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The Difficult Patient in Everyday Medical Practice
The Difficult Patient in Everyday Medical Practice WILLIAM A. STEIGER, M.D., F.A.C.P.* HERMAN HIRSH, M.D.**
Every physician has had the frustrating, even exasperating experience of trying to help a patient and finding it difficult to do so. While the patient who fails to respond to the therapeutic efforts of the physician may be defined as the difficult patient, it is evident that there are, as well, certain features of the physician, with all of his knowledge and training, which may contribute to the problem. One physician may find a given patient difficult, another may not. It is more correct then to speak of the difficult doctor-patient relationship rather than the difficult patient. The subsequent discussion of this subject will encompass both sides of this relationship. Viewing the relationship between doctor and patient in simple transactional terms,! the patient's symptoms and complaints may be designated as "offers" and the physician's side of the transaction as "responses." The offers of the difficult patient will be described under ten different headings representing the majority of difficult patients encountered in everyday medical practice. THE PATIENTS' OFFERS AND HOW THEY ARE MADE
The Multiple Complainer These patients are trying to communicate through their symptoms an urgent request to be taken care of and given magic release from pain or discomfort by the doctor. The plea for help may be due to underlying anxiety or depression which is being expressed somatically. A 29 year old machinist complained of difficulty in breathing and heaviness
* Professor **
of Clinical Medicine and Chairman of the Department of Community Medicine, Temple University School of Medicine Associate in Psychiatry, Temple University School of Medicine
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in his chest which he attributed to the cutting oils used on the lathes at work. He had left several good jobs in New England because of such fumes. Since coming to Philadelphia he was bothered by traffic fumes; he had pains in his shoulders and back, vertex headaches and a sensation which he described as "a loose ball rolling around in my head." As he detailed his symptoms he spoke in bursts using intellectual terms indicative of great concern and much underlying tension. However, when asked if he felt nervous, he promptly denied it although admitting he was "on edge." He then went back to repeating his complaints, adding on a few more. The doctor's interest in his symptoms led into more detailed explanations and various rationalizations about their incapacitating effect. Initial attempts to probe the meaning of being "on edge" were resisted, but slowly the tense young man told about the unsatisfactory state of his marriage, loss of interest in sexual activities and his sensitivity to remarks made by his fellow employees. As he "opened up" about his psychological problems, the multiple symptomatology faded into the background.
Many unrealistic statements indicated this patient's fears of being harmed by the poisonous fumes, derided by his co-workers and exploited by bosses at each job. Anger which he felt toward his wife and children was being displaced to his work situation, reversed and felt as a hostile attack upon himself. This mechanism, known as projection, suggested a paranoid psychopathological process in this young man. Pertinent here also is the interview technique in which this obstruction to understanding can be overcome. This will be enlarged upon in the third section of this paper.
The Silent or Uninformative Patient The patient's offers may be limited to a few words or there may be total silence. The physician may be stumped from the outset and at a loss to know how to proceed. A senior medical student was observed through closed circuit television as he interviewed a 38 year old woman who had come to the Comprehensive Medicine Clinic with a note from her family doctor requesting a protein-bound iodine test and other studies. All attempts to obtain the reasons for these studies were met by a silent shrug of the shoulders. During a brief consultation with the supervising physician it was suggested to the student that such interrogations were useless unless we could understand her reluctance to talk. When the student said he felt angry at the patient for her nonresponsiveness, the supervisor suggested that this might be the way the patient felt. On resuming the interview the student confronted the patient with her silence and wondered aloud what this might mean. The patient squirmed, kicked out with one of her feet as her facial expression hardened. The doctor then said, "I get the feeling that you're angry," and the patient responded, "You're darn right I am," and went on to speak of her feelings about being sent to the clinic by her doctor, about the 1 hour wait to see the clinic doctor, etc. The student concurred with the patient's grievances, then proceeded through an adequate medical interview with no further difficulty.
Silence or poverty or verbal expression may have varying significance; the meaning can be determined only by such confrontations and then careful observation of and listening to the response of the patient.
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The Verbose or Tangential Talker
The bane of many physicians' lives is the talkative patient who never seems to arrive at any goal. Recently such a patient was sent for a psychiatric opmlOn. The referring physician remarked cryptically that the patient and her husband would explain the problem. Each time the husband started to narrate a story about their 5 year old child's death following intestinal resection, the patient interrupted. A story of depression and a suicidal gesture by the patient was related slowly. The wife continued to interrupt with explanations, conversations in full detail about what the doctor said, what she said to the doctor, etc. The psychiatrist sensed that the patient felt very guilty about the tragic incident and that her verbosity was an attempt to explain away her guilt. As the time allotted for the interview was rapidly passing the psychiatrist said to the patient, "You must feel very guilty about your son's death." She stopped talking and started to cry. The husband then completed the story and appropriate recommendations could be made.
The verbose or tangential patient often is talking away from something. The physician should attempt to understand why the patient is doing this rather than to follow the content of the verbalization. If the patient seems blithe or overly cheerful one should wonder whether he is covering up sadness. At times some embarrassing or frightening symptom may be present and the patient is attempting to hide anxiety or shame by denial. When the stream of ideation emerges as though there is pressure behind it we must consider the possibility of a manic depressive psychosis. When the ideas are bizarre or make no sense at all, a thought disorder indicative of schizophrenia may be present. The Blamer or Scapegoater
Another patient who may pose a problem is the one who recites symptoms, discomforts or details of an illness and then proceeds to attribute their misfortune to someone who is closely related. Husbands blame wives and vice versa. Parents blame children, and this too may be reversed. In-laws are especially prone to offer each other as culprits to thc family doctor. Often the illness may be exaggerated in order to justify care, concern or even intercession by the family doctor on the patient's behalf. The mote in the other one's eye is often the beam in the patient's eye. How common is the suffering woman patient who has gastrointestinal symptoms, headaches, elevated blood pressure and obesity as her presenting symptoms and then proceeds to offer as the cause of her troubles an alcoholic spouse. Acceptance of this manifest idea may lead to an impasse unless the physician is able to cope successfully with the spouse's drinking. Treating the patient's symptoms, likewise, is a limited and often fruitless goal. The physician should attempt to view objectively the interpersonal relationship which the patient describes and to recognize that in such interaction "it takes two to tango." If the husband's drinking makes the wife ill, what does the wife do (or not do) to encourage her husband to resort to drink?
