Bioethics Discussion Blog: Two Way Street and Compassion in Medical Care





Saturday, October 21, 2006

Two Way Street and Compassion in Medical Care

Many of the views expressed on my blog thread ”I Hate Doctors” show little, if any, compassion for the plight or burdens that physicians must carry in their general professional life or with regard to specific patients. And yet, as I have mentioned previously, the doctor-patient relationship is not a “one-way street”. To accomplish the goal of the best medical care, both patient and physician have information and responsibilities to relate to each other, which will help to attain that goal. The physician can’t accomplish the task of diagnosis and therapy alone. The participation of the patient is also required. As part of the professional relationship with the patient, the physician must behave in a manner to engender trust with an attentive, thoughtful, considerate and particularly express compassion for the patient. But, my view, which I would like to put up for discussion here, is that the patient should not expect the best out of the doctor, if the patient is belligerent, uncooperative, angry and shows no compassion toward their physician. There are patients out in the world who present to their physicians that very way and expect that the doctor will ignore the patient’s non-productive behavior and be able,nevertheless, to do a good job. Well, doctors are human beings too and despite their education, they have weaknesses as all humans have. A good doctor will try to investigate and understand the basis for anger in an angry patient and attempt to mitigate the patient's concerns. A good patient must, however, remember that he or she is part of the treating team and their own behavior can affect outcomes. Patients should try to avoid behaviors that clearly create roadblocks toward effective treatment of their illness. The two-way street toward a satisfactory therapeutic ending should not be dead-ended by disruption of the doctor-patient relationship by either party. ..Maurice.


At Saturday, October 21, 2006 9:05:00 PM, Anonymous Jaine said...

How many patients are we talking about here who are “belligerent, uncooperative, angry and show no compassion toward their physician?” If 20% of doctors have emotional problems and 20% of the general population have emotional problems what percentage of those, in either camp, would express their problems by being belligerent and so on? I have never spoken with a patient who admitted behaving this way. I have certainly talked to many patients who have dealt with a doctor who behaved this way. Although in a smallish city it tends to be the same group of doctors who behave this way. Example: A specialist who is rude to a large percentage of patients.

Over the last 6 months or so I have heard many complaints about a doctor who works in the emergence room. It is the same doctor because each person describes the same physical features. I have no idea how many patients behave this way. Obviously if a patient is belligerent and so on there is a limit to what a doctor need put up with. If I had to estimate, based on what I hear as a member of the public, the percentage of doctors who really push the line would be 2.5% and then ranging to lesser objectionable behaviour on to fine and dandy. Going with the idea that the general population shares the same emotional problems I’d estimate 2.5% of the patients are also pushing the line to the breaking point. Those who deal with patients would be able to estimate the percent of belligerent types. I know after dealing with a nasty doctor I would have a short fuse if I saw even a hint of this type of behaviour in a doctor again.

At Sunday, October 22, 2006 1:28:00 PM, Blogger My Own Woman said...

I'm an ER nurse and I have to admit, I have more than one time wished that there was one day a year that I could treat some of these patients as they have treated me. I've often wondered if some of these people act this way in the doctor's offices with their PCP, and now I can see that they must.
I'm sure that there is an equal amount (ok, there can't be an 'equal' amount) of doctors who are rude as well, but I can't imagine that their patients would stay with them for very long.
As health care workers, we take more abuse than most people imagine. I do think that our "job" is to be a bit more tolerant than the general population and take the higher road; but I do think there comes a time when you have to say "Enough is enough."

At Sunday, October 22, 2006 6:23:00 PM, Anonymous Happy-heart-patient said...

I started reading the 47 comments on your post, and stopped temporarily. I find it hard to believe that so many patients are so unhappy with their medical care. In most cases, I would bet that,as you said, this is a two way street and some of those patients helped cause their own problems. I have wonderful physicians, and have been told by them that I am a great patient. I listen, ask meaningful questions, follow their advice, and am having great results. As my cardiologist says, we are a "team". I worked at a hospital for 28 yrs in a non-clinical position, but perhaps that experience helped me appreciate the talent and hard work that physicians bring to the table. It wasn't until I was an inpatient that I really learned to appreciate the empathy and caring of all the health care workers. Now retired, I volunteer at the hospital I worked for. And I'm one of those patients that gets and gives hugs to their physicians. I'm sure there are many patients that feel the way I do.

