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Four Models of the Physician-Patient Relationship

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Four Models of the Physician-Patient Relationship
Emanuel, Ezekiel J; Emanuel, Linda L
JAMA; Apr 22, 1992; 267, 16; Research Library
pg. 2221
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
... The four main models of the physician-patient relationship are outlined in the seminal work by Emanuel and Emanuel (1992): the paternalistic, the informative, the interpretative, and the deliberative model, the latter being recommended. Each model covers four aspects: a) the goals of physician-patient interaction, b) physician's obligations, c) the role of patient's values, and d) the conceptualisation of patient's autonomy (Emanuel & Emanuel, 1992;Devereux, 1992). ...
... The four main models of the physician-patient relationship are outlined in the seminal work by Emanuel and Emanuel (1992): the paternalistic, the informative, the interpretative, and the deliberative model, the latter being recommended. Each model covers four aspects: a) the goals of physician-patient interaction, b) physician's obligations, c) the role of patient's values, and d) the conceptualisation of patient's autonomy (Emanuel & Emanuel, 1992;Devereux, 1992). In subsequent literature on this categorisation of models, the independent expression of values and autonomy in individual patients was even more emphasised, and the patient's education was included (Agarwal & Murinson, 2012;Borza et al, 2015;Kilbride & Joffe, 2018). ...
... Over the past few decades, emphasising patients' role in both literature and public policies, namely patients' values, autonomy, and education, has led to gradual shift from the paternalistic approach in healthcare systems toward the deliberative model. The deliberative model encompasses the physician-patient relationship and encourages practitioners to "delineate information on the patient's clinical situation and then help elucidate the types of values embodied in the available options" (Emanuel & Emanuel, 1992). The basis is that communication between physician and patient about diagnosis and treatment plans is the key, and that the patient should be encouraged to discuss with their practitioner all therapeutic alternatives and their implications. ...
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Trust in the healthcare system is one of the prerequisites for positive treatment outcomes. Studies continuously show positive association between trust and patients’ desirable health behaviours, such as sticking to the recommended therapy. Being a quintessential social role, the role of women as patients is associated with other relations of power embedded in society, and studies have repeatedly shown the influence of gender on healthcare-seeking behaviour. Gender stereotypes reduce women's agency in health behaviour and women are more likely to be distrusted by physicians. Furthermore, most of the current psychological measures of trust in the healthcare system have been constructed and validated in Western, educated, industrialised, rich, and democratic (WEIRD) countries, and hence have a limited application in the other social contexts, such as South-eastern Europe. In this study, we constructed a Women’s Trust and Confidence in Healthcare System (WITCH) scale and validated its structure in Serbia. Exploratory factor analysis in Sample 1 (N=329) indicated four-factor structure of trust in the healthcare system, with two dimensions that capture trust (particularised trust, generalised mistrust), the third being confidence, and the fourth that relates to behavioural outcomes of trust. In sample 2 (N=333), we validated the 3+1 factor structure using Confirmatory factor analysis. We observed that interpersonal trust predicted women’s desirable health behaviours in a positive direction, while generalised trust in the system had a negative impact. This pattern of the results indicates the complex interplay between trust in the healthcare system and health-related behaviours.
... We then contrast our findings with the previous physiotherapy research on value cocreation (Bhatti et al., 2021) and show that the service-dominant logic (Vargo & Lusch, 2004), which has been used as a foundational basis for the majority of the value cocreation studies, is not sufficient to account for the differences in cocreation goals and behaviors across culturally different customer segments and falls short in explaining the complexity of the nuanced context of value cocreation in the well-being experience. By integrating insights from healthcare and cross-cultural literature, namely the physician-patient relationship model by Emanuel and Emanuel (1992) and the cultural framework by Hofstede (2001), we explore the importance of relationship dynamics, culture, and institutional context in healthcare. By doing so, we help develop a more comprehensive understanding of the behaviors of American wellbeing consumers, which occur within complex and nuanced interlocking layers of social contexts. ...
... While value cocreation undoubtedly results in positive outcomes for the customer, not every relationship mode is conducive to a collaborative wellness experience. Healthcare literature differentiates four types of relationship dynamics between physician and patient: paternalistic, deliberative, interpretative and informative (Emanuel & Emanuel, 1992). ...
