Professional-patient Relationship Research Articles

"Sharing Ends" as an Attempt at Securing a Trusting Healthcare Professional-Patient Relationship

"Sharing Ends" as an Attempt at Securing a Trusting Healthcare Professional-Patient Relationship

More than one dollop of cortex: Patients' experiences of interprofessional care at an urban family health centre

While Canada's government has called for collaborative patient-centered care, there is a paucity of research on patients' perspectives of such interprofessional care. This qualitative study conducted at an urban health centre begins to address our knowledge gap through semi-structured interviews and narrative analysis strategies. Findings indicate that “good care” is interprofessional care in the sense that patients perceive it as based in a strong patient-professional relationship that facilitates access to and communication amongst health professionals. Patients affirmed a frequent refrain of family physicians that the most valued characteristics of a health care team are the three “A's”: availability, affability and ability. While on several dimensions, the delivery of care was rooted in a patient-centered model, professionals, at points, struggled to find common ground with patients and initiated interprofessional care as a strategy for grappling with this conflict.

Putting "Rural" Into Psychiatry Residency Training Programs

Evidence indicates disparities in the number of psychiatrists practicing in rural America compared to urban areas suggesting the need for a greater emphasis on rural psychiatry in residency training programs. The authors offer suggestions for integrating a rural focus in psychiatry residency training to foster greater competency and interest in rural psychiatry. The authors surveyed the limited rural psychiatry training and the more extensive family medicine rural residency literature to review efforts to develop rural focused training curricula. Many factors in the rural environment influence mental health care, including overlapping professional-patient relationships, caregiver isolation and stress, limited availability and access to mental health resources, disease stigma, and economic and health status. To enhance both an interest in and the quality of the training for a rural practice, the authors suggest three levels of training for integrating rural factors into psychiatry programs from a basic didactic understanding of the contextual issues affecting rural psychiatry, to creating rural clinical experiences and preceptors, to developing a rural psychiatry fellowship. Providing trainees with an understanding of the rural mental health issues and experiences might contribute to trainees' selecting rural practices and enhance the rural competency of psychiatrists.

Professional-patient communication in the treatment of mental illness: A review

The quality of the professional-patient relationship in the treatment of mental illness predicts patient outcome. Hence, we conducted a review of recorded professional-patient communication to identify existing research, methods, and findings. Sixteen studies focused on (i) how psychiatric symptoms are manifested in patient communication; (ii) the role of therapist communication in patient improvement; (iii) the influence of sociodemographic characteristics on doctor-patient communication; and (iv) how patients and professionals jointly construct therapeutic interactions. The findings were disparate and included (a) patient nonverbal communication is impaired in depression and schizophrenia; (b) the use of specific therapeutic skills led to improvement in depression; high expressed emotion (criticism and emotional over-involvement) in treating schizophrenia was a state rather than trait characteristic of therapists; (c) patient gender, income, and education influenced communication about depression, anxiety, and medication; and (d) psychiatrists' varying institutional agendas, which sometimes competed with patients' agendas, strongly shaped their consultations. Few studies investigated two-way professional-patient communication, with most focusing on either patient or therapist communication in isolation from the other. Finally, methodological advances in linking communication processes with treatment outcomes in large-scale observational studies and trials are a challenge for research on medical communication.

Pessoas vivendo com HIV/AIDS: variáveis associadas à adesão ao tratamento anti-retroviral

This study aimed to describe the adherence of persons living with HIV/AIDS to antiretroviral therapy (ART) and to investigate adherence predictors among the following: level of schooling, presence of side effects, current or previous interruption of ART by the persons themselves, self-esteem, self-efficacy expectation, coping strategies, social support, and satisfaction with the health professional-patient relationship. Adherence was measured by self-reported number of ART pills/capsules missed during the previous week and previous month, evaluated as satisfactory when less than 5%. 101 HIV+ adults took part in this study, 60.4% males, ranging from 20 to 71 years of age (mean = 37.9 years), and 73.3% symptomatic. Data procedures included interviews and the use of validated instruments. The majority of participants (n = 73; 72.3%) reported adherence of > 95%. Logistic regression showed that a history of self-reported ART interruption and self-efficacy expectations were significant adherence predictors. Upgrading of care with interdisciplinary teams is needed to develop an appropriate approach to the medical and psychosocial difficulties of ART adherence by persons with HIV/AIDS.

