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Practical Therapeutics
A dlHlcult physlclan-patlent relatlonshlp rather than just the patient. A high level
can have slgnlflcant consequences for both of awareness. or index of suspicion, that
the physíclan and tire patlen!. DIHlcult re la- such a relationship is developing is also
tlooshlps can le ad to frustratlng, dlssattsty-
important. This article discusses the na-
IIlg, adversarlaf and expe nslve medlcaf care ,
ture, causes and man.agement of the diffi-
The dlHicult relationship ls often a c onse-
cult physician-patient relationship,
quence 01 a breakdown Jn communfcation
between physlclan and patient. Speclllc
Freque ncy
causes kicluoe technlcal communlcatlon
barriers, diHlcufty in dlseussing certaln top- No study has directly examined the fre-
les, unmet or vlolated norms and expecta- quency of the difficu!t physician-patient
tlons (both the physlclan's arxí the patlent's) relationship in family practice, but indi-
and a mlsmatch b€tween the physlclan 's and red. rneasures suggest that physicians find
the patient's personallty styles. Manage- as many as 10 percent of all patient in ter-
ment gl).815for the diHlcult relaUonshlp In- actions to be highly frustrating .' Recent
cluóe malntalnlng professlonal self-esteem,
studies of physicians ' frustration with
matntalll<'1g physlclan-patlent continulty,
patients who are "high utilizers" of rnedi-
minlmlz:lng the "medlcallzation" 01 the prob-
cal care show that one-third of the top
le rn by IImlting the use 01 tests and proce-
dures, and mlnlmlzlng hospltallzatlon and
decile of su eh patients were rated as very
relerra!.lt 15also Important to remember that frustraring by physicians.? Sirnilarly. stud-
althoogh the relatlonshlp may continua lo be ies ha ve demonstrated that as many as
trustratiog or conllictual, It can be etíe ctlve- 30 tó40 percent of patients report signifi-
Iy managed with approprlate strategles. cant diss.atisfaction with any given medi-
cal interaction .'
The frustrating and dissatisfying physi-
Consequences
cian-patient relationship can ha ve signifi-
cant errotional. financial. legal and clinicaI Consequences of the difficuIt physi-
consequences. However. like any rnedi- cia n-pat ient relationship range from the
:.:::!: yeor mcrrib crs
~,:::difjermt cal diagnosis, t he difficult physicia n-pa- annoying to the catastrophic. The diffi-
I ,",<".::colflUulry tient relationship hasspecificcauses, gen- cult physician-patient relationship can
i ~ri':'arE' onieles eral management strategies and specific cause Ieelings of frustration, dysphoria,
I 'e Pract ic a 1 interventions. The recognition of the po- anger and inadequacy, causing physi-
:nerapcutiC5." ru.
I ~'!nc [ifth in a 51'n"e5
tential causes and the successful use of
management straiegies depend on the wil!-
cians to blame patients for the problern .'
A common manifesration of this blame is
·;c", the Universuv
~J.'.1ichigan Medicol ingness of the family physician to see the the labeling of patients with derogatory
I S:hool, Ann Arbor. difficult relat ionship as a problem created na mes. The difficult physician-patient
I
Gucst editors of the by both the physician and the patient, relationship has also been shown to be
:{'1rs are Barbara S
associated with two to three times higher
':>gor, M. D., and
~nornas L. 5ch1..lX'11k.
rates of radiographs, Jaboratory tests and
\!.D. See editorial on page 1389. physician referrals."
TABLE 1
TABLE2
-,
1.' Minimize
2. M.aintain
"medica lizat iori." rhrough judicious use of
inappropriare
diagnostic tests. thcrape utir prcc edure-s. hcspita lization and reíerral,
with correspondingly greater eíícr: to uncover dep ression and ocher
psyehiatric illrcsses.
physician-patient continuit y to t he gre at est ext ent possib]e .
of pat ients. ~.II Effective strategies incluci
request ing feedback from patients
1
an
3. Ma int ain profess ional selí-cstcern rhrough t he maximal use of product ive colleagues about ways to improve coa
a nd constructive physician bchaviors and support systerns. munication skills. rernoving barriers t
4. Focu.s on t he more sat isf yi!'lg a nd product ive aspecis of I he pal ients communication by understanding an
pe rsorialit y and behavior. adapt ing to the pat ierit's communicabo
5. Re-c'Yr'-iJize t ha: r he re latiorehip will probably a lways be less sat isfying style. using an interpreter, involving farr
t ha n desired.
ily members, and providing for a long(
initial visit to allow patients with a les
direct conversational style or cognitiv
ness. although not necessarily with love. irnpa irment to tell their story.
of every patient for whorn the physician The physician should also use effectiv
provides services. \f\.'hen a physician is rechniques of reassurance therapy for th
unable to do this because of physician- many patients who somatize or requ~
pat ient corúlicts in sryle. behavior orvalue help for otherwise trivial physical com
.._ systems, the physician should consider plaints. Effective reassurance therapj .
