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Fighting the Good Fight: Responsibility and Rationale in the Confrontation of Patients

2012; Elsevier BV; Volume: 87; Issue: 1 Linguagem: Inglês

10.1016/j.mayocp.2011.07.002

1942-5546

Nicholas Kontos, John Querques, Oliver Freudenreich,

Ethics in medical practice

All physicians can find themselves feeling compromised by patients who are behaviorally inflexible, temperamentally difficult, or inappropriately demanding. While empathic negotiation, education, and persuasion rightly rule the day with such patients, we notice a general reluctance to confront those who are unresponsive to these measures. When confrontations do occur, they are sometimes mishandled. Our choice of the word confrontation is deliberate and incorporates 3 definitional elements to capture the essence of clinical interactions that (1) are interpersonally "face-to-face," (2) carry the potential for emotional "clashing," and (3) force a "comparison" between 2 points of view on medical care.1"Confrontation." Merriam-Webster Online Dictionary.11th ed. Merriam-Webster, Springfield, MA2011http://www.merriam-webster.com/dictionary/confrontationGoogle Scholar Confrontation stands in contrast to criticism by connoting a communication tool informed by "doctors' sense of patients' best interests" and by a view of patient centeredness that relies heavily on shared responsibility.2Salmon P. Wissow L. Carroll J. et al.Doctors' responses to patients with medically unexplained symptoms who seek emotional support: criticism or confrontation?.Gen Hosp Psychiatry. 2007; 29: 454-460Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar We propose a rationale for the judicious use of confrontation in patient care. Case vignettes are used to frame discussion. As the focus is on confrontation, readers are asked to assume that other interpersonal and social interventions have already been attempted with these patients. Our goal is to stimulate dialogue on an important subject that could reduce therapeutic misadventures, physician frustration, and resource misallocation. Medical literature and training in recent decades have largely neglected physicians' need for guidance in managing patients' maladaptive behaviors and attitudes. Groves'3Groves J.E. Taking care of the hateful patient.N Engl J Med. 1978; 298: 883-887Crossref PubMed Scopus (529) Google Scholar article on caring for the "hateful patient" is a notable exception, but this classic is now more than 30 years old. Its publication evoked a commiserative "collective sigh of relief by doctors across the country" (J.C. Nemiah, oral communication, May 1999), yet few others subsequently broached this topic.4Draper H. Sorell T. Patients' responsibilities in medical ethics.Bioethics. 2002; 16: 335-352Crossref PubMed Scopus (91) Google Scholar, 5Freudenreich O. Kontos N. Querques J. The muddles of medicine: a practical, clinical addendum to the biopsychosocial model.Psychosomatics. 2010; 51: 365-369PubMed Google Scholar Confrontation of patients may seem inconsistent with healing, but the two should not be presumed mutually exclusive. Siegler and Osmond6Siegler M. Osmond H. Patienthood: The Art of Being a Responsible Patient. Macmillan, New York, NY1979Google Scholar found an important place for physician assertiveness with oppositional or hesitant patients. It is worth noting that their work, like that of Groves, was done in the 1970s, which also saw the publication of the initial proposal of the biopsychosocial model by Engel7Engel G.L. The need for a new medical model: a challenge for biomedicine.Science. 1977; 196: 129-136Crossref PubMed Scopus (6919) Google Scholar and the first edition of Principles of Biomedical Ethics by Beauchamp and Childress.8Beauchamp T.L. Childress J.F. Principles of Biomedical Ethics. Oxford University Press, New York, NY1979Google Scholar These works catalyzed the emergence of particular brands of patient-centered medicine and autonomy-centered ethics, which tend to eclipse competing notions about patient obligations and physician authority.9Schei E. Doctoring as leadership: the power to heal.Perspect Biol Med. 2006; 49: 393-406Crossref PubMed Scopus (53) Google Scholar We contend that an imbalanced focus on patient privilege and physician duty neglects patient duty and physician privilege, creating a dishonest, skewed relationship. Proscribing confrontation of patients contributes to this dishonesty and can engender a sense of powerlessness among physicians that goes beyond inconsequential discomfort. Physicians may at times feel forced to "collude with patients and their symptoms, at the expense of their own concerns or judgments on appropriate management."10Chew-Graham C.A. May C.R. Roland M.O. The harmful consequences of elevating the doctor-patient relationship to be a primary goal of the general practice consultation.Fam Pract. 