At Sunday, October 22, 2006 8:51:00 PM, Anonymous Jaine said...

There are bad doctors out there and they have a great deal of protection. If a patient is lucky they will never have the experience of dealing with a bad doctor. However, one experience is all it takes to fully grasp how bad a situation can be and how little protection a patient has. If you worked in a hospital for 28 years then you would also be aware that mistakes and bad behaviour are covered up.

I’m sure the women who dealt with the doctor in the below clip, and reported him only to be ignored, would not feel they caused their own problems or that this was a two way street. I’m sure the Ombudsman, in the below quote, is more than capable of looking at the way complaints are handled and deciding if the process is fair and reasonable. Imagine being sexually assaulted by a doctor in 1999 and then discovering that complaints had been ignored since 1969/ the very people you have to trust to protect you in fact set you up by not dealing with the problem. The medical profession is living in the past. People will no longer accept a protection racket complaint process.

On the other hand, patients who are abusive should be charged after the medical emergence has been dealt with. Set high standards for both doctors and patients. I suspect it is human nature, if a person has only had positive experiences, to believe that negative experiences must stem from the patient (or doctor) doing something to provoke the problem. On the flip side it is also human nature, if a patient (or doctor) has had a bad experience, to believe that doctors (or patients) are capable of doing horrible things totally unprovoked.

Clip: “The 19 women are suing Dr. Mark Stewart, who was sentenced to four years in jail for sexual assaults on patients. They're also suing the college, prepared to argue that the college was recklessly negligent in dealing with past complaints, and that its failures led to the women being abused…”

“There is evidence to show that women had complained about Stewart's sexual abuse back to the 1960s, but nothing was done about him.”

“The ruling - and the college's argument its role doesn't include protecting patients - brought to mind a report earlier this year by provincial Ombudsman Howard Kushner.
Looking at 10 years of investigations into complaints about the college and other professional regulatory bodies, he said they often just don't get it.
"They still believe, perhaps because it is the members who elect the governors and pay for the colleges' operations, that the colleges are primarily there to protect the interests of the members."

At Sunday, October 22, 2006 9:15:00 PM, Blogger Maurice Bernstein, M.D. said...

Here is a different view regarding patient responsibility in the doctor-patient relationship. It was written by Herbert Rakatansky, M.D who is a physician-ethicist. The CEJA Opinion, he describes, is the official statement of ethics by the American Medical Association. ..Maurice.

In thinking about patient responsibilities it is important to separate the patients’ responsibilities to the medical system including all who work within the system and the responsibilities to the individual doctor within the context of the doctor patient relationship. I believe that the patient has a number of responsibilities to the system if the patient expects the system to function in a manner beneficial to the welfare of the patient. These are nicely described in a CEJA Opinion which I have included below.

I do not believe that within the context of the doctor patient relationship the patient has any responsibility for the emotional well being of the doctor. If a patient behaves in a belligerent or threatening manner and the doctor cannot alter that behavior he/she may refuse to provide care since adequate care cannot be given in this circumstance. There is a literature on “hateful patients.” Such patients often have difficulty getting good care anywhere in the system.

