We Doctors Are Required To Do What’s In The Patient’s Best Interest…But We Are Not Required To “Like” Every Patient We Treat

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Don S. Dizon , MD, FACP

This post was originally published on ASCOconnection.org, the American Society of Clinical Oncology’s professional networking site

“Great,” I thought, as I stood at my desk, looking at my patient list early in the morning. She was coming in today. “She” was a patient of mine in her forties, with newly diagnosed triple-negative breast cancer, without nodal involvement. Our first meeting had been several months ago, and it had not been a good one.

I had asked about her history, how she presented; she had been fairly surprised I did not have that information. “You mean, you don’t know?” she had asked. “I would’ve expected you to at least have read my chart or talked to my surgeon,” she said. Then, with a sigh, she had recounted how she got to this point—finding a mass, the normal mammogram, the ultrasound-guided biopsy, receiving her diagnosis. Then surgery, more results, culminating in a referral to me. Every question I asked was met with a furrowed brow, as if I were interrupting her.

“It must be really shocking to be here. No one our age expects something like this to happen,” I said.

She had gotten angry at this. “Just concentrate on the facts, please. I don’t need your pity. What I want is your expertise.”

We launched in to a discussion about her diagnosis, stage, and natural history of the disease. She questioned everything we discussed: “Are you sure your statistics are right? From what I read, it’s more like this . . .” I remember getting defensive, as if each question back to me was a personal attack on my competence as a physician, as an oncologist. I remember feeling flushed as we talked, trying to get my point across as clearly as possible, yet feeling that she did not (and was never) going to “believe” me.

We then discussed chemotherapy—both standard treatments and those available on clinical trials. She had even more questions:

“Why should I get doxorubicin? I heard I’ll be throwing up all day. Are you sure I need it?”

“How is a clinical trial better for me? There’s still a 50% chance I can get doxorubicin, so why is this even an option?”

We covered alternative approaches—ones that did not involve doxorubicin and were available off a clinical trial. I then rendered a recommendation taking into account her tumor, her priorities and beliefs, and what the evidence told me. We talked some more and I fielded additional questions; then I asked her if there was anything else she wanted to discuss.

“Not for you.” She said. I looked to the floor and left the room.

As time passed, I resented having to see her and take care of her because despite what I perceived as my best efforts, I felt we had no real doctor-patient relationship. Each subsequent meeting was tense because I felt more and more certain that (a) she didn’t trust me and (b) she did not like me. I had expected her to find a new doctor—within my practice or somewhere else—but she did not. Indeed, I remember being surprised (and anxious) each time she showed up.

On that day she showed up on my list, I confessed something to my partners: “I don’t like this woman,” I said. They looked at me, shocked. “You should not say that,” one had said. “It’s not her fault she has cancer, and people cope in very different ways.”

Although much time has passed, this patient stays with me because it was perhaps one of my most difficult patient relationships—not because she had questions, but because, as sometimes happens, I felt we did not “connect,” despite my trying really hard to make her like me, and to see that I was a good and decent doctor.

As I developed this blog, I decided to show it to a very dear friend, Dr. Barbara Rabinowitz, whose advice and guidance have been important to me on a number of occasions, particularly when we served on the board of a national organization together. I had wondered what she thought of my experience.

Dr. Rabinowitz:

I do believe we hold high and sometimes unrealistic expectations of ourselves. In spite of your usual ease and rapport with patients, the experience you describe above is far from unknown. According to Haas et al., studies have shown that about 15% of the time physicians experience working with “difficult patients.”

In my experience, health care providers often feel trapped by the resultant negative feelings of these non-satisfying relationships. Though not in this case, difficulties may arise in the physician-patient relationship stimulated by pressures from the health care system itself (time allotted for visits, etc.), from undiscussed differences in expectations between the patient and physician, and the patient’s own previously held (and perhaps undiagnosed) conditions (e.g., personality disorders, etc.). Not uncommonly in cancer care, the free-floating anger at having been diagnosed with cancer may also be aimed at one or more members of the cancer care team.

