VIMS Journal: December 2017


The Changing Scenario of Doctor -- Patient Relationship

Dr. Sumita Basu

The relationship between doctor and the patient should always be built on mutual trust and respect for each other which will ensure a healthy outcome on both sides. But we have noticed that in recent days there has been a break in this trust and it is time we reflect on the reasons behind this unfortunate turn of events.
Doctors work under challenging circumstances at times, with inadequate infrastructure and tremendous patient load and yet succeed in providing effective health care. In situations when the outcome is unsatisfactory it is imperative that we maintain an effective communication channel with the patient family. In most cases it is seen that it is the lack of effective communication which results in unnecessary litigation and harassment. A doctor's communication and interpersonal skills encompass the ability to gather information in order to facilitate accurate diagnosis, counsel appropriately, give therapeutic instructions, and establish caring relationships with patients.[1] We can improve the scenario by addressing some of the key issues which plague the healthcare delivery system like:
Poor communication skills amongst health professionals.
Lack of knowledge about the Patient's Rights.
Lack of knowledge about the Medicolegal issues.

Communication Skills :
Poor communication can result in compromised outcomes for the patient and family and can have medicolegal consequences for the practitioner. Introduction of lessons on effective communication skills in undergraduate medical curriculum is long overdue. It is seen that in most scenarios it is the junior doctor who updates the family regarding the condition of the patient, which at times leads to unpleasant encounters and sometimes even physical assault. This is most unfortunate as the seniors have failed to upgrade the education systems where emphasis needs to be placed on building up soft skills along with sound academic knowledge.
The key concepts of effective communication can be summarized under the following heading:
- Voice
- Body language
- Ability to listen
- Empathy
- Concentrate on what the patient is saying
- Assess the volume of data
- Critical thinking
The voice should be polite, confident, honest, delivered in an appropriate manner in a proper setting, preferably in a room. The volume and content of data will have to be fine tuned according to the education and understanding level of the family. At times it may be necessary to draw diagrams to explain a condition or even point out the problem area in the X-Ray or CT scan. In a complex situation the doctor may take the help of his or her colleagues and approach the case as a team. That may be helpful for the practitioner to safeguard against any litigation.
We also need to change our perspective and adjust to the changing times, as in todays era of the internet the family may do their own research and ask for clarification on various aspect of the patients treatment and we need to respect that.
There are four models of doctor-patient relationship.[2]
In the paternalistic model, the physician adopts the role of a decision maker and decides what would be good for the patient.
In the informative model, the physician acts as an information source, and decision making is in the hands of the patient.
The interpretive model has shared decision making; the physician helps the patient to interpret complex medical evidence and its relevance to the patients illness.
The deliberative model is one where both the physician and patient deliberate on the best course of action.
The barriers of effective communication are:
Personal attitudes
Time constraint
Work environment
Lack of knowledge and inconsistency
Tiredness, stress etc
If we can work on some of these areas we can definitely improve the overall outcome on the patient's treatment and family satisfaction.

Patients' Rights[3]
Patients' rights vary in different countries and in different jurisdictions, often depending upon prevailing cultural and social norms.
The patients have the right to:
a) Courtesy, respect, dignity and timely responsive attention to his or her needs.
b) Receive information from their physicians and to have opportunity to discuss the benefits, risks and costs of appropriate treatment alternatives.
c) Ask questions about their health status or recommended treatment when they do not fully understand what has been described and to have their questions answered.
d) Make decisions about the care the physician recommends and to have those decisions respected.
e) Have the physician and other staff respect the patients privacy and confidentiality.
f) Obtain copies or summaries of their medical records.
g) Obtain a second opinion.
h) Be advised of any conflicts of interest their physician may have in respect to their care.
i) Continuity of care.
Respecting these rights will go a long way in ensuring a healthy relationship between a doctor and a patient with a favourable outcome.
Breaking Bad News : A special emphasis should be placed on situation where the patients condition is very critical and the family needs to be briefed regarding the same. It is preferable that a senior doctor communicates with them keeping in mind the acronym "SPIKES" which stands for Setting, Perception, Invitation, Knowledge, Emotion and Strategy.[ 4 ]

Setting : We need to arrange for some privacy in a room with family members and deliver the information in a courteous way with empathy, making eye contact and allowing time for interactions.
Perception of patient family can be understood by asking questions like.
"What have you been told of the medical situation so far?" Based on his understanding we can tailor the bad news.
Invitation- Obtaining the family's invitation "Would you like me to give you all the information".
Giving Knowledge
"I am afraid I have some bad news".
Warning the patient that bad news is coming may lessen the shock.
It is better not use technical words and we need to check patients understanding.
Respond to patients Emotion with Empathy.
eg. "I understand how you feel" It is preferable not to rush, allowing him or her to express his anxiety and fears.
Strategy and Summary. Lastly we should summarise the condition and strategise the treatment option available.
Medical Jurisprudence
The word Medical Jurisprudence comes from the word Juris which means Law and Prudence which stands for knowledge. In todays world it is advisable that doctors have an idea about the laws which govern the Medical profession. Besides the Medical Council of India Act which governs us, it is also important that we aquaint ourselves with the State Laws such as The West Bengal Clinical Establishment Act which was formulated recently.

