Love, hate and commitment

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“How do you feel about your patients, doctor Tomlinson?”

I was being intereviewed by a medical student about the resiliance of doctors working in challenging areas.When she introduced her project she talked about the effect that patients have on their doctors and how hard it can be for doctors to cope with patients who repeatedly present with problems the doctor cannot solve. The effects that patients have on their doctors has been examined most famously in detail by psychiatrist Michael Balint. The impact can be profound, provoking feelings not just of frustration, confusion and exhaustion, but even hate. The 1978 paper, Taking Care of the Hateful Patient examines this rarely acknowledged and often denied emotion. In seeking an explanation, the author divided patients into ‘dependent clingers’, ‘entitled demanders’, ‘manipulative help rejecters’ and ‘self-destructive deniers’.

Negative feelings about medical and surgical patients constitute important clinical data about the patient’s psychology. When the patient creates in the doctor feelings that are disowned or denied, errors in diagnosis and treatment are more likely to occur. Disavowal of hateful feelings requires less effort than bearing them. But such disavowal wastes clinical data that may be helpful in treating the “hateful patient.”

Since Balint’s time, many GPs have met in small Balint groups to discuss their most difficult patients. Eleven years since my GP training post I still meet every 3 weeks with members of the same group I attended as a trainee. As the years have passed, we have all become increasingly concerned with the relationships we have with our patients and we have all developed deep and enduring interests in what are sometimes called heartsink patients and heartsink problems like medically unexplained symptoms, chronic pain, fatigue, addiction, loneliness, and so on. This deep and serious engagement with the patients and conditions that challenge us most of all was beautifully described by John Berger in his book, A Fortunate Man, ‘still the most important book about general practice ever written’. 

We were all like the central character, Dr Sassall,

… thriving on medical emergencies, impatient with non-specific symptoms and the absence of clear-cut physical diagnoses and underlying pathology. He moves gradually towards an empathic listening and companionship with his patients and their families, striving to recognise who they are and the meaning of their illness to them. Physical and psychological intimacy is central to his relationship to his patients.

We are trained in detachment and objectivity, and are afraid of intimacy. We are afraid of our patients being dependent on us, or becoming dependent ourselves on our patients. We are afraid of crossing professional boundaries, of becoming over-involved, of being paternalistic or meddling. Part of this fear is a fear of vulnerability and a denial that as social beings, we actually do depend on each other.  If it is hard for us doctors to come to terms with actually hating our patients, it is even harder to admit that we need our patients to love, respect, care about and depend on us.

My reply to Rebecca, the medical student who asked how I felt about my patients was to say, “I love my patients”. We both paused, allowing a moment for this to sink in. “Really?” she asked.

I don’t think ‘love’ is too strong a word. Love entails risk; we need to be prepared to withhold judgement and care unconditionally, we care for our patients whether they take their medication, come to their appointments, drink, smoke, binge, self-harm, take drugs, disregard our advice and argue with us. This doesn’t mean that we are without any boundaries, indeed many of our most challenging patients have suffered from a lack of boundaries, or a wildly inconsistent enforcement of boundaries, particularly in childhood, but it does mean that we are committed to working with them. For these patients most of all, continuity of care matters.

Medicine reflects our ‘post-political, liberal-permissive society’ in which commitment is social deviance. This is why the NHS reforms force us to choose a good GP or hospital, because, we are told, through a steady media tide of bad NHS news stories, we can trust none of them. A sustained therapeutic relationship is counter-neoliberal-cultural, so long term NHS staff contracts are being torn up and GP surgeries are being franchised to Virgin and other multinationals, undermining the possibility of building up long-term relationships with care givers. The social determinants of health such as poverty, poor diet, smoking, addiction, lack of education, fresh air and exercise are being re-framed as ‘lifestyle choices’ and there are growing calls from think tanks and politicians for patients to take more responsibility and do more self care.

The relationship between doctors and patients is a challenge to this contemporary orthodoxy and fundamentally reflects how we all relate to eachother. To engage with the endless struggle that challenging relationships demand is harder than withdrawing and calling for patients to take more responsibility or giving up altogether. Without the insights of Balint and the support of our peers, the challenges of intimacy and care can be too much to bear. Dr Sassall, the central character in A Fortunate Man, eventually committed suicide. If we are to build the resilience necessary to care deeply, we need to come to terms with the emotions we are afraid of and put kindness, love and compassion at the heart of healthcare,

It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat. Theodore Roosevelt. Man in the Arena.