The basic principle that decisions in the context of the doctor patient relationship are always made in the best interest of the patient implies that the emotional well being of the patient trumps the emotional well being of the doctor. When a doctor accepts the patient as a person even partly responsible for the emotional well being of that doctor, a boundary is crossed and the patient can no longer receive the care to which he or she is entitled. Of all doctors, psychiatrists are taught this most rigorously. All doctors violate this boundary occasionally including psychiatrists who do it at least as much and probably more than other doctors. Thus formal education about this issue is important but not sufficient. It is critically important that doctors have relationships outside of their medical practices and the these relationships are “healthy” - that is they are mutually emotionally satisfying to both persons. In my many years in the physician health arena the doctors I have seen get in trouble with this issue virtually always have this lack of healthy relationships in their lives. Unfortunately medical education has not been conducive to recruiting or training persons with this skill. Current trends in medical education are taking notice, however. Small violations of this boundary are the top of a very slippery slope leading at the bottom of the mountain to sexual boundary violations. One psychiatrist I knew many years ago suggested that the only obligation the patient has to the individual doctor is to pay. In our society this takes the form of government, insurance, etc. but the principle stands. It is the responsibility of the doctor, not the patient to maintain the integrity of this boundary and to neither seek nor accept satisfaction of personal emotional needs. Of course this does not include the satisfaction the doctor feels by solving a difficult problem, performing a difficult procedure or decreasing pain and suffering and making the world a little better, etc.

Here is the CEJA Opinion:

E-10.02 Patient Responsibilities
It has long been recognized that successful medical care requires an ongoing collaborative effort between patients and physicians. Physician and patient are bound in a partnership that requires both individuals to take an active role in the healing process. Such a partnership does not imply that both partners have identical responsibilities or equal power. While physicians have the responsibility to provide health care services to patients to the best of their ability, patients have the responsibility to communicate openly, to participate in decisions about the diagnostic and treatment recommendations, and to comply with the agreed-upon treatment program. Like patients’ rights, patients’ responsibilities are derived from the principle of autonomy. The principle of patient autonomy holds that an individual’s physical, emotional, and psychological integrity should be respected and upheld. This principle also recognizes the human capacity to self-govern and choose a course of action from among different alternative options. Autonomous, competent patients assert some control over the decisions which direct their health care. With that exercise of self-governance and free choice comes a number of responsibilities. (1) Good communication is essential to a successful patient-physician relationship. To the extent possible, patients have a responsibility to be truthful and to express their concerns clearly to their physicians. (2) Patients have a responsibility to provide a complete medical history, to the extent possible, including information about past illnesses, medications, hospitalizations, family history of illness, and other matters relating to present health. (3) Patients have a responsibility to request information or clarification about their health status or treatment when they do not fully understand what has been described. (4) Once patients and physicians agree upon the goals of therapy and a treatment plan, patients have a responsibility to cooperate with that treatment plan and to keep their agreed-upon appointments. Compliance with physician instructions is often essential to public and individual safety. Patients also have a responsibility to disclose whether previously agreed upon treatments are being followed and to indicate when they would like to reconsider the treatment plan. (5) Patients generally have a responsibility to meet their financial obligations with regard to medical care or to discuss financial hardships with their physicians. Patients should be cognizant of the costs associated with using a limited resource like health care and try to use medical resources judiciously. (6) Patients should discuss end-of-life decisions with their physicians and make their wishes known. Such a discussion might also include writing an advance directive. (7) Patients should be committed to health maintenance through health-enhancing behavior. Illness can often be prevented by a healthy lifestyle, and patients should take personal responsibility when they are able to avert the development of disease. (8) Patients should also have an active interest in the effects of their conduct on others and refrain from behavior that unreasonably places the health of others at risk. Patients should inquire as to the means and likelihood of infectious disease transmission and act upon that information which can best prevent further transmission. (9) Participation in medical education is to the mutual benefit of patients and the health care system. Patients are encouraged to participate in medical education by accepting care, under appropriate supervision, from medical students, residents, and other trainees. Consistent with the process of informed consent, the patient or the patient’s surrogate decision maker is always free to refuse care from any member of the health care team. (10) Patients should discuss organ donation with their physicians and, if donation is desired, make applicable provisions. Patients who are part of an organ allocation system and await needed transplant should not try to go outside of or manipulate the system. A fair system of allocation should be answered with public trust and an awareness of limited resources. (11) Patients should not initiate or participate in fraudulent health care and should report illegal or unethical behavior by physicians and other providers to the appropriate medical societies, licensing boards, or law enforcement authorities. (I, IV, VI) Issued June 1994 based on the report "Patient Responsibilities", adopted June 1993; Updated June 1998, December 2000, and June 2001.

At Monday, October 23, 2006 12:03:00 AM, Anonymous Moof said...

