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| Journal of the New Zealand Medical Association,
01-April-2005, Vol 118 No 1212
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Reflecting on the ‘difficult’ patient
Hamish Wilson
Clinical care is usually straightforward: most patients
improve and the goals of being a health professional seem achievable. Sometimes
however, it is not so easy; a doctor or nurse in any branch of medical practice
may experience quite marked difficulties with a particular patient. Various
terms have been used to describe these patients such as ‘difficult’,
‘heartsink’, ‘problem’, or even
‘hateful’—but these terms obscure a range of underlying
medical conditions including chronic pain, personality disorder, somatisation,
and incurable suffering.
It is likely these labels are a reflection of doctors’
emotional responses to patients; negative feelings may start with simple dislike
or minor annoyance, but can progress to frustration, exasperation, hopelessness,
sadness, and anger.
In this context, Schwenk et al noted it is the
physician-patient relationship that is the underlying issue, rather than
specific characteristics of the individual
patient.1 However, it is uncommon for doctors
to view their ‘difficult’ patients as illustrative of a problem in
their relationship with a patient; there are relatively few doctors who explore
their personal reactions to patients in a deliberate way.
This article proposes that ‘difficult’ patients
can be superb triggers for learning about important issues in modern medicine:
awareness of self within the doctor-patient relationship, professional
maintenance, models of health care. Various activities in reflective practice
are proposed as a method of learning about these issues.
BackgroundIn the UK, O’Dowd initiated
discussion of such patients in 1988,2 coining
the term ‘heartsink’ to describe intuitive feelings of impending
doom or helplessness when certain names appear in the appointment book. There
have been several useful articles in the general practice literature since
O’Dowd, which have focused on contributing characteristics of the
doctor3 as well as helpful approaches for
practitioners.4 In 1994, Norton and Smith
identified various issues in ‘the transaction’ between doctor and
patient,5 while an excellent review of the
‘heartsink’ phenomenon came from Clarke and
Croft.6
The overall impression from the literature is that
‘difficult’ patients consume considerable time and resources,
receive many unnecessary investigations, can be litigious, and can cause their
doctors considerable anguish. However, rather than blaming the patient, it is
helpful to review some of the tacit or unconscious expectations of the modern
practitioner.
The assumptions of modern medical practiceOstensibly, students enter medicine
to help others, motivated perhaps by their experiences of being helped
themselves or through family traditions of service. As they progress through
medical school, they learn the current principles and methods of modern
medicine, which are based almost exclusively on ‘disease theory’ and
developed as a product of the modern scientific method in the 17th and 18th
Centuries. Box 1 lists two versions of these methods or
‘rules’ of modern medical science.
Given the powerful socialisation process into medical
culture,8,9 it is perhaps not surprising that
graduating doctors accept these models of practice without ever examining them
explicitly. A problem arises, however, if the inherent assumptions in these
models are implicitly challenged by patients presenting with unexplained or
untreatable illness. Doctors could unintentionally blame a person for being less
than the ideal or model patient.
When asked to describe their own ‘rules’ of
practice however, practitioners can have difficulty in putting their ideas into
words. As an illustration, GPs in the Masters of General Practice degree at the
University of Otago review seminal readings on models of medical practice and
write essays on their experience of work, including their views on the
biomedical model. It takes several months of study before these experienced
postgraduate students become articulate about biomedicine and can identify its
utility and its limitations. These graduates have been exposed to more recent
ideas about medical practice in the last 20 years such as the
‘biopsychosocial’10 and
‘patient-centred’ models,11 yet
acknowledge the continued dominance of biomedicine.
A theory of ‘difficult’ patientsTo recap, a theory that could
explain the ‘heartsink’ or ‘difficult’ patient
phenomenon is: Doctors have good intentions of helping patients. Over many years
of immersion in medical culture they acquire, and tacitly accept, the
assumptions of modern practice that are based on a positivist, empirical
convention that arbitrarily separates ‘mind’ from
‘body’. This model works well most of the time, especially when the
patient presents with a physical illness of known cause and an effective
treatment is available. However, the model is less accurate or helpful when a
patient has symptoms without identifiable cause, remains persistently unwell,
does not conform to the expected social role of ‘patient’, or has
symptoms that cross the mind-body
‘divide’.12 It would be possible to
view such patients as challenges to the underlying model or paradigm of
practice,7 but more commonly doctors become
irritated or annoyed by the patient who does not fit their a priori assumptions
of how medicine should be and how patients should
behave.13 The outcome for the doctor can be
frustration, leading to a complex and difficult interaction with the patient.
