Difficult doctors, difficult patients

The doctor-patient relationship is inherently unequal. Yet, patients can become a doctor’s best partners in treatment

By Chong Siow Ann, Published The Straits Times, 9 Apr 2014

AS A doctor, I have a special status. Doctors have for long been much respected and admired for possessing special knowledge and expertise. And because they use it for the good of society, they are seen as noble as well.

In my parents’ time and even when I was growing up, that semi-ecclesiastical authority that doctors had was almost absolute and sacrosanct.

But times have changed.

A more-educated public, greater access to information, and the occasional public airing of the shenanigans of miscreant doctors have progressively chipped away at the pedestal on which doctors have stood.

But there is still that lingering aura of power that surrounds the doctor. Accentuated by a sense of dependency on the part of the patient, the doctor-patient relationship is fundamentally unequal.

An article published in the medical journal Health Affairs in 2012, about a series of focus groups among well-educated and affluent patients in the San Francisco Bay Area, said that a large number of the participants felt inhibited when talking to their doctors.

They were afraid of angering or upsetting them, of being labelled as “difficult”. Some even feared some sort of retribution.

They found themselves behaving like “supplicants” in the presence of what they perceived to be “authoritarian rather than authoritative” doctors. More damningly, they felt this was perpetuated by the doctors themselves.

There is no doubt that hubris is often found among doctors. Perhaps, as suggested somewhat caustically by a writer of an op-ed piece in the New York Times in 2004, it comes from “the cumulative intoxicating effects of years spent fully dressed, vigorous and vertical, ministering to the underdressed and miserably horizontal.”

There are also some doctors who like to maintain that power imbalance because that makes it easier for them to relate to their patients.

The kingdom of the sick

“ILLNESS is the night-side of life, a more onerous citizenship,” wrote the American intellectual and writer Susan Sontag.

“Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later, each of us is obliged, at least for a spell, to identify ourselves as a citizen of that other place,” she said.

And so it was inevitable that I would cross that border from being a doctor to being a patient.

In that “kingdom of the sick”, despite my familiarity (and privileged position) with the health-care system, I find myself fretting not over my medical problems but over how I behave as a patient. I feel somewhat bad and guilty about taking up my doctors’ time.

In their respective consulting rooms, I’m always acutely conscious of that crush of other patients in the waiting room. I find myself hurrying up the consult so that often, after leaving the clinic, I realise that there were other questions that I ought to have asked.

I think this lack of assertiveness arises because I am a doctor who has often experienced the pressure of time in my own clinic and has encountered “difficult patients”.

So, I assiduously try not to overtax my overworked colleagues and be a “good” patient - or so I thought.

Difficult patients

I HAVE my very small share of “difficult” patients, or more colloquially, “heartsink patients”.

The latter was a term coined by general practitioner Tom O’Dowd in his 1988 paper, which appeared in the respected British Medical Journal.

It was based on 28 of his patients whom he followed up for five years and who had apparently induced “the feeling felt in the pit of your stomach when their names are seen on the morning’s appointment list”.

That was because they were the sort of patients “who exasperate, defeat and overwhelm their doctors with their behaviour”.

In my case, my “difficult patients” include those who persistently don’t comply with my instructions, or who complain incessantly and, at each consult, present a long litany of old and new complaints for which nothing seems to work.

Then there are those who are argumentative and aggressive, and those who I suspect are trying to manipulate me.

Such patients leave me feeling depleted, angry, frustrated and impotent. And they also make me feel guilty for having such negative feelings. After all, they rouse in me feelings that seem to breach some code that appear rather unworthy of a doctor.

The truth is that these patients are not well and are distressed. In the words of a comment in an issue of Health Affairs this year, “we all need at one time or another: reassurance, comfort, compassion, and a helping hand”.

Emotional undertow

THERE is always that undercurrent of emotion in any patient-doctor interaction and communication. Sometimes, the emotions are positive and things go swimmingly well; sometimes, the interaction can be fraught with negative feelings.

Such feelings can be perilous. The patient might not reveal vital information, and the doctor would want to get the difficult and awkward consultation over with as quickly as possible. The consequences are an incomplete or distorted picture, potential lapses in assessment and judgment, and a short-changed and disgruntled patient.

Medical schools now teach doctor-patient communication. But it is not merely a matter of technique. It is also about being sensitive to the feelings of patients and being aware of the emotions that doctors themselves feel in these difficult clinical situations.

Doctors, I suspect, are not very comfortable talking about the emotions they feel in such situations. Most are fearful of letting their feelings show.

Much of the training of a doctor is towards rational and critical thinking, attaining mastery and control. Talking about one’s feelings - in addition to being an uncomfortably touchy-feely experience - is anathema to that.

We talk much about “patient-centred care” and “shared decision-making” in modern medicine. But that entails working through a number of things, including making systematic changes to allow for more face-to-face consulting time.

It also means training our doctors to be more emotionally attuned, able to process their emotions and use them in the service of their patients.

It also entails a change in the mindset of both the doctor and the patient.

Harvard Medical School Professor of Medicine Jerome Groopman made a detailed study of how doctors made mistakes in their thinking.

He made the following observation. “For three decades practising as a physician, I looked to traditional sources to assist me in my thinking about my patients: textbooks and medical journals; mentors and colleagues with deeper or more varied clinical experience; students and residents who posed challenging questions…

“But… I realised that I can have another vital partner who helps improve my thinking, a partner who may, with a few pertinent and focused questions, protect me from the cascade of cognitive pitfalls that cause misguided care… That partner is my patient or her family member or friend who seeks to know what is in my mind, how I am thinking.”

Patients must understand that the doctor is a practitioner of a less-than-perfect science with its limitations and uncertainties. They should also realise that he is not infallible and doesn’t have all the answers and solutions - and temper their expectations accordingly.

And so, the next time I see my doctor, I shall have my pertinent and focused questions ready. And I will not feel bad about asking them - or least I will try not to feel bad about it.

The writer is the vice-chairman, Medical Board (Research), at the Institute of Mental Health.