I can't think of a relationship which is more fraught with responsibilities, on both sides ... outside of intimate family relationships.

I believe that the physician has a responsibility to be professional, to truly possess the knowledge he claims, and to use it to the best of his ability for his patient.

The patient, in turn, is responsible for honesty in the relationship, and for compliance ... (although that's more of a responsibility toward his own well being) ... and to give the physician his due for his services.

Those are the most basic of the responsibilities each has ...

On a human level, each person - no matter the profession or relationship - has the responsibility to treat other human beings with dignity and respect. If they fail in that responsibility, then I don't believe anyone owes them any more than they're giving. No one should have to take responsibility for another person's churlishness.

That's not to say that people who are normally cooperative and friendly may not occasionally have a bad day, and say or do things they later regret ... however, that applies to both sides of the doctor/patient equation. Equally, I think that both sides should be willing to give the other the benefit of the doubt on a first occasion.

I believe that if physicians refused to see patients who had a chronic attitude problem, that if the patient really wanted to be seen, he would simply have to learn to modify his behavior ... or put up the consequences.

At Wednesday, October 25, 2006 1:00:00 PM, Blogger Pieces of Mind said...

Rude, hostile and demanding behavior is not limited to the doctor-patient relationship.

It is an issue for anyone who deals with the public.

I would venture to guess that the patients who are belligerent and uncooperative display similar behavior in the workplace, the fast-food restaurant and at home.

I think it is a societal problem, really, and not one that physicians are going to solve on their own.

At Thursday, November 30, 2006 2:17:00 PM, Anonymous Anonymous said...

I think we need to define what constitutes 'bad' patient behaviour. I have been badly treated by a doctor befcause I refused further prednisone therapy after a bowel obstruction (which later turned out to be mechanical) due to the psychiatric effect the prednisone was having on me; I explained this to the doctor and he said that it was not possible that such a low dose (30 mg) could be having psychiatric effect. He then said to a nurse, over my head "feed her then, and see if she throws it up". He also did not deign to contact my personal physician who had proposed a different course of treatment, and said that that treatment was used "only to prevent surgery" (which I had, nine months later).

At the time when this occurred, I was in a hospital bed, having spent 24 of the previous 48 hours puking my guts out, 12 of them bouncing off the walls from yet another dose of prednisone, and the final 12 sedated. No, I was not at my very best, but neither was I rude to this man. Does refusing his approach to treatment in a chronic illness situation make me belligerent? Does researching an aintobiotic I was prescribed and finding it contraindicated for colitis, politely pointing this out to the prescribing doctor (who was not my own doctor, and who I had to see in a semi-emergent situation) and requesting a different one make me belligerent? Does preferring to maximise quality of life, rather than minimise microscopic disease in a chronic illness situation make me belligerent?

If any of the above holds true, then I am your classic "belligerent" patient, despite being as polite as I can to my doctors while still questioning their absolute knowledge of my personal situation. I personally think none of the above make me belligerent, but if doctors see it differently, does that mean I deserve a lesser standard of care?

On another note entirely, I am a teacher at a university level -- one with a lot of student contact. I am a woman in a computer science department. Many of my students come to me with a defensive, rude or intolerant attitude. Sometimes, the student is just generally unpleasant and badly behaved, btu I am still required to do the very best I can to ensure they have the opportunity to get the education they pay for -- and that means being pleasant to them even when they are being unpleasant to me. And I get paid a hell of a lot less than any doctor I know. Many students who are initially unpleasant though, I have later found are scared, or have been coerced into the course by course requirements, or parental admonition, or have just generally been mucked around by so many people by the time they see me that they despair of ever finding what they need from the system. It may take many times of my seeing them to sort the sheep from the goats, but once I have, I can usually make a real difference to the lives of the ones who have a different motivation for their behaviour, just by saying "yeah, the situation is bad, but these are the things we can do to get through this". In either case I am expected to be tolerant of bnad behaviour (though not abuse), and provde the best I can, and to expect anything less form a physician, to me, is the physician absconding from their responsibilities. Yes, I have had bad days and snapped, but I always apologise for it, and try to make amends -- even when the person is unpleasant. I would expect no less from my doctor.