The therapeutic relationship in secondary mental health care: a conceptual review of measures

The study aimed to determine the conceptual basis of measures of the patient-professional relationship used in routine mental health services research by reviewing their face, content and construct validity. A comprehensive literature search identified measures of the relationship used in mental health services research. The conceptual basis of each identified measure was identified by a review of measures' authors assessments of face, content and construct validity plus item analysis of the measures themselves. The search identified 15 measures. The seven developed in psychotherapy were likely to be better validated conceptually; most were based on therapeutic alliance models. Measures developed specifically for mental health services were based on a wider range of models including global assessments of the relationship. Most of the better validated measures originate in psychotherapy, but there is limited evidence for their validity in general mental health services. Four measures are recommended.

The Expert Patients Programme: a paradox of patient empowerment and medical dominance

Self-care is seen as a key element in managing resource demand in chronic disease and is also perceived as an empowering right for patients. The Chronic Disease Self-Management Programme developed in the USA has been adopted in a number of countries and in the UK has been as adapted as the Expert Patients Programme. However, despite its potential as a lay-led empowering initiative, the Expert Patients Programme has been criticised as perpetuating the medical model and failing to reach those in most need. This paper revisits a critique of the Expert Patients Programme, and drawing upon a qualitative study seeks to explore whether the Expert Patients Programme enables empowerment or replicates traditional patterns of the patient-professional relationship. A grounded-theory approach was adopted utilising focus groups, in-depth interviews and participant observation. Data were analysed through the constant comparative method and the development of codes and categories. Conducted in the relatively affluent area of the south-east of England, this paper draws on data from 66 individuals with a chronic illness who were knowledgeable, active and informed. The study revealed a number of characteristics common to expert patients that were linked to a systematic, proactive and organised approach to self-management, a clear communication style and the ability to compartmentalise emotion. The study included participant observation of an Expert Patients Programme and a professional-led self-management course. The paradoxical nature of the Expert Patients Programme was revealed, for whilst there was evidence that it reinforced the medical paradigm, there was a concurrent acknowledgement and support for the subjective experience of living with a long-term condition. Furthermore, whilst the policy emphasis has been on individual empowerment within the Expert Patients Programme, there is some evidence that it may be triggering a health consumer movement.

Breaching Patient Confidentiality: A Study of Physician Assistantsʼ Awareness and Attitudes

INTRODUCTION All health care providers, including physician assistants (PAs), have a longstanding ethical obligation to maintain patient confidentiality, which dates back to the Hippocratic Oath and continues to be reflected in contemporary codes of ethics.1,2 The duty of confidentiality is grounded in the ethical principle of respect for autonomy and honors the patient’s right to decide with whom to share personal information. An implicit or explicit promise of confidentiality can also help build trust in the health care professional-patient relationship, which may affect the patient’s willingness to seek professional help, reveal relevant information, and adhere to treatment plans.1,3 Thus, the promise of confidentiality is essential for the health care professional to fulfill his or her fiduciary responsibility to protect and promote the patient’s health-related interests. In addition to an ethical obligation, health care professionals have a legal obligation to protect patient confidentiality. This legal duty can be found in both federal and state law. The privacy rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) sets a national floor for protecting patient confidentiality by restricting the ability of covered entities to use and disclose identifiable protected health information without written authorization. However, many state laws provide even greater protection than HIPAA. For example, according to the Texas Occupations Code, all written, verbal, or observed communications with the patient are generally held to be confidential and may not be disclosed to outside parties, unless an exception either requires or permits disclosure.4 These exceptions are explicitly listed in the statute and vary on a case-by-case basis. It is therefore important that all health care professionals are aware of what these exceptions are and how they apply in specific cases. In the state of Texas, all physicians are required to take and pass a Karmen Slabic was a PA student at the Baylor College of Medicine, Houston, Texas, when this research was conducted. Amy Maguire is an assistant professor of medicine and medical ethics at Baylor College of Medicine.