The Logic of Care and the Problem of Patient Choice. Mol

You May! Slavoj Žižek writes about the Post-Modern Superego

Resilience in Doctors who work in Challenging Areas. A Qualitive Study

12 responses to “Love, hate and commitment

  1. I am a health care professional but not a GP and I especially love the patients* who “drink, smoke, binge, self-harm, take drugs, disregard our advice and argue with us” because they are more like me and I am human!
    (*patients, not clients or service-users. A patient is for life, not just for an ‘episode of care’)

  2. Thank you for coming to Barts to speak to us yesterday. I am incredibly heartened by your honesty and commitment to your patients. This is medicine as I want to (and already try to) practice it. It takes courage, perseverance and self-awareness, and it is all too easy, as a student, to feel out in the wilderness.
    I had a discussion a few months ago with a fellow student about what, for us, is at the heart of medicine and we both agreed that the doctor-patient relationship must evolve from a recognition of our common humanity. I do not think it is possible to understand what is ‘going on’ with our patients if we approach them with a sense of ‘separated-ness’ and keep them at arm’s length. We are taught to be approach medicine scientifically and objectively; to ‘not get too involved’, lest our clinical judgment become clouded. Of course boundaries are important but surely it is possible to maintain these and still care deeply for our patients. It is hugely encouraging for the student who constantly questions ‘what sort of doctor am I becoming’ to find that, in fact, it is indeed possible to be professional, caring and involved.

  3. I’m dismayed that “heartsink patient” is actually an accepted term! I don’t feel that it is helpful. It makes me wary of seeing a doctor at all knowing that this is what they may think of me. No-one wants to be thought of like that, do they? That someones heart will sink when they see your name – it’s horrible!

    (by the way I’ve done nothing wrong and I very rarely ask for any help. I just have a severe illness that isn’t well understood (and has no effective treaments) and it is this that makes me a “heartsink”)

    Your blogs are always interesting 🙂

  4. JT – an excellent, courageous post. Curious that your last, also excellent, post on shame has many comments, while this has so few. Perhaps shame is a ‘white taboo’, while owning up to what we really feel about patients is still a ‘dark taboo’. Too much by way of a comment to post here, so Dr No has posted his thoughts here.

    Laura – heartsink is very much an accepted term, if only because it describes so well the emotional reaction of the doctor. Whether it says more about the doctor or the patient is a very good question, but it is better all round if the very real emotional reaction is at least acknowledged (and ‘owned’), and an honest (as JT does here) attempt made to deal with it. The alternative is to deny it, and we all know where denial can lead. Splitting, projection and all manner of unpleasantries are just round the corner.

    That said, Dr No fully appreciates it is personally very discomforting to know that one is a heartsink patient.

  5. As a patient, I am so grateful that there are doctors who are committed to their patients, even when they are angry and frustrated. Consistency can be so difficult to find in the NHS, when consultants are often not in clinic, ‘seeing your GP’ may indicate seeing a duty doctor at the large inner city practice, and where vital information can get lost in the many conversations with juniors, students and locums. I don’t smoke, drink to excess, binge, self-harm, or take drugs other than those prescribed to me. I do, however have a complex and chronic illness, and therefore recognise that I may well be a heartsink patient. I am hugely grateful to my faithful doctors (I call them my Dream Team) who approach me from a point of shared humanity, and continually encourage me that, though there are some problems with which I just have to learn to live, we (not just them; not just me) will continue to try to improve my quality of life, avoiding unnecessary interventions and admissions, and reducing those symptoms that can be reduced without unacceptable side-effects. I often disagree with my doctors, which I believe shows that I am committed to getting the treatment plan right. I will continue to research, consider and debate. I hope that I am a better patient for this, and that my doctors are better doctors! I am so grateful especially to the doctors that step out of the mentality of ‘them and us’ – those doctors who know why it took me so long to agree to a particular admission because they would have tried all the same things first, those who don’t suggest unnecessary tests or appointments, and those who fight my corner when no-one else seems to be listening. I am so, so grateful to the F2 who came back to see me after a ward round, in which the consultant had told me that there was no way that I could go home with IV antibiotics (despite being afebrile and asymptomatic for several days, and despite normally managing my own IV line at home, including administering medications and changing dressings), to say that he understood why I had been argumentative (tickets to see Daniel Barenboim at the Royal Albert Hall, among my reasons). He had contacted the IV team and microbiology to involve them in the discussion about whether I could go home to finish the course of IV Ertapenem, and I was eventually allowed to go home on treatment. I understand that doesn’t mean that I’m always right (or even that I was right in that case), but I’m grateful to be allowed to express my views, and was so grateful for the F2 who stepped out of line, despite knowing that his consultant would be cross. From the bottom of my (only slightly malfunctioning) heart, I thank you for encouraging young doctors to engage and connect with patients. We may not always be able to express it, but we appreciate it.

  6. Regarding “Heartsink patients”, why do you choose to locate what is essentially your own emotional problem as a problem within the patient? Why label the patient because of your own psychological issues?

    Why don’t we ever hear from doctors about ‘heartsink doctors’? Are we to assume that all doctors are objective, neutral blank slates with no psychological imperfections or psychological needs of their own?

    Could it be that the negative feelings a doctor feels might actually have more to say about the doctor’s psyche than the patient’s psyche? Could it be that the doctor expects to be flattered and worshipped by patients, or the doctor expects to be seen as the ‘expert’ or the doctor is a narcissist who wants his/her ego needs met by the patient? Or perhaps the doctor has a God complex?

