"In Sickness and In Health Till Death Do Us Part": Is This What We Ask of Our Doctors?
My threads on patients hating doctors have stirred a lot of conversation here. I am still trying to understand fully the explanations patients give as the reasons for that hate. After reading the article "A Sentimental Patient" by John Portmann in the Cambridge Quarterly of Healthcare Ethics (2000, 9, 17-22), I wonder if sentimentality is one such mechanism. Portmann defines sentimental, in the sense of the doctor-patient relationship, as "a contrived exaggeration of emotional availablility of physicians." What this means is that the patient expect more emotional and concerned feedback from the physician than what is realistic. Portmann, however, says that sentimental patients are not hateful, however they may experience the same issue: attempting to deal with their concept of an "ideal doctor" vs the doctor's response which is likely based the realities of what is facing the physician trying to care for "sick and troubled" patients. I, myself, wonder nevertheless, whether sentimentality is not a major cause for the feeling and expression of hate for one's physician or physicians in general.
It is understandable that some patients may need sentimentality if their own emotional needs are unmet and especially so during times of illness and discomfort.
They would want their doctor to be more interested in them, more comforting to them and provide them with something more than a cold and casual paper prescription, if even that. When their doctors don't meet their expectations, the patient will look at their physician as heartless and anything that the doctor accomplishes to the benefit of the patient will appear incomplete and anything not accomplished will appear what the patient expected. Portmann writes "Belief in caring generosity of physicians falsifies what we know about them by emphasizing their virtues and underplaying their other committments and motivations."
The question is whether the establishment of the doctor-patient relationship actually, to some patients, represent almost a marriage vow in terms of what medical ethicists (Quill and Cassell, 1995) by their definition of the doctor-patient relationship as "a covenantal relationship grounded in mutual respect and caring... [including]caring, fidelity, altruism and devotion...[and] the particular importance of long-term, engaged presence... [and] the promise to face the future together."
If all this is what some patients expect from their doctor beyond skill and technical knowlege and willingness to listen, try to understand and try to provide supportive empathy, then I can see displeasure and even hate if the doctor doesn't provide more.
What do you think is the role of sentimentality on the part of the patient and it's role in the expressed hate? Do you think patients expect more emotional concern or involvement by their doctor, perhaps almost in a family way, than they usually receive? ..Maurice.
posted by Maurice Bernstein, M.D. @ 2:33:00 PM
15 comments
15 Comments:
I think it's possible that some patients may have unrealistic emotional expectations of their doctors. I wouldn't consider myself one of those patients. I do not want, or seek, an emotional connection to, or empathy from, my doctor(s). I see them as information consultants and service providers. I want to be spoken to and treated in a professional and respectful manner, and to have more than 5 minutes of their time to have a discussion of the possible diagnoses (if any), evidence for and against, and how to proceed, or if to proceed, with testing or treatment. I have found doctors who are able to do this, but I have experienced many more who cannot.
The ones that make me angry are the ones that treat me unprofessionally and disrespectfully. This only started to happen when I sought help for medically unexplained symptoms. I think this kind of patient frustrates certain doctors because they don't immediately have the answer and can't 'fix' you in a 5 minute appointment, so there is not much job satisfaction for them. Their reaction is to ridicule, question the patient's motivations and character, and dismiss and label the patient as depressed or psychosomatic. In this way, the doctor is the one who moves the relationship to an emotional level. In fact, as I write that last sentence, at least for the situation I describe, it could be the doctor (not the patient) having the most problem with unmet emotional expectations from his/her job, and of him/herself as a doctor.
The implication of what you say here is that if patients hate their doctors, or feel let down by them, the problem lies with the patient, not the doctor. Obviously, human relationships of any kind are complex and I am sure there are lots of nightmare patients, who make unreasonable demands. But I agree with the comment above, that often it is the doctor's expectations that are thwarted, and, sometimes, their inability to admit shortcomings - or outright blunders - which infuriates patients. The "Godcomplex" may be not be the problem it used to be but that is as much because informed and intelligent "consumers" are less inclined to be overawed than in the past. Dealing with life and death on a daily basis is likely to make one feel powerful; saving lives to lead to a strong sense of satisfaction; admitting mistakes and dealing with an unfamiliar sense of failure might come to seem intolerable?
