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Summary of the Text on Physician-Patient Relationships

This document focuses on the ethical considerations and practical implications of physician-patient relationships in medical practice. It highlights the importance of this relationship as the cornerstone of healthcare, outlining the roles and responsibilities of both parties.

The text examines various types of physician-patient relationships, including therapeutic and formal interactions. It outlines the compulsory duties of physicians towards patients and the state, including reporting notifiable diseases, responding to emergencies, and maintaining confidentiality. The voluntary duties are also detailed, emphasizing the physician's responsibility for providing reasonable care and skill, obtaining informed consent, and issuing accurate certificates.

The document stresses the significance of patient-centered care, which considers the individual's circumstances and various aspects of their health. It emphasizes the importance of consultation in complex cases, ethical dilemmas, and when a patient's health is at risk.

The text concludes by addressing ethical dilemmas, particularly the process of ending a professional relationship with a patient. It highlights the need for fairness, justification, and clear communication when making such decisions.

This document provides valuable insights for medical professionals, equipping them with the knowledge and understanding necessary to navigate complex situations and maintain ethical practices within the physician-patient relationship.

Instructor information
• Contact: Professor Rania Abdel-Rahman
Ethics & Communication module Co-ordinator
• E-mail:
• Academic hours:
 Saturday
 Wednesday
10:00-1:00 PM
Lecture Outline

1. Clinical correlate.


2. Types of physician-patient relationship.


3. Voluntary & compulsory duties of physicians.


4. Conditions that need consultation.


5. Patient’s personalized and centered care.


6. Case discussion.


7. Self-reflection and feedback.


8. Summary, references, learning resources.
   Learning Outcomes
   By the end of this lecture, the students will be able to:


9. Recognize the significance of physician patient
   relationship.


10. Illustrate the types of physician patient relationship.


11. Identify the duties of physicians.


12. Identify conditions necessitating consultation &
    significance of patient-centred care.


13. Evaluate ethical dilemmas regarding physician-patient
    relationship .
    Clinical Correlate, Practice points (1)
    Three night watchmen drank tea and they began
    vomiting (tea was discovered later on to have contained
    arsenic). They went to the Emergency department of the
    local hospital. A nurse telephoned the responsible
    physician, Dr Banerjee, who advised that the men
    should go home and call their own doctors. Dr Banerjee
    himself felt very tired and did not see the men at all.
    (The three men died from arsenic poisoning).
    Clinical Correlate, Practice points (2)
    A patient’s breast biopsy was confused with someone
    else’s sample by the histopathologist, with the result that
    a healthy patient had a mastectomy & suffered distress,
    believing herself at risk of premature death. The mistake
    was suspected by a senior oncologist who contacted the
    histopathologist & asked him to review the slides. This
    revealed normal tissue without evidence of malignancy.
    Learning outcome 1
    Recognize the significance of physician patient
    relationship.
     The physician-patient relationship is the
    cornerstone of medical practice.
     When does this relation begin?
    It begins when an individual seeks assistance
    from a physician with a health-related matter.
     When does this relation establish?
    When the physician agrees to undertake
    diagnosis and treatment and the patient agrees.
    Ground rules for physician-patient relationship:
     The Declaration of Geneva requires of the
    physician that "The health of my patient will be
    my first consideration.
    ”
     The International Code of Medical Ethics states,
    "A physician shall owe his/her patients complete
    loyalty & all the scientific resources available to
    him/her.
    "
    Challenges for physician-patient relationship:
    1- Patient autonomy is fundamental for this
    relationship. It is often problematic since many
    patients are either unable or unwilling to make
    decisions.
    2- The physician's obligation to maintain patient
    confidentiality (era of computerized medical
    records).
    3- The duty to preserve life in the face of requests to
    facilitate death.
    Learning outcome 2
    Illustrate the types of physician patient
    relationship.
    Therapeutic Formal
    I- Therapeutic relationship:
    A doctor is free to accept or refuse to treat a patient
    except in emergencies.
    He may refuse to treat the patient in:


14. Beyond his practicing hours.


15. Beyond his competence & skills or not belonging to his
    specialty.


16. Doctor or a family member is ill.


17. Doctor is drunk.
    Types of physician-patient relationship:


18. When doctor is engaged with an emergency or more
    serious case.


19. At night, on grounds of security, if the patient is not
    brought to him.


20. Patient is well and just malingering.


21. Patient fails to pay. ?


22. Patient does not follow the doctor's
    instructions or refuses to give consent.


23. Patient demanding specific drugs, like
    amphetamine, steroids, drugs of abuse etc.


24. Any new patient, if he is not the only doctor available.


25. An unaccompanied minor or female patient.


26. The patient is under other responsible physician.


27. The patient consults another doctor without the
    knowledge of the attending doctor.


28. The doctor gives due notice for discontinuing
    treatment (travelling).


29. Formal relationship:
    It occurs when a third party has referred the patient for
    disinterested medical examination e.g.,
    i. Pre-employment.
    ii. Insurance policy.
    iii. Yearly medical checkups.
    iv. Rape, crimes & any medico-legal cases.
    vi. Psychiatric patient referred by court/ police.
    Doctor has to comply with the directive of the responsible
    party and make their role clear to the patient.
    Learning outcome 3
    Identify the duties of physicians.
    The compulsory duties of a medical practitioner
    towards a patient:


30. Compulsory notification: Births, deaths, infectious
    diseases, and food poisoning from a restaurant. In
    some states, industrial diseases are also notifiable.
    (a) Responding to emergency military service.
    (b) Reporting cases of :
    • Unnatural deaths & suspected homicidal injuries e.g.,
    stab or gunshot wounds (criminal).
    • Homicidal poisoning.
    • Privileged communication…….
    • Suspected child abuse & domestic violence in some
    countries.
    The compulsory duties of a medical practitioner
    towards the state:
    Voluntary Duties of a Medical Practitioner
    A. Responsibility to patients.
    B. Medical examinations and operations.
    C. Issuing of certificates.
    D. Medicolegal examination.
    E. Sending pathological material by post.
    F. Attending to accidents.
    A. Responsibility to patients
    As soon as a patient requests and the doctor agrees to
    examine the case, this is an implied contract (9 items).
    (1) To continue to treat….
    (2) Reasonable care.
    (3) Reasonable skill.
    (4) keep professional secrets except in…………
    (5) Not undertaking procedures beyond skill.
    (6) keeping abreast of recent advances in the field.
    (7) Consultation under certain conditions.
    (8) Special precautions in case of children & adults not able
    to take care of themselves.
    (9) Special precautions regarding dangerous drugs &
    poisons.
    Reasonable care:
    • A doctor must use proper, clean instruments & provide
    patients with proper medicines (he should legibly write
    prescriptions, using well-accepted abbreviations &
    mention full instructions for the pharmacist).
    • He should give full directions in simple language to his
    patients regarding administration of drugs & other
    remedies including diet.
    • He is liable under the doctrine of negligent choice' for
    referring his patient to an incompetent doctor.
    Reasonable skill
    • It is the average degree of skill possessed by the
    physician’s colleagues of the same standing as
    himself to achieve good treatment to his
    patients.
    B. Medical examination and operations:
    • Consent & secrecy.
    • Laboratory aids when necessary.
    • X-rays taken in all cases of accidents unless trivial.
    • Not to operate on wrong patient or wrong part.
    • Safety by ensuring fitness for anesthesia, check of
    count as regards sponges, needles, instruments, and
    postoperative care, no experimentation.
    C. Issuing of certificates:
    • Illness; vaccination; death; insurance &
    compensation, etc.
    • The data mentioned in the certificate must be
    true to the best of doctor's knowledge and belief.
    D. Medicolegal examination and documentation:
    • After proper authorization & identification.
    • Verification of facts e.g. in psychiatric illness
    certificates.
    • Material preserved when necessary, e.g. in cases of
    poisoning, drunkenness, etc.
    Certificates should be issued properly
    in details and a copy is preserved.
    E. Postmortem pathological examination:
    • For scientific purposes and only after obtaining
    consent.
    F. Sending pathological material by post:
    Precautions to be taken to prevent spread of disease.
    G. Attending to accidents:
    • A physician has an absolute right to select his patients.
    • The physician who attends an emergency (a traffic
    accident) should provide a reasonable standard of care.
    • Usually, first aid is given & the victim is referred to his
    physician or hospital.
    Learning outcome 4
    Identify conditions necessitating consultation and
    significance of patient-centred (personalized) care.
    • Patient-centred or ‘whole person’ care takes account of
    individuals’ circumstances & various aspects of their
    health. Approach is built up case by case.
    • Personalisation’ is seen as a benchmark for good medical
    practice because the new developments are claimed to be
    more tailored to the particular genetic & physiological
    characters of each individual (as ascertained by testing and
    imaging) and thus likely to be more effective than older
    methods.
    Psychological, spiritual & practical support
    • ‘Whole person’ care also involves recognising the
    psychological & emotional elements of the patients.
    • When people are sick or facing very serious life events,
    they often experience a range of physical, emotional,
    psychological and social needs.
    • Discussion of patient’s anxiety with proper
    counsellors or other professionals can help
    them with their serious or long-term illness.
    • Some primary care practices provide practical
    support for patients by co-operating with other
    agencies to provide advice e.g., work & housing.
    • Patients may be supported to change unhealthy
    lifestyles & learn new skills as well as manage
    chronic illness.
    Consultation is necessary in:


31. When diagnosis is difficult or in doubt, the patient is
    not responding to treatment or has taken a serious
    turn.


32. When a question arises whether it is necessary to
    perform an operation which may be dangerous to life.


33. An operation may affect the
    intellectual or reproductive functions.


34. Termination of pregnancy according
    to the legal regulations.


35. Suspicion of a professional
    criminal act.


36. When desired by the patient or when it appears that the
    quality of medical service may be enhanced.


37. When full disclosure is not possible & there is ethical
    dilemma from whom informed
    consent can be obtained
    (in a neurotic patient for example).


38. When a do-not-resuscitate order is to
    be issued.


39. Organ transplantation.
    Learning outcome 5
    Evaluate ethical dilemmas regarding
    physician-patient relationship.
    Ending a professional relationship with a patient
    •This may occur if a patient is violent to you or a colleague,
    has stolen, or persistently acts unreasonably.
    •You should not end a relationship with a patient just for
    a complaint the patient has made about you or your team,
    or because of the resource
    implications of the patient’s
    care or for having difficult or
    multiple health problems.
    Before you end a professional relationship with a
    patient:
    • You must be satisfied that your decision is fair .
    •You must be prepared to justify your decision.
    •You should inform the patient of your decision and
    your reasons for ending the professional
    relationship, wherever practical in writing.