Physicians, heal thy troubled patient-clinician relationships

Caleb Zimmerschied , Contributing News Writer

Some patients are a delight for physicians to work with. Such patients are respectful, show up for appointments, ask good questions and do their best to follow a mutually agreed upon care plan.

But then some patients can be just the opposite. They are, as the pejorative term of art goes, “difficult.” What obligations do physicians have to so-called difficult patients, and what can they do to build the therapeutic capacity of their relationship?

This month’s AMA Journal of Ethics® features many perspectives on how patient-physician relationships can go sour, including the role that clinicians play in challenging relationships with patients. The issue covers factors that shape patient-clinician relationships, the obligation physicians have to foster positive relationships with patients, and ways to prevent negative first impressions and repair troubled relationships.

Contributing writers also ask questions about assumptions patients and clinicians can have about each other, the moral psychology of nurturing healthy interactions with patients, and approaches to take when a colleague makes an unwarranted medical request because a patient is part of his or her family.

Take a moment to consider this question: A colleague asks a primary care physician to order a medically unwarranted MRI for her son. How should the physician respond?

  • Order the MRI out of courtesy.
  • Ask the colleague to explain why she wants the MRI.
  • Agree to do an MRI if the symptoms worsen.
  • Tell the colleague “no.”

Give your answer and find responses to this question in the April issue of the AMA Journal of Ethics, which explores moral psychology and “difficult” clinician-patient relationships.

“Roles of Physicians and Health Care Systems in ‘Difficult’ Clinical Encounters. “Difficult” patient-physician encounters are two-way streets. This article discusses common issues physicians face, such as burnout, limited psychosocial training and communication skills development, and how to prevent these factors from fostering negative patient interactions. Mitigation methods include peer discussion groups, a greater focus on mental health in the workplace and an emphasis on communication skills in medical training.

How Should Physicians Respond When Patients Distrust Them Because of Their Gender?Some patients request physicians of the same gender, and there are  reasons why this can be beneficial. However, this article discusses how gender preferences can also present challenges. When are such requests appropriate, when do they interfere with patients’ treatment and how should physicians respond to them?

Do Physicians Have an Ethical Duty to Repair Relationships with So-Called ‘Difficult’ Patients? This essay, which won the 2016 AMA Journal of Ethics annual Conley Contest, makes the case that being a physician comes with the responsibility to repair a damaged patient-physician relationship. It argues that physicians’ and patients’ attitudes affect patients’ health, and that because physicians have more power to repair a broken or troubled relationship, they have a greater responsibility to do so. The essay also discusses how pain inherently makes a patient more vulnerable, and why a healthy patient-physician exchange should be a foundation of good practice.

“How Should Clinicians Respond to Medical Requests from Clinician Family Members of Patients?” Requests from colleagues are commonplace, but they can get tricky when a patient is a relative of a colleague and the request is not made by the patient’s attending physician. In addition to raising ethical questions, such as those related to patient autonomy, these requests can strain relationships among friends, patients and professionals. This article discusses how to address a colleague’s concerns without compromising ethical and medical judgment.

In this journal’s April podcast, issue editor and third-year medical student James Aluri interviews Autumn Fiester, PhD, about “Rethinking So-Called ‘Difficult’ Patients.” Dr. Fiester is assistant chair for education and training in the Division of Medical Ethics at the University of Pennsylvania’s Perelman School of Medicine. She discusses strategies for easing tensions in difficult patient-clinician relationships.

The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. Submit a manuscript for publication. The journal also invites original photographs, graphics, cartoons, drawings and paintings that explore the ethical dimensions of health or health care.

Upcoming issues of the AMA Journal of Ethics will focus on ethics in mental health and oncology, and moral distress and medicine. Sign up to receive email alerts when new issues are published.