2004; 21: 229-231Crossref PubMed Scopus (47) Google Scholar Confrontation in such a scenario can risk severing the physician-patient relationship. Given the sacrosanct nature of that relationship, taking this risk may seem like a major transgression, but an imbalanced or intractably countertherapeutic physician-patient dyad hardly warrants reverence. Confronting patients can lend itself to misuse or outright sadism. Most fights are not worth picking to begin with. We propose 3 questions to help a physician choose a "good fight" and fight it well. The goal here is not to subdue one's opponent but to capitalize on the physician's "apostolic function"11Balint M. The Doctor, His Patient, and the Illness.Rev ed. International Universities Press, New York, NY1972Google Scholar to turn the patient into an ally in the better fight for health. This question trumps all others in choosing and navigating patient confrontation. A patient who works with his or her physician toward the prevention, control, or resolution of disease can be objectionable in many ways. Excluding frank abusiveness or disruptiveness, unpleasantness alone is never grounds for confrontation. A 55-year-old man with hypertension is stable and adherent, but at each visit, he belittles the size of his physician's office and brags about dominating and demoralizing his employees. He reports and demonstrates satisfaction with his life. Confronting this patient would violate the physician's "functional specificity," that is, the restriction of his or her role to that of "doing everything possible" to optimize health.12Parsons T. The Social System. Free Press, Glencoe, IL1951Google Scholar Clinical medicine's goals can entail secondary attention to just about any aspect of the patient's life.13Kontos N. Biomedicine: menace or straw man? Reexamining the biopsychosocial argument.Acad Med. 2011; 86: 509-515Crossref PubMed Scopus (29) Google Scholar However, such attention is paid in the interest of dealing with disease, and material unconnected to this purpose is "none of the doctor's business."12Parsons T. The Social System. Free Press, Glencoe, IL1951Google Scholar While this patient's behavior may be boorish, it does not stand in the way of his care, and confrontation is not indicated. Conversely, patients' attitudes and behaviors that adversely affect clinical progress are the physician's business. Sometimes this business cannot be transacted in a way that produces a negotiated change in the patient,14Jallinoja P. Absetz P. Kuronen R. et al.The dilemma of patient responsibility for lifestyle change: perceptions among primary care physicians and nurses.Scand J Prim Health Care. 2007; 25: 244-249Crossref PubMed Scopus (112) Google Scholar and in such cases, confrontation might be justified. We stress negotiated change and do not seek to return to a purported era of physician paternalism. According to Pellegrino,15Pellegrino E.D. Patient and physician autonomy: conflicting rights and obligations in the physician-patient relationship.J Contemp Health Law Policy. 1994; 10 (Spring): 47-68PubMed Google Scholar paternalism undesirably "makes the medical good of the patient the only good and subverts other goods to that good." A patient may quite validly not prioritize health. Good physicians explore and try to work within patients' priorities. The physician also occasionally tries to influence them, but medicine's mandate to minimize disease burden cannot be imposed on the patient except in special circumstances. Problems arise when patients make substantial demands but do not prioritize health highly. A 50-year-old woman with type 2 diabetes mellitus has long-standing poor glycemic control due to nonadherence. She attends appointments sporadically and refuses to see a nutritionist. During an emergency department visit for chest pain, she states, "I'm not afraid. If it's a heart attack, they'll just operate on me." This patient warrants confrontation of her approach to high-stakes health issues as a 1-sided affair for her physicians to sort through. The consultation of a physician by a patient mobilizes a set of complementary rights and duties that comprises an "ethics of responsibility" as much and as important as an ethics of rights.16Pellegrino E.D. Toward a reconstruction of medical morality.Am J Bioeth. 