... This physician-patient model applies to the relationships between customer and expert (service provider) in the well-being sector, in general, and in the physiotherapy setting, in particular, as it is a knowledge-intensive professional service (Chen et al., 2020). Similar to the healthcare setting, there exists knowledge asymmetry between the two actors and the well-being service provider is hired for his knowledge and 'expert position,' which can be contrasted with the customers' limited knowledge and understanding of the specific well-being or healthcare issue (Emanuel & Emanuel, 1992;Knutsson & Ulla-Karin, 2020). Moreover, as we will discuss, these four relationship dynamics have important implications for willingness and motivation to co-create value. ...
Article
Purpose: We study the U.S. based (American) physiotherapy customers’ goals to engage in value cocreation activities during their well-being experience. Design/methodology/approach: We perform Smart PLS-SEM analysis of the primary data of physiotherapy service customers in the USA. Findings: Our findings show that the U.S. well-being customer engages in physiotherapy for individualizing, empowering, development, concerted, and ethical motives but not for relating motives. These findings are contrasted with previous research to show that the service-dominant logic is not sufficient to account for the contextual complexity of the well-being experience and to explain the identified differences across culturally different customer segments. Research Implications: By integrating insights from healthcare and cross-cultural literature, we highlight the importance of relationship dynamics, culture, and institutional context in well-being sector and develop a more comprehensive understanding of the cocreation behaviors in this industry. This helps advance the value cocreation research in well-being sector and promote the well-being experiences such as physiotherapy. Originality: We draw from a variety of disciplinary perspectives and challenge the S-D logic as insufficient in explaining the value cocreation between the customer and expert in the well-being sector. We adapt physician-patient relationship model from healthcare literature and cultural values of power distance from cross-cultural literature to complement the S-D logic to account for the complexity and nuanced context of the well-being cocreation experience.
... The survey instrument was developed based on an extensive literature review. Research articles discussing the reasons for consultation with pharmacists around HDS use [40,41,[44][45][46][47], pharmacist-or HCP-patient communication and relationship [48,49], and complementary medicine disclosure to HCPs [50][51][52] were used. Based on the literature review, the consultation and non-consultation with CPs about HDSs can be influenced by the consumers' perceptions of the consultative roles of CPs with respect to HDSs, facilitators (e.g., having a good relationship with CPs, having adequate time to consult CPs, willingness of CPs to spend time providing consultation, etc.), and barriers to consult CPs (e.g., feeling uncomfortable discussing HDSs with CPs, not being asked by CPs about HDS use, not having time to consult CPs, etc.), the health concerns, beliefs of the outcomes of the consultation, and perceived-need of the consultation [40,41,[44][45][46][47][48][49]. ...
... Research articles discussing the reasons for consultation with pharmacists around HDS use [40,41,[44][45][46][47], pharmacist-or HCP-patient communication and relationship [48,49], and complementary medicine disclosure to HCPs [50][51][52] were used. Based on the literature review, the consultation and non-consultation with CPs about HDSs can be influenced by the consumers' perceptions of the consultative roles of CPs with respect to HDSs, facilitators (e.g., having a good relationship with CPs, having adequate time to consult CPs, willingness of CPs to spend time providing consultation, etc.), and barriers to consult CPs (e.g., feeling uncomfortable discussing HDSs with CPs, not being asked by CPs about HDS use, not having time to consult CPs, etc.), the health concerns, beliefs of the outcomes of the consultation, and perceived-need of the consultation [40,41,[44][45][46][47][48][49]. ...
... However, it should be noted that in the study, the consumers believed that the final decision to use HDSs, or otherwise, should not be dictated by the pharmacists [41]. This reflects an interpretive model of the patient-HCP relationship in which pharmacists provide consumers with information and assist them in elucidating and articulating their values, but do not participate directly in the decision-making [49]. ...