I believe there is an even greater pressure to “like every patient” in cancer care than in general practice, as in this case, as exemplified by the reactions of your colleagues to your frustrated admission.

Ultimately, I clarified something with my partners: “I did not say anything about having cancer being ‘her fault’—I said I did not like her.”

With that, I realized that even with our white coats on, we possess our feelings, likes, dislikes, and personalities. Medicine requires us to do what is in the best interests of our patients, to “do no harm.” It does not compel us, however, to “like” everyone we treat. As a result, I experienced something interesting—almost liberating. I found that subsequent discussions and encounters with this patient became easier and that I was able to listen to her questions and answer them without getting defensive.

I realized that when I stopped trying to make her like me, I was able to take care of her. The pressure of wanting to be “liked” faded. It dawned on me that I was working so hard to make her like me (and vice versa), that it was affecting my ability to care for her. Once I admitted to myself that it was okay to not like a patient, I was able to do what she wanted me to do—to be her doctor.

At the end of the day, doctors are not a deity—omnipresent and omniscient. We are people—we are fallible, prone to our prejudices and our preferences, insecurities, and biases. I have learned that to become a good doctor, one must be honest with one’s self and exert introspection in order to become self aware; to admit that maybe the difficult patient is perceived as difficult not because of who or what she says, but rather the pressures we put on ourselves to “like” everyone we treat.

17 Comments

  1. Robin says:

    Thank you for sharing. I am resident faculty in a nursing school and students need to understand the other side of our team. Physician are challenged everyday to take care of as many patients as they can. Please continue to communicate with the nurses and have an even stronger working relationship. I will share this with my students…in their clinical rotation.

  2. Kathy Torpie says:

    It is unfortunately that even with “patient centered care” the physician is trained to be more aware of the patient’s expectations, values and beliefs without being encouraged to be self aware…without being encouraged to recognize that they too are unique human beings with their own bias and that we (clinician and patient) influence each other. I is not a one way street!

    • Kathy- I agree with you. Even after more than 10 years in practice (closer to 15 almost) I feel self-awareness is something I am still working on. Being cognizant of one’s views and beliefs (one could call it their “self-schema”) is as important as understanding the history and background of their patient. It is definitely not a one way street. Thanks so much for your comment.

  3. beth neary, md says:

    Great post. I will share with the med students that I am working with.

  4. Joyce N. DeWitt says:

    As a patient, I don’t find it surprising at all to hear that doctors don’t like some of their patients. Let’s face it, there are just difficult people in the world, and we meet them in all walks of life. I’m a retired high school teacher, and I can assure you that I did not like all of my students. I love working with teens, but every year I encountered a few students who made things difficult. They were challenges in different ways, but the ones who stick out in my mind as most unlikable were those who were mean to other students. By the time a person is 15 -18 years of age, basic human kindness and consideration should be obvious. When I had a student who disrespected everyone except his/her own little circle of friends, it was very hard to like that kid. Every so often, when making a seating chart, various students said out loud, “Oh no. I can’t sit next to him/ her. I don’t like him/ her and I can’t stand to sit there.” They said these things in front of the person and the whole class! Yet I had to teach these students, and perhaps even tutor them before or after school. It took a lot of patience because some of these kids had a sense of entitlement that put their own interests squarely at the top of every list. If I was walking around the room checking work, or answering questions, a student might say, “I need your help! Start on this side of the room, don’t help her, she doesn’t need it as much as me!” without giving me a chance to work my way over there. If I was trying to schedule a make up test for a student, he or she might say, “I can’t come in then. I can’t come before OR after school. I don’t get here until right before the bell, and I have practice after school every day. I can’t skip practice.” I might then suggest he/or she bring their lunch to my room and take it then. “No, I can’t eat and take a test at the same time.” So then my only choice would be to allow the student to take the test during class, either in another teacher’s classroom during her conference period, or in the library. If we then started a lesson during the time the student was out, I have had kids actually tell me, “You have to give me extra time for that assignment. Mine can’t be due tomorrow. I was taking a test.” Try to argue that with a kid, and you’ll have a parent in your room the next morning. So, we deal with these kids the best we can, put on our blank faces, swallow the words that we would like to say, and just blow it off. It was never worth it in the end to battle most of these types of things, but when they abused other kids, that is when I could not tolerate the behavior. I would step in every time, although it is impossible to teach common courtesy to a kid who doesn’t have it by the time they are in high school. These kids grow up to be …. difficult employees, difficult customers, and…. difficult patients.