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This kind of situation was dramatically exemplified in a tense, thin woman, who feared having another nervous breakdown (for which she had received a course of electroshock therapy two years previously). The cause of her recent anxiety was the drinking of a few beers by her husband on a previous weekend after neglecting to take his daily Antabuse for 3 days. The patient's recent emotional status had been excellent until 3 weeks before this, when she awakened very upset by a dream. "1 dreamed that my husband killed my brother, Jay, and hacked him up in pieces and put all of him into a trash can." Shortly after relating this dream the patient stopped, thought for a moment and said, "1 guess I'm responsible for him starting to drink again-I've been nagging at him a lot." This form of understanding can be obtained if the physician is able to focus on the relationship rather than on the patient's complaints, and then, nonjudgmentally explore with the patient what part each is playing in perpetuating the neurotic marital interaction. The dream portrayed the patient's own past anger toward her younger brother as it was carried out dramatically by the husband. After having the dream she nagged and provoked her husband in real life and he, as in the past, resorted to drink rather than lose control of the rage which she aroused in him. The central problem in the home was their 21 year old son, who had a severe case of cystic acne, was unable to hold a job and spent most of his time at home manipulating both parents into blaming each other for his indolence. These facts were revealed in the session as the basis for the insight which her statement implied.
The Masochistic Patient Of special difficulty is the perverse twist in human behavior that manifests itself in seeming gratification through suffering mental or physical pain. Examples are the incomprehensible surgical addict, the woman who divorces one brutal man only to marry another one, and the man who is described in the following clinical vignette. This 42 year old refugee from the Nazi holocaust had escaped from Poland in 1939. After spending the war years as a slave laborer in Siberia and along thc Mongolian border of Russia he found his way to the United States from a displaced person's camp in 1946 when he was 26 years old. He married, quickly became fluent in English, and became a salesman of electrical appliances. When 38 he suffered a coronary thrombosis while exercising vigorously at a country club. Six weeks later (against his cardiologist's orders) he again exerted himself dancing a polka. During his second hospital stay it was necessary to threaten to tie him to the bed to make him rest after his second coronary attack. He denied that there was anything amiss with him, and was eager to prove his strength to anyone who would listen. In each of the succeeding 2 years he again suffered occlusions of his coronary vessels, and finally was referred to a psychiatrist who had seen his wife in brief psychotherapy. She complained bitterly about her husband's impotence and lack of regard for her needs for affection. During his sessions with the psychiatrist the husband acknowledged a neurotic wish and need to prove himself indestructible; his attitude masked his guilt about abandoning his parents to the Germans at the outbreak of the war. Actually this man was driving himself to his death. The masochistic patient may best be dealt with by his own persona)
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physician if a firm order is issued countermanding the self-destructive behavior. At times a threat to discontinue treatment and refusal to accept future responsibility for the patient's well-being may be in order.
The Red Herring (By-the-Way Disease) Performing a medical examination for a stated complaint only to find that the symptoms described are not the real reason for the patient's visit can be frustrating. 'Ve have called this phenomenon the "red herring" complaint, since it is offered as a rationalization to obtain the attention of the physician by many people who think they must have a physical symptom at; a calling card. Dr. Scott of Edinburgh considers patients of this sort to have "by-the-way diseases," in which the real reason for the patient's presence emerges with the phrase "by the way, Doctor." For instance, a woman had undergone a complete history and physical examination for some vague gastrointestinal symptoms. As the doctor summarized his findings and management, shc broke in with the question, "What is schizophrenia?" The doctor was takcn aback and wondered why she should ask such a seemingly irrelevant question. She then took up the next 15 minutes talking about her son, who had been acting strangely. After this issue emerged, the patient forgot about the "offers" which she had made in the form of symptoms as her concern about her son came to the fore.
The Hysterical or Dissociated Patient A distressing experience for most physicians is the patient who exhibits wild, uncontrollable behavior or lapses into a sudden state of detachment or trance as the result of overwhelming anxiety. This occurrence may be comprehended easily when its onset takes place in the doctor's office. In other circumstances, when the source of the threatening anxiety is not so apparent, such an incident may give the appearance of an acute emergency and unjust demands may be made for the physician's services. A prompt survey of the surrounding circumstances is in order. Acute anxiety may be precipitated by a threat of harm, a sexual attack or a loss of control by the patient. Epilepsy, acute psychotic behavior and hypoglycemic shock must be considered in the differential diagnostic survey. A previous history of grand or petit mal, tongue biting and loss of sphincter control indicate a convulsive state. Prior bizarre behavior and evidence of an abnormal mental state in the past would incline one to think of a more malignant psychic etiology. Profuse sweating and a history of such incidents consequent to missed meals or use of insulin in a known diabetic lead to the diagnostic probability of hypoglycemia. A recent incident in the Comprehensive Medicine Clinic exemplifies the hysterical patient who may be encountered in any doctor's office. This 24 year old woman became agitated as a senior medical student questioned her about her symptoms. She began to scream, tore at her clothing and tried to run out of the examining room. A consultant was summoned; he quickly appraised the situation and firmly took her by the hands, leading her back into the room. He spoke to her in a calm, reassuring voice yet insisted in a commanding manner that she. regain
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control of herself. Gaining her attention he said, "I know you're scared." The patient stopped struggling, started to cry and nodded confirmation of her fear. She then went on to talk of her apprehension on coming to the clinic that morning; she went on to give her history and undergo the physical examination cooperatively.
The key to managing the hysterical patient is the recognition of anxiety as the cause of the behavior displayed. The frightening thoughts are usually of being hurt or of losing control and hurting someone else. Although the behavior seems purposeless or illogical, it does serve to release or control the release of aggressive or sexual energy. The physician must be firm and gentle and must address his remarks to the fear which the patient is experiencing rather than to react with violence to the sudden display of intemperate behavior. Recognition of the feeling state of the patient has a calmative and reassuring effect.
