Wednesday, February 16, 2011

That sinking feeling...*

I suppose it had to happen sometime. The word is out. There are times when consultations don’t go so well. Like any other human interaction a slight misread of body language, an ill chosen word or a momentary friction between personality types derails things and the express train of therapeutic discourse and discovery goes hurtling off down the wrong track, or smashes headlong into the buffers.

(Yes yes I know derailed trains don’t do either of the above in reality, but it’s my train set and it follows my rules ‘k? ‘K.)

I’ll be the first to admit to my share of disasters, but I hope that I recover most of them before any lasting harm is done to the therapeutic relationship. And though you might not believe it of us as a group, we all try our best not to put our size nines in our mouths too often, or to deliberately rub our patients up the wrong way.

After recent discussions with friends, both face to face and “virtual” (you know who you are) I’m a little worried that sometimes the poor souls of the receiving end of such consults then feel they’ve been labelled, and somehow singled out from the rest for “special” attention. So allow me to set the record straight.

There are times when the doctor-patient relationship dysfunctions, and continues to dysfunction repeatedly and serially over a sustained period. To be non-PC about it terms like “Heartsink” and “Quack” get bandied about and a rift opens between patient and the profession as a whole.

Let me be quite clear about this—though the term and the concept of the “heartsink” patient exist and I’m perfectly certain that the equal and opposite concept of the “heartsink” or “quack” doctor also exist, from where I sit the terms loose currency through overuse. In a career of over 25 years responsible for the care of upwards of 14,000 patients on a day to day basis, and with a dedicated personal list of over 2,000 patients theoretically entirely my own in that they have named me their personal physician by registering on my list, I can’t think of even a handful of patients whose name would instil in me that feeling of apprehension implied by the term. Yes I have many patients who at times test my patience, just as I’m sure there are even more patients whose patience I test from time to time. That doesn’t amount to the same.

One bad consultation, even a run of awkward encounters doesn’t amount to the same thing. Indeed often you have to negotiate a period of awkwardness until you achieve an understanding as with any other interpersonal relationship. Patients know how they feel, even if they don’t intuitively know why. Problems arise when the way they express their symptoms, feelings, fears and apprehensions isn’t heard or isn’t interpreted correctly, or appears to have been ignored and disregarded.

If we can be grown up enough to acknowledge this and back track a bit and try over mostly we can make progress and though we may not be destined to be firm friends we can work together—after all it’s the patients who do all the heavy lifting in any therapeutic process barring the most trivial. We might prescribe the meds, the lifestyle changes or perform the operations, treatments, manoeuvres needed to fix things, but the punters have to take the pills / advice and adapt to the aftermath of the procedures. If we get it wrong first go we have to have the trust of the recipient that our next effort will be better. It’s when this breaks down, and stays broken that we risk loosing an effective therapeutic relationship. At that point the majority of patients, quite sensibly decide that it’s time for them to find another doctor—who will hopefully understand them and their needs better. Sometimes it behoves the doc to suggest this perhaps by means of a personal recommendation.

Where we risk sliding into a longer term “institutional” dysfunction that ends in mutual “heartsink” is where a patient runs through a series of such dysfunctional relationships, or feels trapped within one, ongoing and without possible exit. It’s easy then for patients to feel abandoned, doc’s to feel their well intentioned advice is ignored and for both sides to give the impression either that they’ve stopped trying or are completely disinterested and merely going through the motions.

* anybody else know where I nicked the title from? EVCHN on offer as per usual.

Addendum: For the counterpoint see this from Anna. (Thanks Anna).