The West Bengal Clinical Establishment Act 2017 All institutions such as a Hospital, Nursing Homes, Polyclinics in the state of West Bengal as well as individual Doctor's Chambers where dressing or any injection or intervention is done comes under this Act.[5]
The salient features of this Act are that the institution should have.
- Minimum standards of accommodation and appropriate arrangements for disposal of biomedical wastes as may be prescribed etc.
- Every case of a victim of accident and injury or trauma received or accommodated or both in the Clinical Establishment needs to be reported to the nearest police station, after providing immediate medical treatment.
- Every Clinical Establishment is required to provide necessary medical treatment to victims of accidents, persons suffering from sudden calamities, acid attacks and rape victims, without taking into consideration the ability of the patient to pay the costs.
- Strictly follow the fixed rates and charges including the Package Rates.
- Required to pay compensations in case of medical negligence. Clinical Establishments are proposed to a fine of Rs. 10 lakh or more, on contravention of any of the provisions.
- Required to strictly discourage repetitive laboratory tests for any service recipient, unless essential.
- Clinical Establishments, which have received land or other facility from the Government during initiation and in course of continuance of their projects are required to provide completely free treatment to 20 percent of Outdoor Patient and 10 percent of Indoor Patients.
- Every clinical establishment shall maintain a Public Grievance Cell for lodging of any complaint regarding treatment, improper billing, deficit in service, attending staffs behaviour etc. and for redressal thereof;
- Every clinical establishment shall set up a proper Help Desk to maintain regular and proper communication with the service recipients or their representatives regarding treatment, recipients condition, regular billing etc. and for their proper counseling;
- Every clinical establishment shall immediately after coming into force of this Act, implement e-Prescription, maintain Electronic Medical Records and provide a set of all medical records and treatment details along with the discharge summary at the time of discharge of the service;
- Penal Measures under the Bill ranges between compensation and cancellation of the license granted which also includes imprisonment up to 3 years.
The Protection of Children from Sexual Offences ACT, 2012 (POCSO Act) The Protection of Children from Sexual Offences Act (POCSO Act) 2012 was formulated in order to effectively address sexual abuse and sexual exploitation of children and the doctors should be well versed with this Act.
The registered medical practitioner rendering medical care shall (i) collect evidence after a thorough medical examination, (ii) treat the physical and genital injuries, (iii) conduct age assessment of the victim (if required), (iv) offer prophylaxis for sexually transmitted diseases including HIV, (v) discuss emergency contraceptives with the pubertal child and her parent, (vi) do baseline evaluation for mental health issues, (vii) monthly follow up at least for six months to look for development of psychiatric disorders, (viii) do family counselling and (ix) assist the court in interviewing the child and testifying in the court.[6]
The Act provides for mandatory reporting of sexual offences. This casts a legal duty upon a person who has knowledge that a child has been sexually abused to report the offence; if he fails to do so, he may be punished with six months imprisonment and/ or a fine.[7]
Section 166B of Indian Penal Code specifies that no hospital whether the private or public can deny treatment to a rape victim. Treatment should be provided immediately and free of cost.
If a hospital staff is involved in rape, then law dictates punishment for a minimum of seven years.
Keeping ourselves up to date with sound medical knowledge along with various aspects of Medical Jurisprudence and delivering our care with empathy and good communications skills will go a long way in ensuring that we do justice to the medical professions and succeed in bringing the trust back. We were all made to recite the Hippocrates Oath in our Medical school which is our guiding principle and it is time we go back to it. Good ethical practices will remove the need of the Consumer Protection Act.[8]

  1. Fong Ha J, Longnecker N. Doctor-Patient communication: A Review. Ochsner J. 2010; 10(1) : 38-43. accessed on 21.10.2017.

  2. Ghooi RB, Deshpande SR. Patientís rights in India: an ethical perspective. Indian J Med Ethics. 2012; 9:4 accessed on 22.10.2017.

  3. Frank A, Riddick Jr. The Code of Medical Ethics of the American Medical Association. Oschner J. 2003; 5(2) accessed on 21.10.2017.

  4. F Baile W, Buckman R, Lenzi R, Glober G, Beale E, et al; SPIKES- A Six Step Protocol for Delivering Bad News. The Oncologist. 2017; 22(10).

  5. The Kolkata Gazette-Part111. Acts of the West Bengal Legislature. The West Bengal Clinical Established Act, 2017.
    http:/ Lpdf accessed on 22.10.2017.

  6. Moirangthem S, C Kumar N, Bada Math S. Child Sexual Abuse: Issues & Concerns. Indian J Med Research. 2015; 142(1):1-3. accessed on 27.10.2017.

  7. The Protection of Children from Sexual Offences Act, 2012.
    http:/ The%20Protection accessed on 23.10.2017

  8. MCI Code of Medical Ethics. accessed on 22.10.2017.


Current Issue