The Psychotic Patient In 1954 effective psychotropic drugs became available and since then the former mental hospital patient has become the partial responsibility of the general practitioner. Although the patient may receive follow-up care from a clinic or a psychiatrist, when he becomes medically ill he still turns to his family doctor, who must be able to recognize psychotic symptoms and early ego disintegration and particularly to differentiate between biological illness and physical complaints arising on a psychophysiological level as manifestations of intrapsychic tension. The ambulatory schizophrenic who has been released from hospital or who has avoided hospitalization through timely psychiatric care and the use of drugs may need his drug dosage adjusted because of increased stress in his life, intercurrent illness or family pressures. The patient who becomes careless about taking the dosage prescribed is a troublesome problem. Longacting tablets may be substituted so that another member of the household may be present to be sure that they are taken. Familiarity with dosage and the toxic and side effects of the phenothiazines and the antidepressant group of drugs will enhance the family doctor's skill in guiding the former mental hospital patient. The families of these patients often turn to their doctor for support and advice in coping with the many problems of readjustment. The physician's understanding of the familial and cultural aspects of severe mental illness will also be useful. The cardinal signs of the most common psychotic disorder, schizophrenia, are withdrawal from reality, disordered thinking, inappropriate or decreased emotional expression and ambivalence. Recently a 32 year old man gave a history of repeated loss of jobs and some vague physical symptoms. He stated that he had no interpersonal relationships except with a brother who supported him. He exhibited an untidy appearance and in an unfeeling and intellectual manner expressed a series of ideas which were scattered and disorganized. He had some thoughts about being unable to get along with people and gave evidence that he lived in a world of his own. He related a shocking story of having been to several doctors with complaints referable to his nose, throat and anus. A submucous resection, a rhinoplasty and 2 rectal operations
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had been done with no change in his symptoms. This man's symptoms and behavior were classically schizophrenic.
Before elective surgical procedures are advised or performed it is wise to appraise carefully the personality of the patient. If there is any doubt about the real need for the procedure when the patient's motivation seems bizarre or inappropriate, psychiatric consultation should be considered. The Severely Depressed Patient
Depression is a medical disorder commonly overlooked or misdiagnosed. It should be thought of in any illness in which fatigue, anorexia, weight loss, insomnia, constipation, and sluggishness on awakening are present. The threat of suicide in depression is ever present whether the depression is reactive to a real loss (of health, body part, function or possession) or the so-called endogenous depression of constitutional or hereditary origin. As encountered in a medical practice, a suicidal intent may be communicated to the family doctor by the patient in subtle ways. Expressions of hopelessness, extreme fatigue and self recrimination associated with the depressive triad of anorexia, constipation and early morning insomnia should prompt the physician to ask a series of graduated questions somewhat as follows: (1) Do you feel very unhappy? (2) Do you feel as if the joy is gone out of life? (3) How much have you thought of doing harm to yourself? (4) Are you considering ending your life? (5) How do you plan to do it? Affirmative answers to the first four questions indicate a serious suicidal intent whether or not the patient can spell out the means he has considered using to end his life. Tentative positive answers should not be taken lightly and psychiatric advice is indicated. The patient who is not intending suicide will answer in the negative to questions 3 and 4, but if the responses are vague, evasive, or silent we must consider the patient suicidal until proved otherwise. The restless or agitated depressed paticnt is more capable of ending his life than the apathetic, slow moving or rctarded one. A sudden improvement in a severely depressed patient may forebode a serious suicidal attempt, for the person may have settled on a "way out" of his misery. The quantity of energy which such a patient displays to the observing physician is a good measure of the possibility of a suicidal attempt when the intent exists. Constant (24 hours) observation by someone in attendance is advisable until the patient is hospitalized. The Hostile, Arrogant or Critical Patient
Difficult as this type may appear, the physician may readily manage such a patient if he remembers two cardinal rules: 1. The outward attitude usually represents an armor or veneer which the patient uses to cover up his fear of being hurt or rejected. The patientoften operates on the principle that the best defense is to be on the offensive. 2. The unpleasant hostile or carping exterior is not personally in-
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tended for the physician. Rather it represents a general regressive attitude about being needy, weak or sick. The hostile, defiant or critical patient may be exemplified in a representative vignette such as that of the hysterical patient mentioned earlier. Other examples are patients who verbally assault the physician about having to wait, about the physician's age (too old or too young), or about the anticipated expense of treatment. Such people are best handled by recognizing their anger and encouraging them to speak about their feelings. By accepting their remarks without remonstration the physician allows a corrective emotional experience. When the steam seems to be running out of the patient's comments the physician can get down to the business at hand. THE DOCTOR'S REACTIONS (RESPONSES) TO THE DIFFICULT PATIENT
In his everyday dealing with patients the physician will encounter reactions within himself which he may recognize in various ways. Fatigue, digestive disorders, palpitations, backache, headache and troubled sleep are some common symptoms which give evidence that the physician may be having difficulty in dealing with patients. In such an instance the physician may modify the old aphorism and say, "Physician, observe thy self."
Doctors Are Human \Ve are not God-like creatures even though some adoring patients regard us such. We too have our frailties, feelings and failings and must acknowledge that patients can frustrate, anger, gratify, appeal sexually or cause disgust and loathing within us. To recognize such feelings, particularly if they interfere with our professional skills or personal integrity, is of utmost importance. To detach ourselves from them requires energy and defensive processes which can be antitherapeutic for the patient and exhausting to the doctor. If wc accept ourselves as human beings we may allow ourselves to feel our reactions and then ask, "Why do I feel this way about this patient?" Very frequently such introspection gives us an understanding of or empathy with the patient which opens up vistas of the patient's feeling states that are of primary importance. Recently a 62 year old physician was under the care of one of the authors for an emotional disturbance associated with parkinsonism which impaired his surgical ability. Following the initial interview with him the author felt very oppressed, his muscles aehed and he became aware of having morbid thoughts. Taking cognizance of his own feelings he realized the intensity of the patient's depression and ordered the required therapy for this man's involutional depressive reaction.
