What Can Go Wrong with the Doctor-Patient Relationship
Is this any way to solve a problem?… Is this any way to treat a patient?
A friend told me the story of a doctor who believed his patient was about to make a decision about his care that would have dangerous consequences and perhaps shorten his life. The patient’s decision was based on a number of erroneous assumptions and irrelevant issues. The doctor was getting no- where in his attempt to redirect the patient’s reasoning and finally said to him, “Is this any way to solve a problem?” Sometimes, there is a similar question to ask the doctor: “Is this any way to treat a patient?” Here is what physicians sometimes do that derail the relationship.
Be unavailable. We can be unavailable in many ways, by failing to pro- vide a timely appointment or return phone call or by being physically pres- ent but inattentive.
Not care enough to inquire. When a middle-aged woman made many phone calls to her physician in preparation for a breast biopsy, he labeled her “manipulative and demanding” instead of recognizing that she had good reasons for concern and her cascade of questions. She was concerned about how long she would have to be off medication for her chronic illness. In addition, she had a number of prearranged speaking engagements and needed to know which to reschedule. And she was frightened. Her con-cerns and questions were valid; calling her “manipulative and demanding” was a bum rap.
Stifle the expression of feelings. By interrupting weeping patients, instead of remaining silent and allowing them to show emotion, and by not allow- ing patients to express anger, fear, anxiety, and doubt, we thereby squander the opportunity to explore these issues and to expand awareness of the pa- tients’ stories.
Leave matters unfinished. Physicians leave things unsaid and undone. “After the orthopedist injected my knees with cortisone, both he and his assistant left me. He didn’t tell me what I could or couldn’t do. There I was, on the examining table. Suppose I couldn’t get off the table?” It is not only what we say, but also what we do or do not do.
Lose focus on the patient. Sometimes a family member becomes “the cen- ter of the drama.” Conflict arises between the physician and the family member because of unrecognized issues. To the detriment of the patient, the family member’s issues become paramount. Sometimes physicians be- come the center of the drama. They feel threatened by a request for another opinion or by questions about their diagnosis or treatment plan. They be- come defensive when a patient suggests a test that they have not consid- ered. And sometimes the institution becomes the center of the drama. A representative of the hospital or the insurance carrier declares, “The pa- tient no longer needs to be in the hospital” or “This test [consultation, etc.] is not warranted,” and the physician accedes prematurely.
Fail to understand that patients have different needs. When a 50-year-old woman called the surgeon’s office to ask about the risks of her upcoming spine surgery, the assistant relayed this information from the surgeon to the patient: “You have less than a 5 percent risk of infection, less than a 1 per- cent risk of paralysis, and less than a 1 percent risk of death.” What the pa- tient really needed was a personal conversation with the surgeon to express her fears, get reassurance that the surgery was absolutely necessary, and get his commitment to do all he could to make sure that things turned out well. Not all patients need that comprehensive a response, but it is important that physicians respond to the variability of needs.
Fail to truly grasp what is going on.
Though I generally see my patients at their scheduled time, I was five minutes late for this first meeting with a 75-year-old man who greeted me with, “You’re late! Who the hell do you think you are?” Angry and defensive, I was inclined to re- spond, “I sense that we’re not going to get along. I think you should find another doctor.” Instead I asked myself, “What’s his anger all about? What’s my anger all about?” I recognized that he reminded me of someone who had been depressed for many years; his anger was an expression of his depression. Instead of dismissing the patient, who was indeed depressed, I relaxed, continued the interview, and used that insight in his care.
In this mental exercise, which took less than thirty seconds, I applied what I had been taught in medical school: Part of the mental status examination of a patient, is asking yourself the question, “What’s my reaction to the pa- tient and what does my reaction mean?”
Not recognize where the patient is in the story. When a patient has been deal- ing with another illness, physician, and set of assumptions for a long time, it is no wonder that she may initially reject a new physician’s opinions.
Expect patients to make decisions too quickly. Difficult decisions cannot be made in a moment.
Patients’ and families’ behavior, too, can have a negative impact on rela- tionships with physicians. Here are two common ways.
Misinterpret the physician’s motives. When the son of a nursing home resi- dent called to request psychiatric consultation for his mother who had be- come confused, I suggested an alternative: “I’ll see her first to look for nonpsychiatric causes of her confusion.” He rejected the proposal, accus- ing me of “trying to save the state some money by being ‘the gatekeeper.’” A relationship would have helped. The son had clearly constructed his own story about me.
Sometimes it is appropriate and necessary to confront a patient about in- appropriate behavior, an opportunity to discover previously unidentified is- sues and strengthen the relationship. “Very few people can be cured by a doctor they do not like…. [As a doctor], I have never been able to do much for a patient I thoroughly disliked.”1 If the relationship is consistently ad- versarial, the physician needs to ask, “Why? What are the issues?” and some- times that is a reason to recommend that the patient find another doctor.
Continually shop around for another physician. Lacking trust and an ongo- ing relationship, patients may wander from doctor to doctor and self-refer to specialists who do not have the whole story.