Viewing such patients as challenges to the theory or
practice of medicine is more constructive than labelling the patient as
‘difficult’. Box 2 is a recent example from
my own experience, with further notes after reflection in Box 3.
The doctor-patient relationshipAlthough doctors may have quite
intense experiences in relation to certain patients, medical training does not
generally encourage expression or further exploration of these experiences. It
is also uncommon to formally describe patients in terms other than
‘nice’ or ‘pleasant’, even though doctors may be torn
with powerful feelings that threaten their objectivity and even their sense of
vocation. These unresolved tensions have been implicated in compassion
fatigue14 and ‘burn-out’ of both
hospital specialists15 and general
practitioners.16
Given the development of modern medicine as a
‘science’ that assumes the ‘objective observer’ stance,
this naivety to, or even denial of, interpersonal processes is understandable in
mainstream medicine. However, there has been considerable work on the self of
the doctor within the doctor-patient relationship in the UK by Drs Michael and
Enid Balint. Their research method was straightforward; asking groups of general
practitioners to discuss their ‘difficult’ or
‘heartsink’ patients, using a psychotherapist as a resource. The
ensuing Balint movement has produced a number of useful
books17,18 and some GP training schemes have
more emphasis now on self-awareness.19
Graduates are also more aware of stress and other psychosocial factors in the
genesis of illness.
However, while peer groups of GPs are now common throughout
the Western world, few of them include psychotherapists as regular members; more
widespread insights into doctor-patient relationships have been minimal. Despite
the Balintian contribution to understanding the transaction between doctor and
patient, McWhinney’s interpretation of modern medical
practice7 may still be quite accurate (Box 1).
There is no focus on, or even mention of, the doctor being involved in a complex
social interaction and evolving relationship with each and every patient.
Further, the development of the concept of the ‘difficult’ or
‘heartsink’ patient in medicine has been largely within the field of
general practice from 1980 to 2000 with few articles since; there have also been
very few publications appearing in other specialties, Marshall and
Smith20 being the exception.
Reflective practiceSpecifically discussing one’s
‘difficult’ patients (as in a Balint group) is an example of
reflective practice, where practitioners use structured time to review their
clinical experience, their personal responses to patients, and their own ideas
on the nature of practice. Just as formal study of the doctor-patient
relationship is relatively uncommon in medicine, practitioners who take
reflective practice seriously are few and far between. Structured activities of
reflection include journaling,21 critical
incident analysis,22
mentoring,23 and
supervision.24
Brookfield25 noted that reflection can
facilitate emotional release, more objective identification of underlying
issues, and realistic evaluation of one’s method of practice. These
activities are quite different from ‘mulling over’ the day’s
events or chatting with one’s spouse after work.
Activities of reflective practice are good examples of
self-directed learning: doctors identify their learning issues and what methods
to use; the activities are low in cost; the implications for health care of the
patient and peace of mind for the doctor are considerable.
Consistent with medical schools in the
UK,26,27 the undergraduate course at Otago
University now includes various activities of reflective practice such as peer
groups, mentoring and critical incident
analysis,28 in the belief that the next
generation of doctors will be able to critically review their doctor-patient
relationships. These particular local undergraduate activities will be discussed
in further publications.
ConclusionsAll doctors can be irritated (or
more severely troubled) by certain patients, but activities in reflective
practice help them explore their emotional responses. It seems likely that
reflective practice will facilitate greater self-awareness, increase confidence,
and reduce the risks of compassion fatigue and patient complaints, but research
is required to confirm these effects. At the very least, regular reflection on
one’s emotional responses will reduce the likelihood and severity of being
troubled by so-called ‘difficult’ patients.
Summary points
Author
information: Hamish Wilson, Senior Lecturer, Department of General
Practice, University of Otago, Dunedin.
Acknowledgement: I
would like to thank Mr Tony Egan for his invaluable editing advice.
Correspondence: Dr
Hamish Wilson, Department of General Practice, University of Otago, PO Box 913,
Dunedin 9001. Fax: (03) 479 7431; email: hwilson@gp.otago.ac.nz
References:
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