, transferring care of the pat ient to another involves six steps (TabIe 4).12 .-:
physician. U ihese occasions are frequent, Step 1, obtaining a det ailed descriptiJ;
it is necessary to examine the causes for of the pat ients symptoms, often requires
this excer.s: .c stress and the physiciari's more than one appointment. The phyJ..
apparent i.nability to cope effectively. cian can ask the patient to bring Jists to
Being honest about one's feelin.gs to- t.he appointment and can deal wit.h ~
•.••
--arothe patient is critica!. The physician "three most important syrnptoms" at ea<1
who feels depressed, arixious. frustrated visito Step 2 involves eliciting the crnO-
or angry should ask hirnself or herself tional rneaning of symptoms, such as ri-
sorne important quest ions: \Yhat does the alistic Fears. irrational phobias, COnDeO-
pat ient do to elicit these feelings7 What tions to illnesses in friends or relativei,
needs dces the patient nave to behave this fear created in the patient by the absenct
\\--a1'7\f\.'hat is there about the physician's of complete explanations, and "ariniver.
motivations. value systern. stresses or sary" reactions.
behaviors that may be causing this un- Step 3 is the physical exarnination. Itr
productive interaction7 selectively repeating only lirnited por-
Acceptance and uriderstanding of such tions of the examination as necessary dur-
Ieelings can provide relief but may also ing future visits, the remaining time in
cause a feeling of "grief" over the loss of a each visit can be LL<;ee1 for discussion about
satisfying relationship. Because most phy- the patient's concems and underlying fed..
sicians have a slrong desire to be needed ings about being il!.
by their patients, the loss of a previously Steps 4 and 5 involve making a specific
sat isf ying relationship may be "mourned" diagnosis, which may include nonbio-
by the physician, although the physician medica] pathophysiologic explanations
rnay not recognize that his or her response Diagnoses for which the physician needs
eman.ates from this process. to provide extra rcassurance and cornmu-
Strategy 2: Use precise and cffec1ive com- nication include those with strong stress
.. munication and interuieunng t ech niq ues . or ernotional componcnts (strcss-rclated
Srudies have demonst rated lhat bctter phy- diagnoses such as fibromyalgia, chronic
sician t ra inirig in thepsychosocial dimcn- fatigue, tension headache o r irritabk boweJ
S.;\~¡JI~ ,J P?~~c:--:~ c:!:.\? can JCJd to clinical syndrome) and more specific psychiatric
irnprovement in the functional outcomes diagnoses (major depression. genera 1ízed .
1506 volume 46, nurnber 5
Arnc r ic an Fa mily Physicían
y,,\BLE4
physician avoids the lendency to see the seductive behavior mal' necessitate ter-
behavior as a personal threat. Modest mination of the relationship.
gratification for a short time is reasonable The long-slJffering, m asoch ist ic, deriy-
(e.g.. a slightly longer office visit initially), ing paiient . The patient who exhibits these
but il is necessary to set limits when the behaviors has a nce d lo ma inta in his oro
pat tem is recogn iz cd. her "sick ness" and constan: nced of careo
-Setting limils iliCJudes conlrolling the Rather t han being over tly demanding,
length and frequency of office visits and these patients seern to have resigr-ed them-
t elephone calls, and expressing the expec- selves to their fate. Such resignation can
tation that the patient wil] transfer sorne be frustrating for the physician who is
of his or her support needs to other indi- trying to help.
viduals or groups. The paticnt must be The physician should recognize tha!
given an explanation of the decision to set this behavior may be the pat ierit's best (or
limits and the need and importance of only) way of coping with despair, anxiety
doing so. Setting limits requires negotia- or stress. Rather than confront the patienj
tion a nd compromise between widely dis- directly or attempt repeated reassuranc~
crepant views regarding how rT:Lich time the physician can acknowledge the pal .
and attention are necessary. At all times, rient's courage and self-sacrifice in th¿
the physician should use empathy lO focus face of illness or debilitat ion. The ernpha]
on the emational needs that are behind the sis is more on empat hy than on medica1
pat ients seerningly excessive requests. data. The physiciari's frustration can ?1
The dramatic,
involved. affectionate
behaviors
seductive. emotiorwlly
patient. Seductive
should not elicit a similar re-
used as a reflection of the frustration
patient must feel at the lack of control
his or her J ife.
01 thi
sponse Irorn the phys ic ian. but rather TIJe sornat izing, hypochoru:in'iUal pa.
should be seen as a symptom-the patient tient. \t\'hen a patient repeatedly preserif
is needy and asking Ior support and a pos- with a range and intensity of symptoml
it ive response, albeit in a n inappropriate that resist biomedical explanation. the ph~
íashion. Confidentia] consultation with a sician must acknowledge that the syrnp
trusted colleague can help clarify and sep- toms are legitimate and make a commi~
arate the physicians feelings and needs ment to work on the pat ients behalf fo!
Irorn those of the patient. symptom control (as opposed to diseas!
Once this behavior is iderit ified, the cure). The somatizing pat ient frequenth
phvsician should set limits in a n explicit benefits from his or her behavior throug.]
and noripunit ive way. For e xarnple. a spe- seconda ry gain (t he phys icians at tent ioi
cific staternent about [he necessity to stay and the closeness of the medical relation
focused on the pat ients s ymptorns and ship). A high index of suspicion and th
medical needs may be neccssary. \Vhen a prov ision of continued medical careis im
pal ient makes ina ppropr iately fa mil iar or port a nt ("hypochondriacs get sick too")
personal comments about lhe physician but diagnostic proccdures and rcferral
(e .g.. "you seern so much more under- must be select ive and lirnited. for reason
standing about my problems t ha n my ofboth cosl and qua lit y of careo
husband/wiíe"). rhc pat ient should be Somatizing pat ient s necd support arv
lold ihat such comments are unhelpful or reassurarxe rather than symptornat ic trea!
cven that they rnake the physician Ieel rnent or biomedical cure. They may bm
uncomfortable. An irnrnediatc st aí ernent fil [rorn an explanation t hat their syrnp
redirecí ing the discussion to the pertincnt toms may be a way of dealing with strd
medical issue is thcn advisable Persistent Occasionally, the secondary gain that t1í
]508
J
volurne 46, numberi
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Arncr ica n Family Physiclan