    If a patient presents a problem that you can’t solve, if a patient doesn’t flatter you or massage your ego, if a patient challenges your medical ‘authority’ or knowledge, if a patient highlights the fact that modern medicine is extremely limited in what it can do for many diseases, if a patient presents a problem that is currently poorly defined and poorly understood by medical science, if a patient knows more about their condition than you do, if a patient presents a problem that leaves you feeling impotent and incapable of helping, then is the discomfort you feel the patient’s problem or is it yours?

    Any doctor who thinks of patients as ‘heartsink patients’ is a doctor to be wary of. Sick patients have enough to deal with without having to manage a doctor’s ego. Rather than joining Balint groups, wouldn’t it be more appropriate for doctors to join psychotherapy groups as patients themselves in order to manage their own personal issues rather than expect sick patients (who are after all paying indirectly for a service) to meet their unmet psychological needs?

    • A Balint group is a psychotherapy group designed to do exactly what you suggest.
      The term ‘heartsink’ patient is discussed in detail in the hyperlinked articles. The inadequacy and other negative emotions felt by doctors (and other carers/ teachers etc) is very much related to feeling unable to help people whose problems or demands fall outside our skills or resources. Very often patients hearts sink when they meet their doctors, and whilst I could write a blog about it, I know there are a lot of patients writing about it already. Whilst I could write about ‘heartsink doctors’ , it might seem a bit contrived as I have far more experience of being a doctor, than a patient.
      Examining our need to be treated as Gods, is as Dr No suggests, a ‘dark taboo’, very rarely acknowledged, but certainly within the remit of a Balint group.
      Thanks for your thoughts.

  7. This reminds me of Julian Tudor-Hart talking about caring for patients and making them feel that they are ‘valuable people’. http://www.youtube.com/watch?v=oJm2laOGX00

    That’s a big compliment in my book 🙂

  8. Thanks for talking about this. My personal approach/ view is more in line with dr No’s (linked on your twitter feed). However, the highlighting of compassionate doctor patient interaction that you are leading is an important antidote to the focus on finance, health policy and self care that is currently dominating health care.

  9. Thanks for your response (above). However, I’m still not sure why you uncritically accept and use the label “heartsink patient”? Should all labels that appear historically in the medical literature be accepted uncritically?

    Rather than label a patient because of the negative emotions that you (yourself) feel as a result of not being able to help the patient (thereby locating the problem in the patient rather than owning your own emotions and insecurities), why not acknowledge your own emotions and reconsider your own self-concept and relabel yourself?

    For example, instead of saying “I’m about to see that “heartsink patient” Mr Jones whose back pain I can’t cure”, why not think “I am a doctor who has trouble dealing with the inadequacy and impotency I feel when faced with Mr Jones’s back pain which I can’t cure. Perhaps Mr Jones’ incurable problem challenges my self-image as a God-like entity, perhaps Mr Jones’ problem is highlighting the limits of modern medicine, perhaps Mr Jones’ poor response to my treatment isn’t flattering me in the way that I’d like so it’s easier on my ego to label Mr Jones a “heartsink” than it is to seek help for my insecurities etc.”

    Also I would argue that a Balint group is not the same as an ordinary psychotherapeutic group. To take part in a psychotherapeutic group where your role is that of a patient seeking help would be different to taking part in a work-related psychotherapeutic group where your role is a doctor seeking help from colleagues.

    Perhaps if doctors spent more time in the patient role, it would be less easy for them to label patients and their problems in the way that you do.

    • My experience of Balint groups is that they do everything you would want them to do, including and especially challenging the labels we use, the roles we assume, the balance of power and much more. I’m sorry if this didn’t come across clearly.

  10. Jobo

    An excellent doctor recommended I read Balint and I would recommend it to you – quite pricey yet an invaluable book. (Available from Amazon.)

    Doctors are human too and as fallible as their patients and as an ‘other’ health ‘professional’ – a nurse – it is true that we cannot screen out negative feelings about particular patients for that is who we are (human) – but we must examine why we feel that way – which may be our own frustration in being unable to offer practical help, an awareness of our own limitations, something in that patient that stirs a negative emotion in us, etc. – and if possible sort out OUR own problem as it is indeed OUR problem and not the patients.

    Through Balint and the excellent doctor who recommended I read him I do tend to think (more) often about doctor-patient relationships and as a patient have been able to put my thoughts into words – and indeed a few are in the pipeline.

    Last year I wrote a post re Heartsink Doctors http://hypercryptical.blogspot.co.uk/search/label/heartsink%20doctors which you may find resonates and recently http://hypercryptical.blogspot.co.uk/2012/11/its-not-cardiac.html dealing with communication breakdowns in information sharing between doctor and patient. It is my attempt to plug the gaping hole in patient perspective in the doctor-patient relationship.

    Good honest doctors who are prepared to bare their soul on the internet are a rare breed and Dr. Tomlinson is to be commended for doing so as is the good Dr. No who I recommend you vist.

    Anna :o]

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