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Herbal and dietary supplements (HDSs) are frequently obtained from community pharmacies, but community pharmacists (CPs) have been underutilized for information regarding them. This study aimed to determine the prevalence of, factors behind, and reasons for consultation with CPs among HDS consumers in Malaysia. A cross-sectional study using an online survey was conducted among conveniently sampled individuals in Malaysia. Reasons for consultation or non-consultation with CPs about HDSs were sought from the respondents. A logistic regression analysis was conducted to determine the predictors of consultation with CPs. Overall, 40.3% (239/593) of participants consulted CPs about the HDSs that they purchased. The participants were predominantly unmarried (362/588, 61.6%) and belonged to the 18-29 age group (332/593, 56%). The multivariate analysis showed that a suburban residential setting was the only significant predictor for consultation with CPs (adjusted odds ratio = 0.390, 95% CI = 0.260-0.583). Respondents who consulted CPs generally agreed that the CPs were the right people to consult on HDSs (mean = 4.37, SD = 0.73). However, their discussion with CPs regarding HDSs mostly revolved around the benefits and directions for use, but little on the potential risks. Meanwhile, most respondents who did not consult CPs agreed that they had never thought of consulting CPs about their HDS use (mean = 3.45, SD = 1.02). The majority of them referred to the Internet (61.3%, 217/354) and social media (59.9%, 212/354) for information about HDSs. The findings from this study show that more efforts are warranted in encouraging consumers to consult CPs about their HDS use and to enhance their awareness of the roles of CPs in ensuring the safe use of HDSs.
... É interessante notar que esta segunda forma de relacionamento profissional-paciente também se encontra bastante distante do princípio da escuta compassiva, pois prescinde de qualquer esforço de compreensão e conexão genuína entre profissionais de saúde e pacientes/familiares. Por isso, tal abordagem também pode frequentemente resultar em intervenções que aumentam, ao invés de diminuir, o sofrimento de pacientes e seus entes queridos. Tal fato ocorre, muitas vezes, porque os próprios pacientes podem não ter total clareza sobre o que desejam 21 , ou sobre a rede de elementos que contribuem para seu sofrimento, e podem solicitar, por exemplo, por puro desespero, intervenções que não atenderiam às suas próprias necessidades. Adicionalmente, muitos pacientes podem se sentir desamparados e subjugados sob o peso de decisões que precisam ser tomadas 22 . ...
... Esta será construída através do diálogo continuado, do esforço autêntico de compreensão mútua e da abertura para reavaliação de pontos de vista e de decisões prévias. O papel do profissional de saúde pode ir além da simples interpretação dos valores e objetivos do paciente e de como os mesmos seriam mais bem atendidos por determinadas abordagens terapêuticas ou diagnósticas, envolvendo a reflexão conjunta sobre valores e objetivos 21 . Por isso, é essencial reconhecer a necessidade de um alto grau de autovigilância e humildade cultural para que, durante o processo deliberativo, os profissionais de saúde não incorram em uma postura paternalista velada e terminem por impor, ainda que de forma inconsciente, seus próprios valores culturais disfarçados através do esforço relacionado à articulação dos valores e preferências dos pacientes. ...
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Os cuidados de saúde com pacientes portadores de doenças graves usualmente implicam a necessidade de tomada de um grande número de decisões, envolvendo desde a forma como a informação é compartilhada até quais procedimentos diagnósticos ou terapêuticos serão adotados. A maneira como tais decisões são tomadas têm importantes implicações do ponto de vista individual e coletivo, podendo contribuir tanto para o alívio como para o agravamento do sofrimento. No presente documento de consenso, o Comitê de Bioética da Academia Nacional de Cuidados Paliativos (ANCP) e a Comissão Permanente de Cuidados Paliativos da Sociedade Brasileira de Geriatria e Gerontologia (SBGG) adotam os princípios da escuta compassiva proposto por Saunders, da natureza do sofrimento proposto por Cassel, dos cuidados preservadores da dignidade propostos por Chochinov e da humildade cultural como ponto de partida para a construção de um posicionamento oficial da ANCP e SBGG acerca do processo de tomada de decisão compartilhada em cuidados paliativos. O posicionamento estabelece que, em contraposição aos modelos paternalistas e consumistas, o processo de tomada de decisão no âmbito dos cuidados paliativos deve seguir o modelo mutualista de decisão compartilhada, no qual as decisões são construídas a partir do diálogo entre profissionais de saúde e pacientes/familiares. O documento estabelece os pressupostos deste processo, os limites da autonomia de pacientes/familiares e profissionais de saúde, a distinção entre tratamentos fúteis e potencialmente inapropriados, bem como ratifica sua incompatibilidade com quaisquer formas de coerção e conflitos de interesse alheios ao melhor interesse dos pacientes.