2006; 6: 65-71Crossref PubMed Scopus (99) Google Scholar While sickness entitles patients to care, relief from certain responsibilities, and a degree of blamelessness for illness, it also obligates them to seek and to cooperate with care.12Parsons T. The Social System. Free Press, Glencoe, IL1951Google Scholar Cooperation is not equivalent to passivity; responsible patients engage actively in the pursuit of their own health and in medical decision making.17Parsons T. The sick role and the role of the physician reconsidered.Milbank Mem Fund Q Health Soc. 1975; 53: 257-278Crossref PubMed Scopus (381) Google Scholar The foundation of patient confrontation is clinical inefficacy within a medical relationship in which the patient's rights and the physician's responsibilities are disproportionately weighted relative to the physician's rights and the patient's responsibilities. In this setting, confrontation can be justified as an attempt to bring the 2 sides into productive balance. A failing physician-patient relationship of the type described might often be attributed to psychiatric illness. Indeed, many of Groves' hateful patients would today receive formal psychiatric diagnoses. Direct challenging of patients with severe addictions, personality disorders, or other psychopathology may be discouraged based on neurobiological or psychodynamic formulations that question these patients' self-governance.18Szmukler G. "Personality disorder" and capacity to make treatment decisions.J Med Ethics. 2009; 35: 647-650Crossref PubMed Scopus (19) Google Scholar, 19Fuchs T. Ethical issues in neuroscience.Curr Opin Psychiatry. 2006; 19: 600-607Crossref PubMed Scopus (73) Google Scholar However, we caution against automatically equating compromised with absent free will. Presumed helplessness places patients in an "impaired role," which effectively renders them less than full citizens and should be reserved for patients acutely in extremis or for those with the most dire long-term prognoses.6Siegler M. Osmond H. Patienthood: The Art of Being a Responsible Patient. Macmillan, New York, NY1979Google Scholar Otherwise, the physician's good intentions are purchased at the expense of the patient's dignity. Of course, a given patient's unproductive approach to medical care does not ipso facto indicate the presence of mental illness. Important as it is to identify resolvable obstructions to health, overemphasis on psychopathology can engender false hopes, therapeutic excess, and ethical blind spots.20Perl M. Shelp E.E. Psychiatric consultation masking moral dilemmas in medicine.N Engl J Med. 1982; 307: 618-621Crossref PubMed Scopus (39) Google Scholar Medical academia largely presumes a collaborative model of clinical work, but there is a place for considering whether patients are invested in health or merely want it.5Freudenreich O. Kontos N. Querques J. The muddles of medicine: a practical, clinical addendum to the biopsychosocial model.Psychosomatics. 2010; 51: 365-369PubMed Google Scholar Many patients sincerely believe they are tending to their health simply by informing physicians of their needs. They are possibly ill-served by direct-to-consumer advertising or a belief that remedies exist for all suffering, including that which results from remedies themselves. After reasonable efforts at identifying, adjusting to, and reducing barriers to care have failed, confrontation may be all that can dislodge these patients from problematic patterns of medical engagement.21Quill T.E. Recognizing and adjusting to barriers in doctor-patient communication.Ann Intern Med. 1989; 111: 51-57Crossref PubMed Scopus (120) Google Scholar Avoiding conflict and attempting to meet unreasonable demands leave one in the position of "captive healer."4Draper H. Sorell T. Patients' responsibilities in medical ethics.Bioethics. 2002; 16: 335-352Crossref PubMed Scopus (91) Google Scholar Confrontation could be construed as a violation of patient autonomy, which has risen to become a "'default' principle" in contemporary medical ethics.22Wolpe P.R. The rise of autonomy in American bioethics: a sociological view.in: DeVries R. Subedi J. Bioethics and Society: Constructing the Ethical Enterprise. Prentice Hall, Upper Saddle River, NJ1998: 38-59Google Scholar Its ascent relates to the imbalance discussed previously, in which "'rights' now tend to be claimed without any sense of reciprocal obligations."23Stirrat G.M. Gill R. Autonomy in medical ethics after O'Neill.J Med Ethics. 