    • Dear Joyce,
      Your insights into education are really important and as a parent, I often marvel at the patience of teachers (particularly when it comes to dealing with parents, lol). It leads me to wonder, though, if empathy is something that can be taught. Are kids like the ones you describe destined to be difficult later in life? It is something that we continually work on in medical education and beyond, and we should.

      • jlndewitt says:

        Hi Dr. Dizon, I do think that empathy can be taught if children are encouraged at very young ages to think of others. I believe that most parents do model courtesy and basic kindness, and continue to correct selfish behavior as kids grow up. Thankfully, most parents are helpful in backing up teachers and because they are, the majority of students are not as likely to misbehave. They clearly know that their parents expect good behavior. By nature, kids are pretty self focused but this fades with parental guidance, and also as they are developing friendships. Most of the difficult kids that I remember had difficult parents. What we see at school often shows us that some family dynamics promote rude and harsh reactions. I do think that the kids I describe will be inflexible, uncooperative and even volatile later in life. Once in class, we were discussing family meals and how our culture has changed over the years. The lesson was also about other countries (I taught foreign language) and how mealtimes are slower and very family centered elsewhere in the world. We were talking about how often the students in our class dined with the whole family. Very few said “every day,” and most said, “about once or twice a week.” One of my most challenging girls, who had a quick temper and a very selfish demeanor, said “Never! I can’t stand eating with my family. They’re all loud and my little brothers and sisters are so gross. I take my food to my room and eat by myself!” I felt this was sad, but didn’t make any judgment. The fact that her parents allowed this wasn’t so surprising. Her mother was equally difficult in conferences and did not shy away from using curse words or expletives to make her point, loudly. So you can see why teachers are prone to say “The apple doesn’t fall far from the tree.” How can we work with such kids and parents? We can because we promise to take on all learners, so we can think whatever we want, but we continue to strive for grace under pressure and to keep our own professional demeanor. I loved my job, and when I had an outburst and subsequent incident from a kid, my biggest focus was to get that student either calmed down or out of the room as quickly as possible. Then I could shrug that off and return to the classroom full of students who just needed to go on to whatever we were doing when we were interrupted. I might have looked serene, but my blood pressure was rocketing. I’ve even had kids ask me after an incident, “How can you be so calm? Aren’t you mad?” I would just tell them that if I let something like that upset me, it would ruin my whole day.
        I would imagine it is the same for doctors and nurses who have to deal with rude patients. It’s hard to take a verbal beating and go on as if nothing out of the ordinary has occurred. I admire doctors and nurses so much, and I always want to be a cooperative, easy, and “good” patient. I think it’s that teacher in me that wants an “A+” as a patient! Luckily, I have always had great doctors. I have been fortunate to have physicians who have been extremely helpful, professional, and competent. I’ve learned a lot from them and I’ve never felt that I was asking an irritating question or being a bother. I do try to go prepared, to think of things I want to discuss beforehand, and to even have notes if I think I will forget. It’s too bad that tough people can’t see that asking or stating things courteously will usually guarantee polite and thorough answers in return.

  5. edswriter says:

    As a patient, I’ve often felt the burden of having to support the doctor’s self-concept as a “likable guy” (or woman, as the case may be.) It’s nice to see at least one doctor taking that burden off the shoulders of his patients. We have enough to deal with.

    • Eds Writer,

      I wish you would give some examples of what you mean by “having to support the doctor’s self-concept as a “likable guy or woman”? I am not sure what you mean…it sounds interesting?

      Thanks as usual for your comments.