The Apostolic Function of the Physician The personality of the physician, based on his own experiences, philos-
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ophy of life and values, is a powerful influence in his everyday dealings with his patients. What the doctor believes a patient should experience and endure in his illness, even the name of the illness, is often based on some unshakeable conviction held by the physician about his patients. The physician's ability to empathize with any given patient may depend on his social class; thus social class would determine the diagnosis and management. This area has been referred to as the "apostolic function of the physician" and often operates as a constant in medical practice. The rigid, highly moralistic medical practitioner of puritanical background may deal with a young man with a case of gonorrhea quite differently than a physician who has sown his own wild oats in earlier years. The hard working, conscientious doctor who rarely takes a day off will react with indignation to a request for a certificate of disability for a week's absence from work because of a "cold." Our tendency to make our patients believe in and live up to our standards, i.e., to convert them to our way, often backfires or confuses the management of a patient's illness. The Frustrated or Rejected Physician
Emotional stress drains heavily on the energies of the busy physician. Difficult patients play upon his equanimity and tolerance during hectic office hours or while he is making hospital or home rounds. Feelings of frustration and rejection are bound to arise in some of these encounters. At such times the wise physician will pause in his professional chores, briefly introspect and ask himself why he feels as he does at such a time. His feelings may stem from encounters with certain patients, sometimes from two or three who have visited in one office session after which he has felt particularly drained. Scheduling such trying patients on different days may prevent a recurrence. An insightful and effective approach to this problem is to take note of common characteristics of certain patients who are particularly distressing to the physician. He may then avoid such patients or attempt to understand why individuals with these personality traits pose such a problem. A discussion of such difficulty with a trained colleague may be most enlightening. 'The physician may recognize that he has been trying too hard to satisfy an individual patient, to answer all the questions and respond to all the demands made at one visit. Conscientious doctors may feel obliged to hear out such torrents of demands, to appease each of the pleas for help or explain all of the urgent symptoms at one session. Just as psychiatrists regularly set limits when the clock indicates the allotted time has run out, the generalist can terminate the session by firmly and directly stating, "We will have to stop now. Let's go on with this subject next time." 'The occasional patient who rebuffs all the physician's responses may bring about a feeling of rejection in the doctor. In such an instance, direct confrontation of the patient with what he is doing may bring about a
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productive discussion and may clear the air in what can become an otherwise hopeless doctor-patient relationship. Rejection may have many meanings. In the case of a young woman who does not improve with medication there may be a desire for affection and interest, particularly when the patient acts coy and seductive. An older woman may repeatedly rebuff the physician's therapeutic attempts in order to provoke a paternal rage which to her would represent masochistic gratification. Another patient may evoke repeated therapeutic efforts by the conscientious physician to satisfy unmet dependency needs which have existed since childhood and which can never be assuaged. When the physician reviews the record (whether he is one of many physicians who have attempted to help this patient or is the sole respondent to the demands) he may perceive a hidden significant motive running through the series of encounters with the patient. A 29 year old married woman visited her internist every 4 or 6 months with complaints of epigastric pain, nausea after meals, headaches, and restless sleep. After several such experiences the physician suggested a gastrointestinal x-ray series since the patient denied any relief from various medications and slyly hinted that he was incompetent. The initial reaction was one of anger, then rejection; the physician then regained his objectivity and confronted the patient with the pattern of her unremitting symptoms and her visits at regular intervals over the previous 2 years. After a moment's pause the patient's expression changed. She related these visits to her mother's intrusion in her affairs, how she criticized the patient's husband, the way the children were being raised, etc. This process would peak out every few months when this young woman was on the point of exploding at her domineering mother. She then became sick and weak and turned to her doctor (as she had turned to her passive physician father before he died several years earlier). The rejection of the doctor could be equated to rejection of her father, who had used his overdemanding practice as an excuse for not facing up to his wife (and not helping the patient in her early attempts to liberate herself from the controlling mother). With this understanding, the physician began to encourage the patient to stand up to her mother, to ally herself with her husband's previous efforts to curb the mother's intrusions and to recognize her own adequacy as a mother and wife. The patient slowly changed her outlook during the next year and her symptoms subsided.
Overidentification with the Patient The loss of objectivity through overidentification with the patient can eause the physician difficulty. The most effective attitude is one of empathy, a flexible and reversible splitting of the doctor's psyche into an identifying part and an observing part. The function of feeling with the patient (identification) is limited by an observational, reality-oriented aspect (cognition) of the doctor's ego. Too much identification with a decrease or loss of objectivity leads to overinvolvement in the patient's life. The young, earnest tyro is particularly prone to this tendeney, which often leads to embarrassment and ineffectiveness over the long term. At the least, it encourages the patient to exaggerated expectations of the physician, with subsequent disillusionment and disruption of the doctor-patient relationship.
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One of the common manifestations of this type of difficulty is the physician who is carried away by the appeal of an attractive, intelligent young woman whose illness has not evoked sympathy and a kindly response from spouse or family. An inappropriate overinvolvement may ensue in which the physician may take sides with and shower the young woman with care and attention far out of proportion to that given to other patients. Objectivity is lost so that the patient is seen as a maiden in distress or an unhappy child. What ensues depends on the physician's ability to extricate himself and regain his professional status. In general, overidentification should be suspected when the physician finds himself having fantasies or dreaming about a patient.
Intellectualization and the Use of Professional Terminology It is not unusual for the physician to use scientific terminology in his communication with a patient and then need to reword his questions or statements in understandable terms after he meets with a blank stare or a puzzled expression. In time the experienced physician avoids such semantic entanglements by using common phrases suited to the socioeconomic level of his patient. Persistent use of medical lingo must be viewed as a defense on the part of the doctor which may be necessitated by his need to compensate for feelings of inadequacy, his inability to cope with feelings in the patient, or his need to cling to the manner of a senior physician, with whom he has identified and idealized so that the human traits of his God-like father image have been forgotten.
Treatment of the Manifest Complaint The red herring complaint can divert the physician from the real reason for the patient's visit. It is wise to let the patient talk, to listen carefully and look for cues, key words (see below), and not jump to hasty conelusions. Particularly, when a patient has had a certain symptom of long standing it is advisable to ask, "What made you come now?" In addition to long-standing symptoms, rE~latively mild, bizarre or seemingly contrived symptoms are viewed with suspicion by the astute physician. It is often helpful to ask "Is there anything else you'd like to tell me about?" or "Are there any other problems on your mind?" and then allow a brief silenee to intervene before moving on with the next part of the examination.
Treatment of the Chance Objective Finding There are times when no biologic evidence of disease can be found to account for a patient's symptoms but there may be an incidental physical finding. Because of the physician's need to do something for the patient, he may treat what he finds rather than look farther for what may be less accessible.
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A 42 year old postman complained of tiredness in the lower part of his body. The physician discovered some maceration between the toes of his patient but was unable to correlate any other physical findings with the patient's symptoms. He explained at length the cause and management of the patient's itching feet and was about to dismiss him with a prescription for foot powder, etc., but was advised to reopen the interview and ask about the patient's work and home situation. He discovered that the postman had two sons, one in college and one a delinquent adolescent who was in repeated trouble with the law. He was ever weighed down with helping to support the former and trying to keep the latter out of jail.
Premature Reassurance and Advice Giving In the face of distressing illness or an outburst of emotion the physician may feel impelled to offer the patient hasty comfort and words of advice about an as yet poorly defined clinical picture. The physician may well question himself at such a time: "Whom am I reassuring, the patient or myself?" A 46 year old woman had been referred from the Gynecology Clinic for medical evaluation 2 years after a total hysterectomy. She had been in good health and had gained some weight during this time. The physician commented upon her harassed expression and was told that she worried a lot at home. Enlarging on this she stated that she worried about seeing blood in the toilet bowl after stool. She started to cry and became very emotional. The doctor hastened to tell her that she was iust upset and her concern was unnecessary. "I'm sure you're all right. You probably have hemorrhoids, that's all," he added reassuringly. The tears subsided momentarily as the patient blurted out, "How do you know, you haven't even examined me yet?" She continued on with a story of neglect by a physician many years previously when her mother's breast lump was ignored until it was too late. When the physician repeated his previous reassurance based on his objective findings after the physical examination, the patient was satisfied and grateful.