2005; 31: 127-130Crossref PubMed Scopus (119) Google Scholar Patient autonomy is deservedly a core principle of medical practice, but the oft-voiced ideal of simply respecting patients' decisions is dangerously jejune. Complete withdrawal of physicians from patients' value-based decisions can be "a species of moral abandonment."15Pellegrino E.D. Patient and physician autonomy: conflicting rights and obligations in the physician-patient relationship.J Contemp Health Law Policy. 1994; 10 (Spring): 47-68PubMed Google Scholar A 60-year-old man with coronary artery disease repeatedly presents to the emergency department with worsening chest pain and shortness of breath. Each time, he leaves against medical advice after receiving nitroglycerin and morphine. Sometimes the respect that patients receive is for an adolescent form of autonomy in which they behave freely but are repeatedly medically rescued when predictable adverse consequences ensue. Physicians do not simply allow such patients to suffer and die, but our rationale for confrontation uses a model of autonomy in which competent patients are considered accountable for their decisions.4Draper H. Sorell T. Patients' responsibilities in medical ethics.Bioethics. 2002; 16: 335-352Crossref PubMed Scopus (91) Google Scholar, 23Stirrat G.M. Gill R. Autonomy in medical ethics after O'Neill.J Med Ethics. 2005; 31: 127-130Crossref PubMed Scopus (119) Google Scholar Confrontation by one's physician may be the only permissible disincentive for patients whose self-corrosive decisions come with expectations of accommodation. While the asymmetry of the physician-patient relationship should give one pause when considering confrontation, Draper and Sorell4Draper H. Sorell T. Patients' responsibilities in medical ethics.Bioethics. 2002; 16: 335-352Crossref PubMed Scopus (91) Google Scholar point out that patients' "relative vulnerability does not confer an inability to do wrong." Kukla24Kukla R. Conscientious autonomy: displacing decisions in health care.Hastings Cent Rep. 2005; 35: 34-44Crossref PubMed Google Scholar encourages physicians to "use the weight of their medical authority and their ability to demand accountability as tools" to address not just discrete patient behaviors but also underlying maladaptive attitudes. While patients do not necessarily choose sickness, physicians choose their profession. The patient's obligations to the physician are therefore more limited than vice versa. Still, a good-faith physician-patient relationship occurs between 2 autonomous parties with mutual goals. As such, the physician can legitimately have certain expectations of the patient. These might include respect, truthfulness, and adherence to a negotiated care plan.25Pellegrino E.D. Thomasma D.C. For the Patient's Good: The Restoration of Beneficence in Health Care. Oxford University Press, New York, NY1988Google Scholar A truly honest relationship includes respectful confrontation when 1 party finds himself or herself bearing an undue burden in a failing enterprise. A physician is, or ought to be, a caring stakeholder in the patient's health. When other avenues of intervention have been exhausted with a patient whose health is deteriorating through his or her own action or inaction, one should care enough to confront. Articulating this attitude might even soften the blow (eg, "If I didn't care, I wouldn't have this uncomfortable talk with you"). Still, a blow is being struck, and we recognize that our terminology and proposals might seem overly aggressive. However, at the point that confrontation becomes a viable option, a superficially inoffensive relationship between physician and patient is thin cover for the fact that the latter party's health is deteriorating. Harm occurs through passivity as well as through action. Fairness is a vital 2-way concern in confrontation. One must think in advance about whether a patient from a disenfranchised group has been given adequate opportunities to control the variables for which the physician is considering holding him or her accountable.26Minkler M. Personal responsibility for health: contexts and controversies.in: Callahan D. Promoting Healthy Behavior: How Much Freedom? Whose Responsibility? Georgetown University Press, Washington, DC2000: 1-22Google Scholar Reciprocally, the uncomfortable question must be posed about whether a recalcitrant patient is unfairly consuming finite resources. Distributive justice cannot be the primary guiding principle of clinical medicine, but the individual actions of many physicians come at a price for the patients who were left out of decisions in which confrontation of