      Steve Wilkins

  6. edswriter says:

    Ok, Steve, I’ll elaborate. Although I’m an engaged patient, I’m invariably polite. I’ve never had the courage to act as the patient in this article did. She refused to “play nice” and “be friends.”

    Dr. Dizon writes, “I had asked about her history, how she presented; she had been fairly surprised I did not have that information. “You mean, you don’t know?” she had asked. “I would’ve expected you to at least have read my chart or talked to my surgeon,” she said.

    This woman was spot-on. A professional should be familiar with your “case.” I’ve never upbraided a doctor for being obviously unfamiliar with my case. I’ve played nice and repeated information that the doctor should already have. That takes energy seriously ill people seldom have.

    One doctor demanded that films be hand-delivered a week in advance, a difficult task since I was unable to walk and had a small child. I made arrangements for someone else to pick them up and drive them over. I said not a word when she shook them out of the package, untouched in the week that she’d had them, and looked at them for the first time at my appointment. I didn’t want to give the meeting a hostile/unfriendly vibe.

    Dr. Dizon writes, “Every question I asked was met with a furrowed brow, as if I were interrupting her.”

    Well, if he’s like most doctors, he was interrupting. Studies show that doctors interrupt early and often when patients speak. I’ve hidden my irritation when I’m interrupted in the middle of an important point, trying to be “nice,” so that the doctor doesn’t dislike me or think I dislike him or her.

    The patient turned away Dr. Dizon’s attempt at empathy, “It must be really shocking to be here. No one our age expects something like this to happen,” I said. She had gotten angry at this. “Just concentrate on the facts, please. I don’t need your pity. What I want is your expertise.”

    I have never told a doctor not to assume that he or she knows how I feel, though there have been many times that I have wanted to. I’ve smiled and nodded, when I wanted to challenge. Because I knew that there are times when it’s better to let the doctor think that you like him or her–if they dislike you your care may suffer.

    • edswriter,

      Thank you very much for elaborating on your earlier comment. I think your elaboration makes it easier for me and others to understand what you were driving at. As I was reading your comments I was thinking of all the “gratuitous” comments my physician has made in the past realizing that I never paid any attention to them at the time because I didn’t believe they were necessarily sincere. By not saying anything I can see how one could interpret that as feigning some sense of liking or acceptance on the patient’s part.

      I never thought of this before…Thanks!

      Steve

    • Dear edswriter, Thank you for engaging in this discussion, and for reading this post! I cannot deny your sense that some (if not the majority) of physicians have a desire to be liked (or at least come across as a nice guy). I was/am certainly one of them. Yet, I’ve seen the opposite end of the doctor-personality– the one where paternalism/absolutism reigns supreme. I have also seen patients in consultation who were invariably harmed by those experiences- not in a medical sense, but in a psychological sense. It would seem that the lack of empathy- of “touchy-feely” medicine- can be in and of itself damaging.
      Ultimately, patients are not uniform, and needs are different. While some patients need to ensure that the details of their history are accurate, others (like the one I used in my blog) do not relish having to re-state their past (usually not the first, second, or third time).
      Recognizing that a patient is seeing me not to start a friendship means that I have a responsibility to be accurate, precise, and honest, matched with a duty to be sensitive and empathic. The challenge is to do both simultaneously. It’s a lesson that I re-learn with each new patient.

  7. An excellent and vey honest post. As a psychologist (who now does executive coaching), I have treated hundreds of patients over the years, many with severe depression, personality disorders, paranoia and the like. I have always told myself that I am equally committed to ALL my patients, but of course there are some I “like” more than others and that is okay. Dr. Dizon is light years ahead of many of the physicians I have seen and heard of over the years in his humility, self-examination, willingness to learn and change. Research also shows that patients who are listened to more by their physicians are more compliant with their treatment plans. I give him great credit for his willingness to work on self- awareness and the complicated interplay between his own needs and this patient’s needs, and his willingness to share to help others.

  8. Dear Dr. Allen,
    Thank you for your kind words. They are very much appreciated. I know my own experiences are not isolated and I hope to give voice to a community that is often quiet. Best to you always,
    D

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