Avoidance of the Sexual Area of the Patient's Life Many physicians are reluctant to question patients about intimate matters relating to their personal lives, especially to ask objectively about sexual relations. The noncommittal "How are things at home?" to which the patient responds with an indifferent "O.K." is often the substitute for meaningful questioning and the key is lost to understanding many patient's problems. 1he use of "May I ask you something personal?" will often allow a physician and patient to enter this area without undue embarrassment to either.
OVERCOMING THE DIFFICULTIES IN THE DOCTOR-PATIENT RELATIONSHIP; HISTORY-TAKING
In an active daily teaching program with senior medical students we have introduced some practical modifications in interviewing technique which may enable the physician to avoid or surmount obstacles encountered in the difficult doctor-patient relationship. In essence, the patient is re-
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garded as a whole person rather than an object to be questioned, measured and dosed. Buber has described this philosophically in terms of an I-Thou relationship rather than an I-It confrontation. The patient as a person is given more responsibility in relating the history; the disadvantages of a structured questionnaire type of anamnesis with its mechanical computer-like characteristics are avoided. Our suggestions for modifications in history-taking follow. NONVERBAL COMMUNICATION. The first moments of an interview, before any words are spoken, can be very informative. Initial hunches of the experienced physician often prove correct. The sixth sense of men like OsIer was based on skillful perception similar to that of Sherlock Holmes as he demonstrated his remarkable observational powers to his friend Dr. Watson. Some points of observation are as follows: Who comes with the patient to the doctor's office? How is the patient dressed? Does the patient relate to others in the waiting room, or does he seem detached? Does the patient, blanch or flush when spoken to? Does he tremble or seem restless? What does he do with his hands'? How about facial expression; is it animated, eager, sad? Are the patient's eyes bright, dull, listless, restless, sleepy? Are the hands well kept, are the nails chewed down, are there any sears on the wrists? An endless series of such details may be listed. All may contribute to an understanding of the patient's illness. Does the patient seem shy, arrogant, humorous, dejected, argumentative, circumstantial? The attitude evidenced by the patient may prepare the physician for tactful and skillful questions. Does the patient wait to be asked, need to be prompted for details of the illness or does he take the initiative? Does the patient ramble, does he answer the question relevantly or arc his thoughts scattered, profuse or evasive'? Many disorders can be detected by noting these points and considerable time and effort can be saved if the physician uses the information he can gain by observing and listening to his patient. THE PHYSICIAN'S FEELINGS ABOUT THE PATIEN'l' (EMPATHY). One of the unfortunate consequences of scientific medical training is the tendency to overlook the human quality of feelings. The essence of the doctorpatient relationship is rapport based on the empathetic ability of the physician. When the doctor empathizes with his patient he allows himself to become involved to the degree that he puts himself in the patient's shoes. He imagines or fantasies what it must be like to be and feel as does this person before him. He then detaches himself by deliberately breaking the identification, and with the cognitive, reasoning part of his mind he examines the feelings which he has transiently experienced while he was "feeling with" the patient. Many difficulties are avoided by paying heed to this nonverbal frequency band as messages come through just below the levels of words and concepts. If the doctor feels anxious, embarrassed, guilty, depressed, attracted or repelled, angered or experiences any other emotion during the interview he is probably tuning in via empathy. Know-
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ingly or not, he has identified with the patient and is experiencing what the patient feels. Such feeling, when its significance is understood, eonfirms the initial impressioIl gained through initial observations and is then utilized by making simple direct statements such as, "You seem sad," "I get the feeling that you're seared," "You really are worried, aren't you?" "Do you feel guilty about something?" A brief silence following sueh remarks will usually lead to a eonfirmatory response and initiate a salutary doctorpatient relationship. KEY WORDS AND LOADED PIIRASES. An excellent due to the patient's feelings is the frequent appearance of emotionally tinged words and phrases in the early, unguarded moments of the medieal interview. Anxiety is denoted by such words as "jittery," "on edge," "restless," "bad nerves," "butterflies in the stomach," "pounding" or "jumping" in the chest. "Tightness," "doubled up," "a knot in my stomach," "it grabs me" usually denote tension and worry. Phrases such as "weighed down," "tired," "heaviness," "emptiness," "ehoked up," "can't cry," "haven't cried in years" frequently are heard from depressed patients. These expressions can be put to prompt use by repeating them and asking the patient to tell you more about the phrase or word used. This often leads to more explicit expressions of feeling, more informative material, and often an indicatioll that the patient appreciates the physician's understanding and interest. OPEN-END QUESTIONING AND LISTENING TO THE PATIENT. Hearing what is on the patient's mind rather than attending only to that which the physician is formulating in his own mind is the purpose of open-end questioning. The perceptive physician will use his powers of observation early in the interview, listening to and encouraging the patient to talk about symptoms and about himself as a person. While he listens, the physician tunes in OIl the multiple dues coming through on the other wave length previously described. The doctor ean be relatively teIlsioIl-free at this time and convey a feeling of relaxation and calm which puts the patient at ease. Phrases such as "Tell me about it," "Mm-hm, I understand," "How did you feel about it?" and "How did that affect you?" keep the interview open, and flowing. Silences following such questions are often productive after the patient learns that he is being given a chance to express himself. CIRCUMSTANCES OF ONSET OF AN ILLNESS. Distress and pain often lead to chronological eonfusioIl as patients give the history of an illness. Logieal thought and temporal eonnectioIls are pushed aside by the need for help. The physician's responsibility is to restore some order in the historical details. THE PATIENT'S FANTAsn;s ABOUT HIS SYMPTOMS. Any physician who has been ill may recall his fanciful (often terrifying) ideas of what might have been wrong with him. "Second year medical student's disease" is ample confirmation that the mind plays strange tricks on one who has a