... The interpretation of patient autonomy in terms of openness, authenticity and relationships is in line with the deliberative model of Emanuel and Emanuel [4]. They have distinguished four models of the physicianpatient relationship: 1) the paternalistic, 2) the informative, 3) the interpretative and 4) the deliberative model. ...
... The ideal is to decide together. Emanuel and Emanuel [4] argue that too much emphasis on the patient's role is undesirable, as is too much emphasis on the role of the physician. They indicate that the values of the physician are indispensable: "… physician values are relevant to patients and do inform their choice of a physician". ...
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Background In the Netherlands, patients have the legal right to make a request for euthanasia to their physician. However, it is not clear what it means in a moral sense for a physician to receive a request for euthanasia. The aim of this study is to explore the moral values of physicians regarding requests for euthanasia. Methods Semi-structured interviews were conducted with nine primary healthcare physicians involved in decision-making about euthanasia. The data were inductively analyzed which lead to the emergence of themes, one of which was about values regarding end-of-life decisions. Results Four clusters of values related to euthanasia requests are described: values related to 1) the patient; 2) the family; 3) the physician; and 4) life and death. The data show that the participants value patient autonomy as a necessary but not sufficient condition for meeting a euthanasia request. A good relationship with the patient and the family are important. For the physician, the values physician autonomy, responsibility, understanding the patient and relief of suffering play a role. Life as an intrinsic good and a peaceful death are also important values. Conclusion This study shows that next to patient autonomy and the relationship with the patient and the family, it is important for the participants to act in accordance with their professional values and to do justice to values related to life and death. The awareness of going against the intrinsic value of life is crucial, even if performing euthanasia may result in a feeling of relief or gratitude afterwards.
... In the past years, withholding information to protect patients, based on the belief that this would not diminish hope, was common practice. 22 Many physicians mistakenly equated PC and discussing bad news with giving up hope. 23 However, patients with serious illness usually want to hear the truth from their physicians and benefit from knowing the facts, [24][25][26] and the physician can play a valuable role in helping each patient define his hopes. ...
... To some physicians, death inevitability feels like failure. 22 It seems there is only one 'hope': the hope the illness will be cured. That is false and illogical. ...
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About certain patterns of behaviuour seen in PCare practice, on how to teach about them and deal in daily practice
... In the past years, withholding information to protect patients, based on the belief that this would not diminish hope, was common practice. 22 Many physicians mistakenly equated PC and discussing bad news with giving up hope. 23 However, patients with serious illness usually want to hear the truth from their physicians and benefit from knowing the facts, [24][25][26] and the physician can play a valuable role in helping each patient define his hopes. ...
... To some physicians, death inevitability feels like failure. 22 It seems there is only one 'hope': the hope the illness will be cured. That is false and illogical. ...
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Introduction After more than 25 years working in palliative care (PC) observing thousands of patients and family behaviors, I use my long experience and notes as a source of data for a qualitative research study. The aim is to identify frequent families’ behavior patterns in PC and better describe the culture in PC. Methods This article is part of a larger project, using autoethnography as methodology, with the aim of helping doctors and interested health professionals better understand the culture and reality of PC. The focus is not the author but patients and families’ patterns of social behavior – the social context – within the end-of-life period and how to deal with these professionally. Confidentiality and privacy of patients’ data were guaranteed. Results The vast number of treated cases, the regular observation and recording, and the continuous reflection and analysis over many years have led to these results. Due to editorial restrictions, in this article I only describe four of at least eight typical scenarios I have identified. Each is given a short title and I explore some of their inside-issues, integrating previous knowledge, research, and explanations, with practical suggestions on how to deal with them. Significance As far as we know, these scenarios/patterns have never been described in this way. This work expands knowledge, innovates, and contributes to better describing PC culture. The final goal is to create a set of scripts that can be used to help clinicians quickly identify the clinical situation and how to deal with it in clinical practice. Reflecting on how patients and families frequently behave in PC can be very useful and then teach other professionals to better deal with these challenges.
... This will be built through ongoing dialogue, authentic effort of mutual understanding and openness to reassess points of view and previous decisions. The role of healthcare professionals may go beyond the simple interpretation of the patient's values and goals and how they would be better served by specific therapeutic or diagnostic approaches, involving joint reflection on values and goals 21 . Therefore, it is essential to recognize the need for a high degree of self-surveillance and cultural humility so that, during the deliberation process, healthcare professionals do not adopt a veiled paternalistic behavior and end up imposing, even if unconsciously, their own cultural values disguised as an effort to consider the patients' values and preferences. ...