As a physician, I never felt powerful, I never felt God-like. I simply felt that I was educated in medicine (which I was)and I was performing my professional activity. Nothing more, nothing less. If patients think otherwise about doctors, they are misinterpreting what doctors are feeling about themselves.
And "life and death" issues have nothing to do with the way doctors feel or act. Airline pilots hold the lives of more than a hundred people in their control when they are taking off, flying and landing.
Yet, do you think they are looked upon as behaving "God-like" by themselves or their passengers? I suspect that pilots landing the plane at the destination safely and on time makes the pilot feel simply satisfied and nothing more. When doctors have a satisfactory performance, the response is again simply satisfaction--just like any other person doing a good job.
I think an explanation of why patients may express dislike toward physicians is because they only can imagine how physicians feel and why they are motivated to practice their profession. Then they draw a conclusion based on that imagination. Of course,there are physicians who are disliked because of personal misbehaviors which are general human weaknesses and not necessarily part of being a doctor or doing a doctor's job. ..Maurice.
I do not believe you can justifiably say, based on your own motivations that "doctors do not view themselves as godlike". You may not, and the doctors you know may not, but we tend to associate with those most like us, and your experience and personal approach does not disprove the assertion that "doctors think they are like unto god". Sure, this is a stereotype, but stereotypes come from somewhere. In New Zealand as recently as the late 1970s women were experimented on without their consent to track the growth of cervical cancer, and newborn infant girls were given smears without their parents knowledge or consent. The doctor who was running this research program provides a striking counterpoint to your assertion about yourself.
I was going to spend a lot of time on a post about why people hate doctors, but the post about "sentimentality" has shown me that it is very likely a waste of my time; if you cannot see how you need to deal with patients' emotional needs when you are dealing with their health, touching their bodies, or seeing them unclothed, then you are part of the problem not part of the solution.
Placebogirl,accessing and trying to understand a patient's emotional needs is one thing but dealing with it therapeutically is another. Physicians who have but 15 minutes at the most for a visit can only do so much in both evaluating and treating a physical problem along with "dealing" with the patient's emotional requirements especially if it is sentimentality on the part of the patient that motivates the patient. Patient sentimentaly may not be satisfied without some specific behavior by the doctor which the doctor may provide or may not be able to provide either because of time or because it is professionally inappropriate or it is contrary to the doctors personality.
Nevertheless, I do recognize the need for doctors to understand their patient's emotional needs if only to modify therapeutic approches appropriately. In this regard, I wonder whether the developing interest and use of the e-mail and restricted internet sites for patient-doctor communication (see Perspective article by J.H. Stone in June 14 2007 issue of New England Journal of Medicine) actually will make it more difficult for doctors to have a chance to understand their patient's emotions without the vocal and body-language cues. ..Maurice.
Ahh . . . Bernstein in his faux-concerned manner speculating that patients hate doctors because of patients' child-like desire, inevitably disappointed, for a father figure. Well, we would expect such silly Freudianisms from a man named "Bernstein."
The reason patients hate (rightfully so!) doctors is more mundane than your soppy psychodrama. It's economic. The provision of medicine is not transparent. In what is probably the most important thing to people--their health, you can't tell whether you're getting good service of not. It's like dealing with a used car salesman.
Google, evidence-based protocols, the standardization of medicine, increased use of computer detection--indeed, anything that makes medicine more like any other industrial process will solve this problem. When we begin to think of doctors like barbers or pharmacists, we'll stop hating them.
Anonymous, if you read the article, the concept of patient sentimentality is not mine. And I am not sure what surnames have anything to do with theory. I am sure, however, that if physicians can't provide whatever the patients demand, this might lead to the dislike of physicians. Also, I wonder how many of my visitors would want medical care to be similar to an "industrial process". Already the requirements of insurance companies and HMOs are making medicine look more like an assembly line with standardized procedures and required output. ..Maurice.