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little bit of knowledge. Patients too have ideas about their illnesses which may be useful clues to their state of mind and identification with family members, and often will reveal guilt, anxiety and significant emotional ties. There is a technique in interviewing which we have found useful in getting to the base of a patient's fears and worries. By asking "\Vhat do you think about (the symptom)'?" or "What do you imagine (the symptom) might mean'?" we elieit answers which may seem absurd or have no scientific validity, but wc do learn what agonizing fantasies might be keeping the patient irritable, sleepless, dejeeted, or away from the doctor's office until the present time. In asking the patient for his innermost thoughts about his illness we n:cognize him as a person who is entitled to assume some responsibility in describing the illness. \Ve also are showing him that we are interested in him and his ideas as well as the symptoms he has. This is another example of I-Thou rather than I-It. Occasionally, the patient will point directly to some facts which he might not have revealed if the doctor had not asked him what his ideas are about his symptom. Some of the common fantasies which are expressed by patients are of cancer, heart disease, incipient strokes, brain tumors, anticipation of mutilative operations, and infertility or sterility. Bizarre fantasies such as "My insides are rotting," "There are people in my chest talking to me," "Worms are crawling in my skin," "The spirit of God is in me," "I'm turning into a woman" (or into a man, if the patient is a woman) should alert the physician to the existence of a psychotic disorder. Following up the non psychotic fantasy is often revealing. By asking a patient why she at 31 years of age thinks she might have a stroke, the physician may release a guilty confession about some sinful thought. Questioning the patient who thinks he has heart disease often leads to an identification with a parent who died from coronary thrombosis. Such clues not only circumvent many difficulties in interviewing; they often lead directly to significant material and save much of the busy physician's time. DREAMS. There are times when even skillful interviewing with the application of the above suggested modifications does not reveal the contents of the patient's emotional conflict. A glimpse of this material may be obtained through a dream. It is not the province of the medical physician to analyze dreams; however, when a patient makes reference to troubled sleep, tossing and turning at night or early morning awakening, the curiosity of the physician may well be aroused. By asking if the patient dreams and then requesting him to describe a recent dream the physician allows for an expression from a deeper layer of the patient's mind which may be quite revealing. Nervous states can sometime be differentiated by a dream. Characteristically, depressed patients have morbid dreams regarding death, dead relatives, holes in the ground and caskets, and the dreams are often set in somber tones, with purple, black or grey backgrounds. Anxiety and anger often appear in dreams of fighting, violence, fire, explosions, or clashing
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between opposing forces. Guilt is frequently represented by the common dream of death of loved ones followed by their coming alive later in the dream. Recurrent distressing dreams of snakes, being pursued by men, threatening animals or monsters should alert the physician to the possibility of sexual anxiety. He may question the patient tactfully, when such dreams are reported, about the existence of sexual difficulties by asking, "Do you have any fears or worries about sexual matters?" To ignore such dream material would be like avoiding the anxiety of a spinster about finding a man under her bed. The dream is an informative clue to the emotional status of a patient which may be adventitiously reported during a medical history. EARLIEST MEMORIES. An interesting and rewarding query which may easily be introduced in medical history taking is "What is the earliest thing you can remember in your life?" When one considers the many events which occur in a person's childhood, due weight must be given the one or two recollections which may be given in response to this question. Such recall can be considered as summarizing the life-style or principal method of adaption to life stresses. The request for an early memory has often yielded a valuable clue to an otherwise obscure problem. It is not intended that this question be used in every medical history. However, it may be a fruitful source of information when the physician is puzzled about the patient. WHY DOES 'I'HE PATIENT ASK THAT QUESTION? When the patient brings up a question during an interview, the physician tends to respond as an authority from whom the patient is seeking information and advice. It is advisable to pause for a moment and consider before answering. Is this a loaded question? Is the patient trying to put you over a barrel? Is the question relevant to what has been under discussion? Is this truly a quest for your knowledge, or is the patient testing you to check on your values and attitudes? If in doubt, turn the question back to the patient and respond, 'Why do you ask?" The answers are usually informative and sometimes reveal hidden attitudes. One type of question which should always be parried as above is the personal one about the physician. Before a doctor reveals any information about himself he might well wonder why the patient wants it. OPENING AND CLOSING REMARKS. The first words whieh a patient utters may often be very revealing, offering an immediate opportunity to appraise the patient's mood, attitude toward the doctor and reaction to be anticipated during the rest of the session. Equally significant are the parting shots whieh a patient makes on leaving the doctor's office. Some of these are subsumed as "by the way" diseases mentioned under The Red Herring. Other remarks may be personal grievances or expressions of anxiety, rejection or anger which the patient may have been too timid to express when seated. It is not unusual to find that the most important statement made during a visit is the parting remark. Rather than overlook
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such a parting shot, it is often advisable to make a note of it and introduce it at an opportune time on the next visit of the patient.
SUMMARY Difficulties in medical interviewing are considered according to what the patient offers and the responses of the physieian. Ten of the common types of difficult patients are described. Nine of the usual difficulties encountered by physicians in developing the doctor-patient relationship are covered. Several suggestions are offered for overeoming these difficulties by skillful medical interviewing modifications which have been found useful in fostering an optimal doctor-patient relationship.