At Thursday, November 30, 2006 3:44:00 PM, Blogger Maurice Bernstein, M.D. said...

At times it appears that doctors forget,they didn't know, they misunderstand the situation and a bunch of other congnitive gaps. a partner in the diagnosis and management of illness, the patient has every right and responsibility to help mitigate these gaps by informing the physician. The physician has the professional duty to listen to and consider what the patient is offering. Sometimes the patient is misinformed and sometimes it is the physician who is misinformed. Each, however, has the duty to listen to each other. Communication, for it to be effective, has to be civil by both parties.

I am sure all physicians, if they admit it, have been, on occasion, corrected or updated by their patients both in terms of medical history and also therapeutics. I know I have. Both parties can get insight into the behavior of the other party based on the response the other party makes to advice or suggestion. All I can say to the above Anonymous is to tell the doctor what you understand is true and then either accept an understandable explanation if you were misinformed or accept a gracious "thank you for reminding me" by the doctor. Anything else will be unproductive to attain the goal that both the patient and physician desire. ..Maurice.

At Friday, December 15, 2006 7:22:00 AM, Anonymous Faith Mansell said...

I completely agree that physicians as well as patients should be treated with compassion and consideration. I disagree, however, with the inference that most problems with doctors are caused by the patients. I have always done my best to treat all medical personnel with courtesy and respect even when it was not returned. Recently my husband went to an orthopedic surgeon about chronic leg pain and after having an MRI made an appointment to discuss the results of it. The doctor was an hour late for the appointment. The nurse said he had forgotten but he, the nurse, had called to remind him and he was on his way. When the doctor arrived, he didn't apologize that we had to wait. We politely didn't mention it either and proceeded with the appointment. The doctor spent about three minutes with us. He said nothing showed up on the MRI and basically told my husband to ignore his pain and do whatever they asked him to do at work, etc. in spite of severe pain. I tried to ask questions based on the radiology report and he brushed them aside. He didn't discuss pain medication or any other avenues we might pursue. I left the room crying because I had so many hopes that we would finally get some help for my husband's pain. The doctor just said, "Okay, then, I guess that's all" to my husband and walked out. Throughout the appointment we were courteous and gave him no reason to want to leave quickly or not care about our needs but he did not return our courtesy. One thing I think it's important to keep in mind is that while on one hand, doctors are carrying heavy loads of responsibility, on the other hand, patients are often carrying heavy loads of pain, desperation, fear, and even hopelessness. Their concerns should be treated with care and a reasonable amount of listening attention.

At Friday, December 15, 2006 10:27:00 AM, Blogger Maurice Bernstein, M.D. said...

Faith, I fully agree with your evaluation of that physician's behavior. The question is whether nothing further could be gained from the visit in terms of benefit for your husband if one or both of you challenged the physician and explained to him why you are unsatisfied with his responses and your need for better medical advice and attention. All I can say is that physicians such as your unpunctual and unprofessional orthopedic surgeon are the very ones who are the basis for the "I hate doctors" attitude of patients. ..Maurice.

At Saturday, January 20, 2007 4:56:00 PM, Anonymous Redhawk said...

"Many of the views expressed on my blog thread ”I Hate Doctors” show little, if any, compassion for the plight or burdens that physicians must carry in their general professional life or with regard to specific patients.'

With all due respect, the title of that thread is "I Hate doctors," which seemed to be an invitation for people to vent their anger against physicians, and not their love for them. You should not be surprised at the one-sidedness of the comments.