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Health care for patients with serious illnesses usually implies the need to make a large number of decisions, ranging from how information is shared to which diagnostic or therapeutic procedures will be adopted. The method of such decision-making has important implications from an individual and collective point of view and may contribute to either relieving or aggravating suffering. In this consensus document, the Bioethics Committee of the Brazilian National Academy of Palliative Care (ANCP) and the Permanent Committee on Palliative Care of the Brazilian Geriatrics and Gerontology Society (SBGG) adopt the principles of compassionate listening proposed by Saunders, of the nature of suffering proposed by Cassel, of dignity-preserving care proposed by Chochinov, and of cultural humility as a starting point for the construction of an official position of ANCP and SBGG on shared decision-making in palliative care. The position statement posits that, unlike paternalistic and consumerist models, the decision-making process in the sphere of palliative care must follow the mutualistic model of shared decision, where decisions are built based on dialogue between healthcare professionals and patients/family. The document sets forth the assumptions of this process, the limits of autonomy of patients/family and healthcare professionals and the distinction between futile and potentially inappropriate treatments, besides ratifying its incompatibility with any forms of coercion and conflict of interest foreign to the best interests of patients.
... Indeed, there is no autonomy without expression of autonomy and, therefore, without communication. Therefore, in an ethical framework in which there is a role for autonomy as a principle, there must be consideration for bidirectional communication [45]. ...
Article
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Head and neck cancer, the sixth most common cancer worldwide, account for about 1 out of 20 malignant tumors. In recent years a reduction in the incidence of cervical cancer, but a concomitant major increase in the incidence of HPV-mediated oropharyngeal cancer caused by orogenital HPV transmission has been observed. Consequently, in wealthy countries oropharyngeal squamous-cell carcinomas (OPSCC) is now the most frequent HPV-related cancer, having overtaken cervical cancer. Without effective medical interventions, this incidence trend could continue for decades. As no specific precursor lesion has been consistently identified in the oral cavity and oropharynx, HPV vaccination is the logical intervention to successfully counteract also the rising incidence of OPSCCs. However, HPV vaccine uptake remains suboptimal, particularly in males, the population at higher risk of OPSCC. Alternative primary prevention measures, such as modifications in sexual behaviors, could be implemented based on knowledge of individual genital HPV status. Until recently, this information was not available at a population level, but the current gradual shift from cytology (Pap test) to primary HPV testing for cervical cancer screening is revealing the presence of oncogenic viral genotypes in millions of women. In the past, health authorities and professional organizations have not consistently recommended modifications in sexual behaviors to be adopted when a persistent high-risk HPV cervicovaginal infection was identified. However, given the above changing epidemiologic scenario and the recent availability of an immense amount of novel information on genital HPV infection, it is unclear whether patient counseling should change. The right of future partners to be informed of the risk could also be considered. However, any modification of the provided counseling should be based also on the actual likelihood of a beneficial effect on the incidence of HPV-associated oropharyngeal cancers. The risk is on one side to induce unjustified anxiety and provide ineffective instructions, on the other side to miss the opportunity to limit the spread of oral HPV infections. Thus, major health authorities and international gynecologic scientific societies should issue or update specific recommendations, also with the aim of preventing inconsistent health care professionals’ behaviors.
... Vi foreslår en revisjon av veiledningsmateriellet med fremhevning av de to temaene over. Vi oppfordrer også direktoratet og fastlegene til å la seg inspirere av Emanuel & Emanuels klassiske artikkel om fire modeller for legers veiledning av pasienten (8). Saerlig relevant her er den fortolkende modellen, der fastlegen forsøker å få frem pasientens egne verdier gjennom samtalen. ...
Article
In 1984 Mackillop et al.1 sent a questionnaire to physicians and surgeons in Ontario who treated lung cancer. The questionnaire asked the doctors to consider themselves as patients with lung cancer, as specified in a number of clinical scenarios, and to describe the treatment they would wish to receive. One scenario described asymptomatic, locally advanced non-small-cell lung cancer. A majority of the respondents (61 percent) preferred treatment with radiotherapy, and 22 percent preferred no immediate treatment; only 5 percent of the respondents chose chemotherapy. We do not know the reasons for these choices, but they were presumably influenced by randomized . . .