"Industrial process" may not be quite the expression I would choose, but I know what this poster means. But I don't think the problem is caused by "unrealistic emotional expectations" either. What patients want from doctors is to be made better, if possible, and either way to be treated as reasonable adults, even when the fear of illness is making them a bit less reasonable. Doctors have the power of esoteric knowledge, use it, and sometimes abuse it. Doctors can do amazing things on occasions but can seem bored and dismissive with the more mundane. An efficient computer wouldn't behave "de haut en bas", wouldn't patronise, wouldn't get hostile and defensive when it messed up, and wouldn't make you feel you were imagining it if they couldn't find the answer. I have a lot of respect for the hard work of doctors, but their really is a proble here, and it isn't all in the mind of the patients.
But Anonymous (from today), we doctors are not computers.
I just wonder how much of this conversation regarding the patient's description of the behavior of doctors and the doctor's description of the behavior of patients is not all about statistical outliers. In fact, most patients are not personality or behavior problems to doctors and likewise the same applies to most doctors. Wouldn't that be a more realistic way of assessing the issue? Shouldn't we be more concerned with the outliers and not tend to generalize to all doctors and all patients? ..Maurice.
You are obviously right about generalisations and anecdotes from the extremes, but I do think there is a small problem inherent in the structures. Social and educational changes and changes in the nature of the medical profession mean that expectations are much higher and the nature of the transactions between doctor and patient much more complex. Some patients may have unreasonable expectations, including expecting emotional support, but maybe some doctors are more interested in/attracted to the medicine than the patient. Add in mutual distrust and things are going to get worse.
I'm the first poster on this thread.
I'm not quite sure I understood your last post correctly, Maurice. but here's my reply.
I thought all the negative stories I had heard were just patient's whining or statistical outliers. Until I needed medical help. I was very surprised by the number of doctors who have reacted to me in a bad way. Being the kind of person I am, I went looking for the answer to why this should be. I discovered many other patients with similar stories, so given that, and my own experiences, I have a hard time believing we and these doctors are just statistical outliers.
The source of these bad experiences are in part due to the system (everyone is too busy for example). I think another source is in the personality type of a certain subset of people who go into medicine as a career. I suspect another source is that doctors are not being trained properly to deal in a constructive way with the increasing(?) number of people with chronic illnesses or medically unexplained symptoms.
Anonymous (from today), so the best way to mitigate the conflicts you describe would be to change the system . Yes, change the system.
At the start, although as a facilitator for the learning of medicine by first and second year med students, I know that we discuss and try to emphasize the psycho-social aspects of patient illness and emphasize the importance of trying to make emotional and spiritual connections with the patient and to try use empathy as a therapeutic tool, what we teach may not be enough or adequate. So that part of the system could be improved. If we do that and physicians go out into practice intent to be more emotionally receptive and giving leading to the therapeutic benefit of the patient, the insurance companies and HMOs and the government should realize that this is important also and their system should be changed to allow for the time for this function of medical care and to also provide compensation to the physician for taking the time and performing that function well. There should be more professional monitoring of physician behavior to see that they are using all their personal tools available to provide adequate emotional support to the patient just as doctors are being educated though continuing medical education programs and tested by board exams for their diagnostic and therapeutic skills.
Also think, maybe the system is not explaining to the public what exactly and realistically represents modern medical care. Maybe the government and medical societies should, with the active participation of the media, educate the public what the system really allows doctors to do and what are the rational expectations for physician behavior and the diagnostic and therapeutic results. This also means educating the public about the irrational expectations based on some media news items, media dramas and the anonymously directed advertising by the pharmaceutical companies. Perhaps also having the public see by changing the healthcare payment system to one where every person in the country has the potential for the best care regardless of income or social status, patients would not feel they are being denied something others, with money, are getting.
If all these changes in the system are made perhaps a concern between doctors and patients of "why can't we all get along?" will be minimized to everyone's benefit. ..Maurice.
Visitors to this thread might be interested in going to a British Medical Journal News Roundup article which is titled "Being a Caring Doctor May Be Bad for You".