unreasonable demands should have occured.27Rego G. Brandão C. Melo H. Nunes R. Distributive justice and the introduction of generic medicines.Health Care Anal. 2002; 10: 221-229Crossref PubMed Scopus (4) Google Scholar Fairness (to the physician and society) is a delicate but not inappropriate issue to put before some patients. In the context of general medicine, countertransference is most practically defined as the entirety of the physician's reactions and responses to the patient. Whether attributed to countertransference or to ordinary human emotion, physicians sometimes assume that frustration or anger with patients is to be squelched in the interest of medical remove and concern. However, the idea is not that one's responses—positive or negative—are not to be acted on a priori but that they are to be critically evaluated in the full context of the total relationship with the patient; then one can decide whether and how to mobilize them responsibly. While cavalier self-gratification is prohibited, reflexive avoidance of one's feelings and reactions cuts off potentially helpful courses of clinical action and risks unwittingly harmful ones. Winnicott28Winnicott D.W. Through Paediatrics to Psycho-analysis: Collected Papers. Brunner-Routledge, New York, NY1992Google Scholar advises that "however much he [a physician] loves his patients he cannot avoid hating them and fearing them, and the better he knows this the less will hate and fear be the motives determining what he does to his patients." A 38-year-old man with systemic lupus erythematosus is inconsistent in keeping his appointments. When present, he verbally abuses staff and refuses phlebotomy unless his stated needs are met to the letter. At these times, he sometimes adds, "If I end up on dialysis, it will be your fault." On the one hand, this patient's unacceptable affect must not be met in kind. On the other hand, disregarding the physician's legitimate displeasure carries its own risks. Automatic resort to Oslerian equanimity or patient-centered solicitousness in the face of a frontal assault is often ineffective. When the physician's preferences and feelings are taboo and "the customer is always right," imbalanced scales of privileges and duties are tipped even more unfavorably. In the foregoing case, one might address the absurdity and medically constraining nature of the patient's behavior and communicate both an interest in working with him and a willingness to cease doing so. That the confrontation might be pointed should be reason neither to pursue nor to avoid it. Sometimes a powerful emotion is induced by the behavior of a patient experiencing that same feeling. Known to psychiatrists as projective identification, this psychological mechanism is a primitive way for patients to handle intolerable emotions. Unfortunately, the incendiary nature of the feelings involved renders the physician liable to act on them before realizing what is transpiring. Yet, if the physician completely disavows these feelings, patients sometimes escalate their seemingly irrational behavior. The challenge and opportunity here is to tolerate the unpleasant emotions, examine them from the perspective of the patient's experience, and help the patient to identify, understand, and manage his or her own affective state.29Gabbard G.O. Psychodynamic Psychiatry in Clinical Practice.4th ed. American Psychiatric Publishing, Washington, DC2005Google Scholar Strategic and mature expression of frustration by the physician can sometimes be useful and gratifying to both parties. Gratification can cloud judgment, and both countertransference and projective identification involve complex feelings and motives. We therefore advise self-assessment in real time and periodic peer consultation to ensure that these factors are weighed responsibly before, during, and after patient confrontation. Confrontation is a legitimate option in physician-patient relationships that suffer from an imbalance between each party's privileges and obligations. Intended as a starting point for discussion, our proposals focus more on principles than on specific techniques of confrontation. Also, we recognize that some confronted patients will simply find other physicians to do what they want. Hopefully, a dialogue about this topic will lead to more generalized and refined practice patterns such that patients hear a consistent message from the medical community at large. Fighting the good fight enhances the practice of a brand of patient-centered medicine that values honesty, mutual accountability, and social responsibility.