Lay Expert (素人専門家) の制度化をめぐって

Today the concept of ‘lay expert’ is increasingly mentioned in public discussions of health care, the judiciary and other areas. In the health care arena, patients and the family are thought to be a person with ‘lay expertise’. The Expert Patient Programme (EPP), which has been managed by the National Health Service (NHS) in the UK, aims at institutionalising ‘lay expert’ in the national healthcare system. This paper illustrates the out-line of the EPP and analyses literatures on this scheme for understanding the concept of ‘lay expert’ and its impact on people's awareness of patient-professional relationship. It is concluded that the EPP works to promote a new concept of ‘expert’ whilst the new concept can conflict with requirements for the institutionalization of ‘expert’ in modern society.

Personalised care, access, quality and team coordination are the main dimensions of family medicine output

Health organisations continually seek good output indicators of family medicine health care provision because they are accountable to society, they need to compare services, and need to evaluate the impact of organisational reforms. Using the sources of information routinely available in health-service management, we sought to assess the groups of components of primary health care output that best serve to define the outcome of family medicine services. Cross-sectional descriptive study. SITE: Primary health care in Catalunya. 213 primary health care teams. Information was collected on team structure, user satisfaction, quality-of-professional-life of the health care professionals, and physicians' drug prescription. Confirmatory Factor Analysis was used to assess the number of dimensions that best explained the family medicine outcome. The model that best fits the structure of the data (AGFI=0.778) is that which consists of three dimensions i.e. (1) the individual accessibility to the services and professional-patient relationship; (2) the coordination within the health care team; (3) the scientific-technical quality of the service. The first two of these dimensions were correlated between themselves, but the third was totally independent of the other two. Using sources of information that are routinely employed in primary health care services management, the model enables the measurement of the output of family medicine by considering the dimensions such as inter-personnel relationships, internal coordination of the team and the scientific-technical quality of the service. Despite its simplicity, this measure of the output incorporates the views not only of the users but of the health care professionals, as well.

Care as a mutual endeavour: Experiences of a multiple sclerosis patient and her healthcare professionals

In Dutch healthcare policy patients are seen as informed, autonomous experts and active decision makers with control over their illness and care. Healthcare professionals are expected to operate as providers of information. The purpose of this article is to argue that the consumerist approach of the patient-professional relationship is not a productive way to envision the patient-professional relationship. We argue that an interpretive/deliberative model is a more productive way to envision this relationship, especially in the care for people with a chronic illness. This is illustrated with a case study. It concerns a study of the experiences of a Multiple Sclerosis (MS) patient and healthcare professionals involved in her care. The presented stories show that the participants did not act in line with the roles and responsibilities embodied in the consumerism rhetoric in Dutch healthcare policy. Expectation of patients and healthcare professionals are better met when care is redefined as mutual endeavour in which the caring abilities of healthcare professionals and the vulnerability of chronically ill patients are taken into account.

Partnering with patients – a concept ready for action

This paper is a report of a concept analysis of partnership within the context of a professional-patient relationship. The concept of partnership has been previously characterized as immature, with a need for further consensus and consistency. Critical attributes previously reported include relationship, power sharing and negotiation, with empowerment as the primary consequence. Rodgers' evolutionary method of analysis for concept development was used to re-examine the concept of partnership. Historical documents and previously published conceptual papers were reviewed for context. A search of multidisciplinary literature published between 2000 and 2004 was undertaken using the keywords of 'partnership' and 'partnering', combined with nurse/professional/physician-client relationship. Attributes, uses, antecedents and consequences were inductively derived from the citations analysed (n = 62). Previous authors affirmed that partnership involves a process and a consistent set of eight attributes. Relationship, shared power, shared decision-making and patient autonomy are attributes that distinguish partnership from other related concepts. Most of the literature, however, consisted of expert opinion or descriptive research. Little progress has been made in applying theory, developing tools to test the process, identifying when partnerships are needed and what specific outcomes occur when they are present. Partnerships between healthcare providers and patients develop over time. They are created to support patients in having a greater voice in their care and to empower them in self-management. A descriptive model of partnership is proposed to support researchers in generating or applying existing theory to the development of research designs and tools that could test how this process actually works.