The worst of what can go wrong? Neither the patient nor the physician ex- pects a relationship, and neither realizes what is missing.
Congestive Heart Failure: Symptoms and Differential Diagnosis
• Symptoms: shortness of breath, poor exercise tolerance, rapid heartbeat, ankle swelling
• Differential diagnosis: coronary heart disease, valvular heart disease, primary disease of the heart muscle (cardiomyopathy)
“Difficult Patient”: Symptoms and Differential Diagnosis
• Symptoms: Diagnosis is elusive, recovery is prolonged, rapport between patient and physician is difficult to establish
• Differential diagnosis: organic disease, e.g., difficult-to-diagnose malignancy, unusual cause of chest or abdominal pain, other rarely occurring disease; psychosocial problems; “difficult doctor”; “difficult system”
THE DIFFICULT PATIENT
One of the largest groups of patients whose needs go unmet are the so-called “difficult patients.” Often these patients have one or more of these characteristics:
An elusive diagnosis. Despite persistence of his symptoms over a period of weeks or months, his health is not deteriorating. Tests for various common and rarely occurring illnesses are normal, even when done repeatedly. The story does not fit the pattern of any known disease. His chest pain is unre- lated to a disease of the heart, lungs, or other chest contents; his abdominal pain has no obvious source in any of the abdominal organs. His illness con- trasts starkly with that of the patient whose symptoms persist, whose health is failing, who is obviously ill, and yet the physicians cannot yet determine the cause. We have all heard examples: the patient with unexplained chest pain who, after many months and extensive medical consultation, has a se- vere heart attack; the patient with unexplained abdominal pain who ulti- mately is diagnosed with cancer of the ovary or pancreas, illnesses that may be difficult to detect in their early stages. The physicians know something is wrong, but no one can come up with the answer.
An inappropriately prolonged recovery. Despite an illness that has been ad-equately diagnosed and treated, the patient is not feeling better. All the pa- rameters indicating successful treatment are improving, yet the patient feels the same or worse.
Difficult rapport. Even though all the elements of a good doctor-patient relationship are present, the patient distrusts the physician and the rela- tionship is—well—difficult.
Like the butcher with persistent back pain (chapter 9), the “difficult pa-tient” is often dealing with important psychological or social issues. Iden- tifying these issues and providing integrated and thoughtful continuity of care can be transformative. Suddenly a relationship develops, and the diag- nostic and therapeutic questions resolve.
But we cannot take these steps in the care of the patient without this in-sight: Just as the problem “congestive heart failure” (Table 20.1) has a list of symptoms that, taken alone or together, suggest a differential diagnosis, so does the problem “difficult patient” (Table 20.2). Just as we may name the problem “congestive heart failure” on the basis of one or more of symptoms, so we would make the problem statement “difficult patient” on the basis of one or more criteria.
Difficult patients with elusive diagnoses may have a real, though not ob-vious, disease; just as likely, the illness may be related to psychosocial prob- lems. A difficult patient who is not feeling better despite adequate treatment may lack progress not because of an undetected complication, but because of distressing life events. When there is no rapport, despite the physician’s best efforts, the cause may be psychosocial.
As part of the differential diagnosis of “difficult patient,” I included in
Table 20.2 “difficult doctor” and “difficult system,” a view parallel to those
in the book entitled There Are No Problem Horses, Only Problem Riders.2 If the physician consistently deals with each patient with equanimity, then how the patient behaves can be seen as possible data on how the patient deals with others. If, on the other hand, the physician is inconsistent and uneven—if the patient cannot trust that the doctor will be the same on each encounter or if the physician’s demeanor is provocative—then how the patient behaves cannot be seen as data. The doctor will always have to ask, “Was it the patient who provoked this response or was it me?” Or addi- tionally, “Did the system contribute to making this patient difficult, by not meeting his needs?”
A colleague suggested that “any difficult patient started out as a complex
patient.” Patients whose illnesses are complex or who have complex dra- mas going on in their lives may have difficulty in finding a physician with enough patience to address all the issues. Incomplete attention may leave the patient dissatisfied and frustrated. When that happens, the physician also becomes frustrated, labels the patient “difficult,” the prophesy is self-fulfilled, and no one feels satisfied. But not all complex patients be- come difficult, and not all difficult patients are that complex in the right hands. Just as physicians see serious illnesses as a challenge, many physi- cians see “difficult patients” as challenges also. The search for the solutions to these challenges becomes fascinating, and their resolution elevates ev-eryone. Anyone can deal with easy problems or patients. One test of good doctors—real professionals—is how they deal with the difficult ones.
Social workers learn this axiom: “The relationship is the vehicle.” Like any relationship, that between doctor and patient can be used well or abused. Once trust is established, it can be a model for other relationships. Robert Coles writes about what his teacher taught him about dealing with a difficult patient: “Try to learn, and if she can use you to her advantage [and] profit from the relationship and the insight you offer, well and good.”3
If the relationship is a good one, it can be a model to the patient for other relationships. A good relationship facilitates diagnosis, treatment, and overall care.