REFERENCES 1. Balint, M.: The Doctor, His Patient and the Illness. New York, International Uni-
versities Press, Inc., 1957. 2. Hirsh, H.: The general practitioner and the depressed patient. Pennsylvania M. J. 65.· 1467-1471, 1962. 3. Hirsh, H.: The general practitioner and the former mental hospital patient. GP 27: 113-118, 1963. 4. Hirsh, H.: Red herrings in the doctor's office. GP 27: 82-88, 1963. 5. Hirsh, H.: Psychologic clues in the medical history. GP 29: 106-112, 1964. 6. Hirsh, H., Hoffman, F. H. and Steiger, W. A.: Self-awareness in the physician. Pennsylvania M. J. 64: 1140-1143, 1\)61. 7. Katz, R. L.: Empathy. New York, Free Press of Glencoe, Inc., 1963. 8. Steiger, W. A.: Remarks on managing the difficult patient. Psychosomatics 3: 134136, 1962. 9. Steiger, W. A. and Hansen, A. V., Jr.: Patients Who Trouble You. Boston, Little, Brown & Co., 1964. 3401 North Broad Street Philadelphia, Pennsylvania 19140 (Dr. Steiger)
Every physician has had the frustrating, even exasperating experience of trying to help a patient and finding it difficult to do so. While the patient who fails to respond to the therapeutic efforts of the physician may be defined as the difficult patient, it is evident that there are, as well, certain features of the physician, with all of his knowledge and training, which may contribute to the problem. One physician may find a given patient difficult, another may not. It is more correct then to speak of the difficult doctor-patient relationship rather than the difficult patient. The subsequent discussion of this subject will encompass both sides of this relationship. Viewing the relationship between doctor and patient in simple transactional terms,! the patient's symptoms and complaints may be designated as "offers" and the physician's side of the transaction as "responses." The offers of the difficult patient will be described under ten different headings representing the majority of difficult patients encountered in everyday medical practice. THE PATIENTS' OFFERS AND HOW THEY ARE MADE
The Multiple Complainer These patients are trying to communicate through their symptoms an urgent request to be taken care of and given magic release from pain or discomfort by the doctor. The plea for help may be due to underlying anxiety or depression which is being expressed somatically. A 29 year old machinist complained of difficulty in breathing and heaviness
* Professor **
of Clinical Medicine and Chairman of the Department of Community Medicine, Temple University School of Medicine Associate in Psychiatry, Temple University School of Medicine
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in his chest which he attributed to the cutting oils used on the lathes at work. He had left several good jobs in New England because of such fumes. Since coming to Philadelphia he was bothered by traffic fumes; he had pains in his shoulders and back, vertex headaches and a sensation which he described as "a loose ball rolling around in my head." As he detailed his symptoms he spoke in bursts using intellectual terms indicative of great concern and much underlying tension. However, when asked if he felt nervous, he promptly denied it although admitting he was "on edge." He then went back to repeating his complaints, adding on a few more. The doctor's interest in his symptoms led into more detailed explanations and various rationalizations about their incapacitating effect. Initial attempts to probe the meaning of being "on edge" were resisted, but slowly the tense young man told about the unsatisfactory state of his marriage, loss of interest in sexual activities and his sensitivity to remarks made by his fellow employees. As he "opened up" about his psychological problems, the multiple symptomatology faded into the background.
Many unrealistic statements indicated this patient's fears of being harmed by the poisonous fumes, derided by his co-workers and exploited by bosses at each job. Anger which he felt toward his wife and children was being displaced to his work situation, reversed and felt as a hostile attack upon himself. This mechanism, known as projection, suggested a paranoid psychopathological process in this young man. Pertinent here also is the interview technique in which this obstruction to understanding can be overcome. This will be enlarged upon in the third section of this paper.
The Silent or Uninformative Patient The patient's offers may be limited to a few words or there may be total silence. The physician may be stumped from the outset and at a loss to know how to proceed. A senior medical student was observed through closed circuit television as he interviewed a 38 year old woman who had come to the Comprehensive Medicine Clinic with a note from her family doctor requesting a protein-bound iodine test and other studies. All attempts to obtain the reasons for these studies were met by a silent shrug of the shoulders. During a brief consultation with the supervising physician it was suggested to the student that such interrogations were useless unless we could understand her reluctance to talk. When the student said he felt angry at the patient for her nonresponsiveness, the supervisor suggested that this might be the way the patient felt. On resuming the interview the student confronted the patient with her silence and wondered aloud what this might mean. The patient squirmed, kicked out with one of her feet as her facial expression hardened. The doctor then said, "I get the feeling that you're angry," and the patient responded, "You're darn right I am," and went on to speak of her feelings about being sent to the clinic by her doctor, about the 1 hour wait to see the clinic doctor, etc. The student concurred with the patient's grievances, then proceeded through an adequate medical interview with no further difficulty.
Silence or poverty or verbal expression may have varying significance; the meaning can be determined only by such confrontations and then careful observation of and listening to the response of the patient.
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The Verbose or Tangential Talker
The bane of many physicians' lives is the talkative patient who never seems to arrive at any goal. Recently such a patient was sent for a psychiatric opmlOn. The referring physician remarked cryptically that the patient and her husband would explain the problem. Each time the husband started to narrate a story about their 5 year old child's death following intestinal resection, the patient interrupted. A story of depression and a suicidal gesture by the patient was related slowly. The wife continued to interrupt with explanations, conversations in full detail about what the doctor said, what she said to the doctor, etc. The psychiatrist sensed that the patient felt very guilty about the tragic incident and that her verbosity was an attempt to explain away her guilt. As the time allotted for the interview was rapidly passing the psychiatrist said to the patient, "You must feel very guilty about your son's death." She stopped talking and started to cry. The husband then completed the story and appropriate recommendations could be made.
The verbose or tangential patient often is talking away from something. The physician should attempt to understand why the patient is doing this rather than to follow the content of the verbalization. If the patient seems blithe or overly cheerful one should wonder whether he is covering up sadness. At times some embarrassing or frightening symptom may be present and the patient is attempting to hide anxiety or shame by denial. When the stream of ideation emerges as though there is pressure behind it we must consider the possibility of a manic depressive psychosis. When the ideas are bizarre or make no sense at all, a thought disorder indicative of schizophrenia may be present. The Blamer or Scapegoater
Another patient who may pose a problem is the one who recites symptoms, discomforts or details of an illness and then proceeds to attribute their misfortune to someone who is closely related. Husbands blame wives and vice versa. Parents blame children, and this too may be reversed. In-laws are especially prone to offer each other as culprits to thc family doctor. Often the illness may be exaggerated in order to justify care, concern or even intercession by the family doctor on the patient's behalf. The mote in the other one's eye is often the beam in the patient's eye. How common is the suffering woman patient who has gastrointestinal symptoms, headaches, elevated blood pressure and obesity as her presenting symptoms and then proceeds to offer as the cause of her troubles an alcoholic spouse. Acceptance of this manifest idea may lead to an impasse unless the physician is able to cope successfully with the spouse's drinking. Treating the patient's symptoms, likewise, is a limited and often fruitless goal. The physician should attempt to view objectively the interpersonal relationship which the patient describes and to recognize that in such interaction "it takes two to tango." If the husband's drinking makes the wife ill, what does the wife do (or not do) to encourage her husband to resort to drink?
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This kind of situation was dramatically exemplified in a tense, thin woman, who feared having another nervous breakdown (for which she had received a course of electroshock therapy two years previously). The cause of her recent anxiety was the drinking of a few beers by her husband on a previous weekend after neglecting to take his daily Antabuse for 3 days. The patient's recent emotional status had been excellent until 3 weeks before this, when she awakened very upset by a dream. "1 dreamed that my husband killed my brother, Jay, and hacked him up in pieces and put all of him into a trash can." Shortly after relating this dream the patient stopped, thought for a moment and said, "1 guess I'm responsible for him starting to drink again-I've been nagging at him a lot." This form of understanding can be obtained if the physician is able to focus on the relationship rather than on the patient's complaints, and then, nonjudgmentally explore with the patient what part each is playing in perpetuating the neurotic marital interaction. The dream portrayed the patient's own past anger toward her younger brother as it was carried out dramatically by the husband. After having the dream she nagged and provoked her husband in real life and he, as in the past, resorted to drink rather than lose control of the rage which she aroused in him. The central problem in the home was their 21 year old son, who had a severe case of cystic acne, was unable to hold a job and spent most of his time at home manipulating both parents into blaming each other for his indolence. These facts were revealed in the session as the basis for the insight which her statement implied.