It is a description of a study of Australian medical graduates. There is a response to the article which is titled "Encouraging Insensitivity in Doctors is Not an Option" Both are full text and are apparently accessable to everyone. Let me know what you think about the views expressed. ..Maurice.
This is Anonymous again.
I personally, don't want emotional and spiritual connection
with the doctor. I don't think such a thing is realistic or possible,
and may come across as insincere and just plain weird.
On the other hand, I think it is realistic to expect to be treated
respectfully and professionally when I visit the doctor.
What I mean by that is, I would like the doctor to
- refrain from disparaging comments about my motives and character
- refrain from disparaging comments about my intelligence
- refrain from disparaging comments about my efforts to find a diagnosis
- not abruptly leave the room when I question his diagnosis
- not diagnosis me based on his stereotypes, assumptions and prejudices
- not conclude I'm lieing or imagining things because the test results don't match the symptoms I report
- accept and believe that what I am experiencing is real and disabling
- work with me to solve the puzzle
- share copies of my blood work without me having to justify why I want them
- listen accurately to what I say
After reading the above, a person might conclude that I have a difficult personality, but I assure you I have not been intentionally rude, demanding, or provoking to these doctors. I do not react emotionally in their office because I'm either too shocked at the time by the way they behaved, or because their indirect sarcasm or ridicule hasn't quite registered in my consciousness. The anger or tears come out after I leave.
I am not mentally disturbed or displaying extreme behaviours. I am not depressed or lieing or imagining things. I am not a drug seeker, hypochondriac, seeking attention by being sick, or trying to get a lifetime disability pension. And I don't see how it's even possible for a doctor to draw those conclusions from my actions. But that's what many seem to do.
I have now found a "good" doctor. One of the first things she put in my chart was "Patient tired of being stereotyped as a ....". She's newly practising. She doesn't try to know or memorize everything. We surf the internet together in her office looking up information, discuss possiblities and options, the benefits and limitations of referals, more testing, medications. Our appointments are longer and not rushed.
She doesn't assume. She asked me how I would feel if the diagnosis
turned out to be something chronic and incurable. So I told her how I
would feel about that (basically, that I don't care what the diagnosis is, I would just like to know what the problem is so I can understand and deal better with the unpredictable and debilitating symptoms). I don't expect her to empathize (perhaps I don't understand the exact meaning of this word), I just want her to believe and record how it affects my life, and we work together with that. If I need a shoulder to cry on, I'll go to a friend or family member.
This is just my own experience of how I am hurt and angered by some doctors. Is it unusual or common? I have learned recently that unexplained symtpoms is a very common presentation in the doctor's office.
cont. ...
cont. ...
"Also think, maybe the system is not explaining to the public what
exactly and realistically represents modern medical care".
I agree with that. I've learned alot over the past few years about
the limitations of doctors, testing, and healthcare. And I'm ok with that because I'm a pragmatic person. But I had to come to this
conclusion through my own efforts.
Looking back, a short candid
conversation about the limitations of medicine with the first doctor
might have saved me fruitless and disappointing further visits and testing.
At the start, I didn't know I had "vague and non-specific" symptoms and I didn't know what that meant. I do now, and I understand the diagnostic challenge.
I have also been thinking over the past year about the idea that as a
western society our expectations of our health and physical abilities
are unrealistic. We seem to expect to be in 100% physical wellness all
the time, all our lives, able to work long hours, have full days, and do this year after year. So psychologically, for me, coming to terms with being "disabled" has been hard. I wonder if societies in the past or other cultures were/are better at accommodating individuals with less-than-perfect health. I used to be critical of 'lazy' people but I have a different perspective on that now.
I came across an article recently:
'I just want permission to be ill': towards a sociology of medically
unexplained symptoms. by Nettleton S. Soc Sci Med. 2006
Mar;62(5):1167-78.
The title summed it up for me. Does society / myself / doctors / friends / family allow me to be ill? Not if I don't have a diagnosis, not if I look healthy and tests show nothing abnormal.
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