ABS40: Exploring professional and patient attitudes to mobile telephone-based technologies for monitoring asthma: Qualitative study

Mobile phones offer innovative opportunities for healthcare monitoring. It is, however, far from clear how healthcare professionals and patients view the potential offered by such technology and how this may impact on the dynamics of asthma monitoring and care provision. To examine patient and healthcare professional attitudes towards the benefits and practical application of using mobile telephone-based technologies for monitoring asthma. Six focus groups (involving 28 patients with asthma and 12 professionals). Exploration of initial attitudes was followed by demonstration of the e-San/O2 asthma monitoring technology, Subsequent discussion focused on potential applications. Data analysis was iterative, with key emerging themes identified using NVivo. There was broad agreement between patients and professionals that practical applications included more efficiently confirming a diagnosis, identifying triggers (at both individual and population levels) and monitoring severe disease. Divergent opinions were, however, expressed on the impact on the patient-professional relationship: either enabling self-management or, conversely, increasing professional supervision. Perceived benefits identified included facilitating compliance with monitoring and enabling remote consultations. Participants raised concerns about costs, and who should pay (the patient or the health service), reliability and security of technology, and the potential for increasing social exclusion. Although not universally applicable, mobile telephone based monitoring for asthma was seen as having some important benefits for some people in some situations (e.g. enabling newly diagnosed patients to identify triggers, monitoring exacerbations in people with severe asthma) Practical considerations, such as cost, security and dependability of the technology will need to be addressed before widespread uptake. Conflict of interest and funding None. Funding: British Lung Foundation.

Viewing patient need through professional writings: a systematic 'ethnographic' review of palliative care professionals' experiences of caring for people with cancer at the end of life

Aim: A systematic review of palliative care professionals' written accounts of caring for people with cancer who are knowingly facing death; in order to provide another source of evidence on patients' needs.Methods: Systematic review methodology was utilised to locate published 'reflective narratives' (not original research) written by palliative care professionals from a variety of disciplines and institutional settings, which focused on the experiences of caring for patients with cancer as they approached their death. The search strategy yielded 2224 texts which were reduced to a dataset of 202 after the application of the inclusion/exclusion criteria. A quantitative analysis was conducted on the full data set and a qualitative analysis was performed on a selected sub-sample.Main results: Professionals identify a wide range of needs of people with cancer at the end of life. They write particularly forcefully about: patient autonomy; choice and control; access to information; and full participation in decision-making about patient care. However, closer examination of the texts demonstrates that professionals may also have fixed expectations about: management of patients' emotion; over emphasise choice and control; lack recognition of power in the patient–professional relationship; and tend to homogenise patient needs.Conclusions: The research raises questions about professionals' interpretation of patient needs and suggests that the care received by people with advanced cancer is still firmly framed within biomedical culture and the social organisation of medicine, which struggle to acknowledge individual autonomy and meet the diversity of individual end-of-life needs.

Coordinated Agency Versus Autonomous Consumers In Health Services Markets

Despite widespread acceptance of the competitive market model in the U.S. health care system, debate continues regarding the optimal form of competition and the patient-professional relationship. The managed care model envisions organizations that act as the consumer's agent, addressing the challenges that consumers face in the market for health care services. The consumer-directed health plan model envisions autonomous, well-informed, price-conscious consumers shopping among providers unconstrained by organizational affiliations. Although advocates of these two approaches stress their philosophical differences, the realities of the market suggest that both models, as well as hybrids, might be valued by consumers.

Doctors as fiduciaries: do medical professionals have the right not to treat?

In the first part of the paper, the author discusses the origin and obligation of the medical profession and argues that the duty of fidelity in the context of a patient–professional relationship (PPR) is the central obligation of medical professionals. The duty of fidelity entails seeking the patient’s best interests even at the expense of the professional’s own, and refusing to treat a “risk-patient” infected by SARS is a breach of fidelity because the medical professional is involved in a situation of conflict of interests and places his/her own health interests ahead of the patient. The author attributes the failure to the fact that professional ethical codes are not legally enforceable, and this failure at the microethical level damages the integrity of the profession at the macroethical level. The author argues that professional autonomy must be subordinated to professional fidelity for the medical profession to survive as a social institution. In the second part of the paper, the author shows that the PPR has most of the important attributes of a fiduciary relationship, and analyzes several important court cases in some common law jurisdictions to illustrate the increasing importance of fiduciary law in adjudicating disputes between patients and medical professionals, and appeals to law courts and legislatures to apply more stringent fiduciary principles on the medical profession to ensure that the professional duty of fidelity is enforced and the goal of medicine fulfilled for the interests of members of the community who has established the medical profession in the first place.

