious expectation, may question the unquestionable. There is always a latent question: why me? We are in for him all the answers, we require clarity and conviction in them.

Having spent the era of “paternalism” and medical domain, we are in the stage of all why?. The lack of adequate responses to us on demand oral and / or legal to try to avoid.

A patient who has demanded an ever more confident and no doctor at risk of neglect, the anguish and its future is really dramatic. It is governed by the “never again” or “nothing more” and was disappointed to life leads to an attitude that every day it deteriorates a little more.

Models of doctor-patient relationship:

Some authors, taking the various factors involved in the relationship, have analyzed the various possible forms of patient-physician relationship. These include the models, and classic, Szasz and Hollender, Von Gebsattell and Tatossian. These authors examine the different attitudes and interactions between doctor and patient, depending on the type of disease acute or chronic, the greater or lesser capacity for participation and cooperation of the patient, when the medical procedure you are anamnésico, diagnosis, therapeutic, and so on. Although theoretical construct, and therefore artificial, each model emphasizes a factor as a determinant of the dynamics of the relationship in practice are different views of the same reality, which can complement and help to better understand the different stages this meeting.

TYPES OF DOCTOR-PATIENT RELATIONSHIP AS THE LEVEL OF PARTICIPATION:

Szasz and Hollender, taking into account the degree of activity and participation in the doctor-patient interaction, describes three levels or patterns of doctor-patient relationship.

Level 1, or “activity and passivity of the sick doctor,” is the kind of relationship that occurs in situations where the patient is unable to fend for itself: emergency medical or surgical patients with loss or alteration of consciousness, states of agitation or acute delirium, etc.. In these cases, the doctor assumes the role and responsibility of the entire treatment. The prototype of this level of relationship would be that between a mother and her newborn: mother-infant relationship.

Level 2 or “direction of the physician and patient’s cooperation,” is the kind of relationship that tends to occur in the acute, infectious, traumatic, etc.., In which the patient is able to cooperate and contribute to the treatment. The physician directs, as an expert, the intervention takes a directive, and the patient is working to answer your questions, giving his opinion, and doing what is asked. The prototype of relationship would be the level 2 that is established between a parent and adult child: a parent-child relationship.

Level 3 or “mutual and reciprocal participation of the physician and patient,” is the most appropriate form of relationship in chronic diseases in the posttraumatic or postoperative rehabilitation, the physical and mental readjustments, and generally in all situations are common in the medical world today, where the patient can take an active participation, including the initiative, in the treatment: For example, in patients with diabetes, heart disease, diseases of old age, etc. The doctor assesses the needs, directs and supervises the patient, which in turn carries out the treatment himself, as scheduled, with the possibility of suggesting alternative or decide the necessity and priority of a new query. The prototype of relationship is to establish a partnership between adults: adult-adult relationship.

As it seems logical that there is not a relationship better than another, but one more appropriate to a particular condition or a given clinical situation. Often the doctor and the patient will have to modify their behavior along the same disease and adopt one or other relationship pursuant to or required by circumstances.

TYPES OF DOCTOR-PATIENT RELATIONSHIP AS THE DEGREE OF CUSTOMIZATION:

Von Gebsattel describes the stages through which the patient-physician relationship under varying degrees of interpersonal relationship that purchases during the same medical procedure. Thus in a first stage call, the patient comes to doctor seeking relief for their illnesses and the doctor responds by going to meet the needs of the patient. The relationship between a man and a skilled man who is still suffering from the point of view interpersonal anonymously. In a second phase of objectification, the interest of the physician focuses on the “science” of the disease process, so that personal relationships become the background, interacting with the patient as an object of study “as a person.

Finally, in the phase called personalization, and made the diagnosis and treatment plan established, when the doctor relates, finally, not only with a man who suffers or a “case”, but with a certain sick person who is “his” sick.

TYPES OF DOCTOR-PATIENT RELATIONSHIP AS THE PURPOSE OF THE LIST:

Another way of understanding the physician-patient relationship, proposed by Tatossian distinguishes two types of relationship as the interaction between the physician and the patient either directly or interpersonal is mediated by the diseased organ.

In the model of interpersonal relationship, the disease is considered as a whole disorder is part of the patient and is a personal involvement in the relationship, since it provides directly between two individuals with knowledge as a whole emotional and intellectual. The doctor not only sees the diseased organ, but the whole patient, and somatic and psychological. The attitude of the therapist resonates on the patient, so that “the medicine is passed from one person to two people’s medicine.” Is the ratio that is used in psychiatry, and even more in psychotherapy.

In the engineering model of the service, attention focuses on the body “that is not right” and the patient acquires connotations of client requesting the repair. This is a more pragmatic, operational and functional, aimed at obtaining information on the alteration of the body and the type of restoration that is intended. Is the model of relationship that characterizes the general medical practice and medical specialties, and which, if exaggerated, is in danger of ignoring or even plot the patient’s body, treat the diseased organ, as if a real object is involved.

No doubt that both models are complementary, although the main purpose of the relationship may vary depending on the time in question. The physician should pay attention to symptoms and laboratory tests, but without neglecting the relationship with the patient, the one that will provide an understanding of both the symptoms and their psychological development as patient as a whole.

What is the role of family in the doctor-patient relationship?
It seems that the only responsible approach is the patient’s doctor, but really is not … The family of the sick child plays a role, ultimately it best knows the patient. Has sufficient information of vital importance that stress or anger for being very demanding or not the doctor offers, which will damage the diagnosis that is established. Moreover, it is also the duty of the family to ask the condition of your patient, ask in a polite explanation of medical terms not understood or simply ask him to repeat the information that they understood. There is no justification to keep doubts about diagnosis or treatment.
They must be patient, trust the doctors or who are taking their sick child, and always consider that even if he has not been offered the initial approach surely because unfortunately there will always be another patient that his life is in danger and requires immediate attention.

Recommendations to the families to have a good doctor-patient relationship.
1) Give your doctor as much information available about the disease is suspected that during his interrogation.
2) Give your doctor the opportunity to establish a diagnosis and subsequent treatment to determine a good outcome, have confidence.
3) Ask if a doctor gives you the same information at a specific time in the event of hospitalization.
4) Never seek information from many sources, and to find contradictions, which will generate uncertainty.
5) Never be left with any doubt about the problem you are trying to resolve the doctors.
6) If there is no bad outcome or improvement in his patient to let the physician know and, if necessary, expóngale interest to seek another medical opinion.
7) If there must be a responsible family member, who will be solely responsible for issuing and receiving information from the patient’s condition and this in turn will inform the rest of the family, so as to avoid misunderstandings.
Remember that the work of medical help, help for the benefit of his patient.

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