It struck me that many of the people posting there had been severely abused by the medical profession, and you really can't expect people to have much compassion for people who abuse them. You'll also notice a conspicuous lack of compassion in this thread towards patients who get "belligerent," whatever that means, and little understnding what it's like to be on the other side of the prescription pad. Sometimes patients *have to* raise their voices to get proper care and be treated with respect. At other times patients might be frightened, in severe pain, or stressed out, which can make anyone a little grumpy. While there are certainly limits to how much abuse anybody, including a doctor or nurse, should have to take, it has been my experience and the experience of many people I know, particularly chronic pain patients, that doctors are often very arrogant and quick to take offense at the slightest disagreement. When you say "belligerent" to me, I am thinking of someone literally trying to start a fight with me, with intense yelling and screaming or even violence. For many doctors "belligerence" consists of nothing more than a heated disagreement. Milder disagreements get you labelled as "noncompliant" or "difficult patient." Very few doctors respect patient autonomy and are willing to allow you to be an active participant in your own health care beyond just reporting symptoms and the efficay of treatments. They're not interested in whatever research you've gleamed off the internet.

Beyond this there is a knee-jerk "blame the victim, how dare you punch me in the fist with your face" mentality in the medical profession where any kind of dispute or problem between a doctor and his patients is automatically blamed on the patients, as if the patient is responsible for the doctor's behavior. You can see this with the debate over malpractice, where doctors act as if every lawsuit is "frivolous" despite the widely-publicized death rate over over 200,000 patients a year from medical errors and non-error drug reactions. If patients were really as litigious as claimed, you would be seeing 200,000 suits against doctors and drug companies every year.

There is also a cover thy ass culture where other doctors ignore or actively cover up severe abuses by their colleagues and where blaming the victim is an active and integral part of the so-called "White Wall."

As an example there is a rheumatolgist in my area that many women in my fibromyalgia support group have seen. None of these women knew any of the other women before coming to our group, but each one of them reported that this doctor had got in their face and screamed at them like a drill sergeant that "fibromyalgia is not a real disease!" and it's "all in your head" and that "you are just hysterical, and exaggerating your symptoms to get emotional support, and I am sure as hell not going to give it to you!" A casual glance at some of the doctor's blogs out there will quickly reveal this mentality towards people with chronic pain or fibromyalgia is hardly rare, but this guy took it beyond the Pale by shouting in his patients' faces in an extremely abusive manner.

Afterwards, he wrote in the patients' medical records that they were "difficult patients," suffering from "conversion disorders" and were "noncompliant" and "resistant" to his treatment program. Ironically, other patients reported that this same doctor was the one who diagnosed them with fibromyalgia in the first place, and that he was not in any way abusive. The pattern I noticed was that elderly women consistently reported abuse, whereas younger women and men reported that he accepted or made the diagnosis of fibromyalgia. Based on my experience with these women, I would say that they were all well-mannered, well-educated and cultured people who were unlikely to have done anything to trigger this behavior other than assert themselves.

I remember seeing an endocrinologist who suggested to me that a rheumatologist might better be able to help me, but when I asked for a referral she mentioned this guy, but said "he's kinda...uuuuh," and shook her hand from side to side in a gesture that means he's a little questionable. I interjected and said, "yeah, I know, he's a barbarian," at which point she said "well, I think that's a little harsh!" and then I told her about the women in my group and what they had experienced. Her response was "that's all anecdotal evidence, and you can't always believe what patients say." She knew damn well what a bastard this guy was, but when push came to shove, she chose to defend him.

So yeah, I think most of us are well aware that we need to be polite and respectful and reasonably cooperative if we expect decent medical care, and doctors and nurses are entitled to respect. What you and other doctors interested in ethics need to realize is that a lot--and I would venture to say a majority--of your colleagues are extremely arrogant, mean-spirited bastards with a strong tendency to treat patients abusively, and very often patients are simply reacting to that abuse with anger and distrust, albeit sometimes misdirected at you. These doctors are *not* entitled to respect, nor are they entitled to be protected by their colleagues. They deserve to be drummed out of the profession or otherwise severely disciplined. As I stated in that thread, I have been the contact person for a chronic pain support group for over 14 years and I have yet to meet a single person with chronic pain who doesn't have a horror story about abuse from the medical profession--and the story I relayed above is pretty tame compared to most I have heard. Abusive behavior towards people with pain is the rule, not the exception, so if you sometimes find these "drug seekers" acting up in the ER where they have come seeking an alternative to blowing their brains out, you now understand why. Act accordingly.


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