Percepciones y expectativas sobre la atención primaria de salud: una nueva forma de identificar mejoras en el sistema de atención

To analyse the opinions of the users of primary care on the care that they receive and to identify the principal areas of satisfaction. Qualitative study using discussion groups and open interviews during the period January-May 2003. Health areas of Valladolid, Spain. The inclusion criteria were: to have attended a primary care clinic at sometime and to be between 35 and 80 years old. Recruitment was carried out through key informants, using the snowball technique. 6 discussion groups and interviews with representatives of 3 nursing and 1 residents association were carried out. Structural sampling was carried out as regards the variables that influenced satisfaction. The conversations were recorded using tape recorders and literally transcribed on paper. The analysis of the texts was carried out by 2 investigators and concordance was sought between them. The principal areas related to satisfaction were: the treatment received from the professionals, which is considered a fundamental part of care, combined with the technical quality, continuity of the care, the admission services, the bureaucratic procedures, the barriers for accessing specialised services, and waiting lists. Personalized care, the time dedicated by the professional, the continuity of care, and waiting lists are the principal areas related to the perceived satisfaction of the patients. The possible responses to improve this situation are: the implementation of changes in the care management and organisation which would simplify the procedures, investment of resources (human and economic), changes in the model of the professional-patient relationship, and improvements in undergraduate and postgraduate training.

Patient–doctor decision-making about treatment within the consultation—A critical analysis of models

This paper highlights some of the limitations of models of patient involvement in decision-making and explores the reasons for, and implications of, these limitations. Taking the three models of interpretative, shared and informed decision-making as examples, we focus on two limitations of the models: (1) neglect of which decisions the patient should be involved in (the framing problem) and (2) how the patient should be involved in decision-making (the nature of reasoning problem). Although there will inevitably be a gap between models and practice—this much is in the nature of the models—we suggest that these two issues are substantially neglected by the models and yet are fundamental to understanding patient–doctor decision-making. We also suggest that the fundamental problem that lies behind these limitations is insufficient attention to, and explicitness about, the dilemmas of professional ethics, which are played out in the professional–patient relationships that the models are supposed to represent, particularly with respect to the issue of expert and lay accountability.

Ser profissional de saúde em uma unidade neonatal de alto e médio risco: o visível e o invisível

Este estudo tem como objeto as vivências do profissional de saúde que trabalha em uma unidade neonatal de alto e médio risco. Utilizou-se como referencial teórico a fenomenologia hermenêutica de Martin Heidegger com o objetivo de compreender as vivências dos profissionais e as repercussões dessas vivências para sua saúde mental. Foram realizadas entrevistas fenomenológicas com os profissionais da unidade, chegando-se à compreensão, a partir da análise das unidades de significado encontradas, de que o sentido do ser-profissional-de-saúde nessa unidade transita entre o ôntico e o ontológico, na medida em que o profissional ora se protege no modo impessoal, ora se coloca no modo existencial ontológico de ser. Espera-se que a pesquisa possa contribuir para o enriquecimento e a humanização da relação profissional-paciente.

Patient-professional partnership in spinal cord injury rehabilitation.

There has been considerable pressure from both patients and professionals for greater patient involvement in the delivery of health services in recent years, particularly in the domain of rehabilitation. However, it has been suggested that involvement by patients is limited to rehabilitation. Accordingly, this study aimed to explore and describe patients' and professionals' experiences of patient participation in team decision-making processes. This article presents findings from a larger ethnographic study, which employed interviews and participant observation to collect data. This article focuses on the results from semistructured interviews, which were conducted with 30 healthcare professionals and 20 patients in a spinal cord injury unit in the UK. Findings suggest that the experience of team membership and decision-making is shaped by professional paternalism. Patients and professionals perceive that they are involved in a partnership where patients make decisions. However, different levels of paternalism in the professional-patient relationship within team decision-making processes emerged from the data. These have been categorized as 'open paternalism' where power and control lies with professionals; 'they tell me what they are doing' where patients are informed of decisions; 'they can always say no' where patients can agree or disagree; 'making the right choice' where patients are steered towards the choice professionals consider as the 'right' choice; and 'active participation' where patients choose the course of action. It is suggested that professionals should examine their own practice and attempt to develop ways of working that empower patients to become equal members of the rehabilitation team.