Professionalism key to care of difficult patients

A column that answers questions on ethical issues in medical practice

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted July 3, 2006.

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Let's face it, some patients are difficult, disagreeable -- or worse. How does the physician respond to such cases?


That question prompts three others.

Can one go through the motions until a real connection is established?

If we waited for children to feel genuine gratitude for birthday and Christmas gifts and only then tried to teach them to write thank-you notes, the habit of expressing thanks would probably never get passed on to the next generation. Similarly, we require that medical students take histories and do physical exams when nine-tenths of what they hear and observe makes no sense to them.

We trust that as they proceed, gradually, things will start to fall into place and make sense -- just as has happened with generations of previous students. If the new students do not begin to "perform" the rituals of the history and physical fairly early in their training, we fear that the moments of gradual enlightenment will be postponed.

The science writer Nicholas Wade once said, "All medicine is a form of theater." Performance is often misunderstood as fakery. Certain things in life become true because people possessing the authority make it so. For example, if a jury finds me guilty and a judge sentences me, I am, at least for the time being, a criminal. In some sense, whether I actually committed the crime I am accused of is immaterial. Making ourselves behave "as if" may be the best way in the end to develop the genuine sentiment or the relevant process of thought.

If we act out the part of the properly compassionate and attentive physician with a patient who may at first repel us, what happens next? William Carlos Williams, in Depression-era New Jersey, wrote literary masterpieces at night and worked all day as a general practitioner and pediatrician.

He wrote a series of short stories, each of which begins with the physician coming close to actively hating the patient. Nevertheless, the physician soldiers on. And the climax of each story comes when something breaks through the physician's prejudices and self-absorption. The physician gradually becomes more curious about what makes the patient tick. And finally the physician glimpses a spark of the real person who is the patient and whom he has never before understood or appreciated. From that moment on, the physician becomes capable of true compassion (etymologically, "to suffer with"). Finally the physician has glimpsed the patient as a fellow human being and no longer as "the other."

To a large extent, we respond to others in accord with the way that others treat us. If the physician acts in a superficially compassionate manner, or at least an assiduously professional manner, toward a patient for whom he feels no empathy or connection, it is much more likely that the patient will eventually respond to that approach with some level of trust and regard.

Once that level of trust is attained, the patient may reveal other personal qualities or details of personal history. Those newly revealed qualities may only make the patient appear more unlikable, but there is at least a chance that the patient will eventually reveal a clue that allows the physician to realize why he or she disliked the patient so much to begin with and how to overcome that feeling.

Can I transfer the patient to a doctor who might be able to better connect?

The medical school I attended and the specialty I later chose -- family medicine -- both emphasize interviewing skills and the importance of positive relationships. When I began practice, I now realize, I had an inflated idea of my ability to bond productively with every possible sort of patient. Over time I came to dread seeing certain patients' names on my schedule, and we each ended every encounter feeling quite frustrated. Nevertheless, I tried to bear up and persevere. I was quite sure that the care I was providing for them was superior to that they would receive from another doctor.

I came gradually to see that this was all about my own ego and not about the good care of the patient. I was humbled when some of these patients found their way to other physicians and immediately got on just fine. The other physicians were never as frustrated with these patients as I had been. I had been trying to force the round pegs of the patients into the square holes of my own needs and expectations. As soon as that pressure was removed, patients immediately became easier, and much more fun, to care for.

No physician can be a good match with every type of patient. My lack of compassion or inability to connect with a particular patient may be a signal that a different sort of physician might provide much better care.

Have we distributed the care of the least desirable patients fairly among ourselves?

Eliminate the patients for whom the "aha!" moment of connection will someday arrive. Eliminate the patients whom we have the capacity to transfer to others, who have the resources to go elsewhere for care and who would be happier and better off if they left. That leaves the patients whom all physicians would equally find difficult (if not downright detestable), and who for whatever reason -- lack of insurance or of other resources -- have no place else to go.

If medicine were an ideal profession, we would divide among ourselves the care of these difficult patients as evenly as possible. We are far from an ideal profession, so many of us are able by virtue of specialty choice or location of practice to avoid having to encounter such patients for the most part. Others who work in emergency departments or community clinics in low-income neighborhoods get far more than their fair share. These latter physicians deserve our thanks and our respect. They often receive neither.

Whether we have a lot or a few of such patients to care for, that care demands professionalism in the strictest sense of the term. One opposite to professional is amateur, which in turn is derived from the word "love." The point of calling ourselves professionals is that we are supposed to deliver high-quality care for people for whom we feel no love or friendship.

Military physicians, for instance, are charged by the code of military justice with treating wounded enemy combatants -- who perhaps a few minutes before were trying to blow up the army hospital -- with the same standard of care they would deliver to our own soldiers. These are demands of professionalism. The outrage we justifiably feel when these standards of professionalism are breached indicates that we believe that these standards of professionalism are both appropriate and attainable.

Abraham Lincoln once said, "My father taught me how to work; he never taught me to like it." Medicine is our work. Most of the time, for most patients, it is worth doing our best to like it; we take better care of more patients that way. When we cannot find ways to like it, it remains our work. We should do it as well as we can manage.

Somehow, as a family practice intern in 1977, I managed to learn a lesson that has stood me in good stead ever since. On night call in the emergency department for the medicine or pediatrics services, we'd be snatching a few minutes' sleep only to be awakened to see a newly arrived patient. Bleary-eyed, we'd go to see the patient, thinking that there had better be a good reason we were awakened. We'd more often than not be irritated to find a person with a routine, chronic problem that could easily have waited until the next day, or even the next week.

My fellow interns were enraged at such behavior. I started to follow their example, until it hit me that it was my choice whether I spent my on-call nights developing hypertension or in some other mode. I decided to be curious. I decided to ask each such patient, in polite, nonjudgmental tones, "What was it that made you decide to come to the emergency room right now with this problem?"

Somewhat to my amazement, virtually all such patients had a quite rational account of how they made the decision that this was the time when they needed to seek care.

For the most part they did not think as I would have. But they all had thought about it and made a choice that was, according to their lights, a reasonable one. Once I found this out, I was no longer so angry at being awakened, and I found it much easier to bond with the patient.

Perhaps curiosity can be a general antidote to the patient for whom we have no compassion. It almost always makes sense to ask, "What makes this patient tick? What accounts for the fact that I have had such a strong negative reaction to this person?" This curiosity may lead in some cases to the "aha!" moment of enlightenment during which we gain true compassion and empathy. In other cases, perhaps the best we can hope for is that it will keep us professionally focused.

Howard Brody, MD, PhD, director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston. Previously he was professor of family practice and served in the Center for Ethics and Humanities in the Life Sciences, Michigan State University in East Lansing

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.

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