The Masochistic Patient Of special difficulty is the perverse twist in human behavior that manifests itself in seeming gratification through suffering mental or physical pain. Examples are the incomprehensible surgical addict, the woman who divorces one brutal man only to marry another one, and the man who is described in the following clinical vignette. This 42 year old refugee from the Nazi holocaust had escaped from Poland in 1939. After spending the war years as a slave laborer in Siberia and along thc Mongolian border of Russia he found his way to the United States from a displaced person's camp in 1946 when he was 26 years old. He married, quickly became fluent in English, and became a salesman of electrical appliances. When 38 he suffered a coronary thrombosis while exercising vigorously at a country club. Six weeks later (against his cardiologist's orders) he again exerted himself dancing a polka. During his second hospital stay it was necessary to threaten to tie him to the bed to make him rest after his second coronary attack. He denied that there was anything amiss with him, and was eager to prove his strength to anyone who would listen. In each of the succeeding 2 years he again suffered occlusions of his coronary vessels, and finally was referred to a psychiatrist who had seen his wife in brief psychotherapy. She complained bitterly about her husband's impotence and lack of regard for her needs for affection. During his sessions with the psychiatrist the husband acknowledged a neurotic wish and need to prove himself indestructible; his attitude masked his guilt about abandoning his parents to the Germans at the outbreak of the war. Actually this man was driving himself to his death. The masochistic patient may best be dealt with by his own persona)
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physician if a firm order is issued countermanding the self-destructive behavior. At times a threat to discontinue treatment and refusal to accept future responsibility for the patient's well-being may be in order.
The Red Herring (By-the-Way Disease) Performing a medical examination for a stated complaint only to find that the symptoms described are not the real reason for the patient's visit can be frustrating. 'Ve have called this phenomenon the "red herring" complaint, since it is offered as a rationalization to obtain the attention of the physician by many people who think they must have a physical symptom at; a calling card. Dr. Scott of Edinburgh considers patients of this sort to have "by-the-way diseases," in which the real reason for the patient's presence emerges with the phrase "by the way, Doctor." For instance, a woman had undergone a complete history and physical examination for some vague gastrointestinal symptoms. As the doctor summarized his findings and management, shc broke in with the question, "What is schizophrenia?" The doctor was takcn aback and wondered why she should ask such a seemingly irrelevant question. She then took up the next 15 minutes talking about her son, who had been acting strangely. After this issue emerged, the patient forgot about the "offers" which she had made in the form of symptoms as her concern about her son came to the fore.
The Hysterical or Dissociated Patient A distressing experience for most physicians is the patient who exhibits wild, uncontrollable behavior or lapses into a sudden state of detachment or trance as the result of overwhelming anxiety. This occurrence may be comprehended easily when its onset takes place in the doctor's office. In other circumstances, when the source of the threatening anxiety is not so apparent, such an incident may give the appearance of an acute emergency and unjust demands may be made for the physician's services. A prompt survey of the surrounding circumstances is in order. Acute anxiety may be precipitated by a threat of harm, a sexual attack or a loss of control by the patient. Epilepsy, acute psychotic behavior and hypoglycemic shock must be considered in the differential diagnostic survey. A previous history of grand or petit mal, tongue biting and loss of sphincter control indicate a convulsive state. Prior bizarre behavior and evidence of an abnormal mental state in the past would incline one to think of a more malignant psychic etiology. Profuse sweating and a history of such incidents consequent to missed meals or use of insulin in a known diabetic lead to the diagnostic probability of hypoglycemia. A recent incident in the Comprehensive Medicine Clinic exemplifies the hysterical patient who may be encountered in any doctor's office. This 24 year old woman became agitated as a senior medical student questioned her about her symptoms. She began to scream, tore at her clothing and tried to run out of the examining room. A consultant was summoned; he quickly appraised the situation and firmly took her by the hands, leading her back into the room. He spoke to her in a calm, reassuring voice yet insisted in a commanding manner that she. regain
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control of herself. Gaining her attention he said, "I know you're scared." The patient stopped struggling, started to cry and nodded confirmation of her fear. She then went on to talk of her apprehension on coming to the clinic that morning; she went on to give her history and undergo the physical examination cooperatively.
The key to managing the hysterical patient is the recognition of anxiety as the cause of the behavior displayed. The frightening thoughts are usually of being hurt or of losing control and hurting someone else. Although the behavior seems purposeless or illogical, it does serve to release or control the release of aggressive or sexual energy. The physician must be firm and gentle and must address his remarks to the fear which the patient is experiencing rather than to react with violence to the sudden display of intemperate behavior. Recognition of the feeling state of the patient has a calmative and reassuring effect.
The Psychotic Patient In 1954 effective psychotropic drugs became available and since then the former mental hospital patient has become the partial responsibility of the general practitioner. Although the patient may receive follow-up care from a clinic or a psychiatrist, when he becomes medically ill he still turns to his family doctor, who must be able to recognize psychotic symptoms and early ego disintegration and particularly to differentiate between biological illness and physical complaints arising on a psychophysiological level as manifestations of intrapsychic tension. The ambulatory schizophrenic who has been released from hospital or who has avoided hospitalization through timely psychiatric care and the use of drugs may need his drug dosage adjusted because of increased stress in his life, intercurrent illness or family pressures. The patient who becomes careless about taking the dosage prescribed is a troublesome problem. Longacting tablets may be substituted so that another member of the household may be present to be sure that they are taken. Familiarity with dosage and the toxic and side effects of the phenothiazines and the antidepressant group of drugs will enhance the family doctor's skill in guiding the former mental hospital patient. The families of these patients often turn to their doctor for support and advice in coping with the many problems of readjustment. The physician's understanding of the familial and cultural aspects of severe mental illness will also be useful. The cardinal signs of the most common psychotic disorder, schizophrenia, are withdrawal from reality, disordered thinking, inappropriate or decreased emotional expression and ambivalence. Recently a 32 year old man gave a history of repeated loss of jobs and some vague physical symptoms. He stated that he had no interpersonal relationships except with a brother who supported him. He exhibited an untidy appearance and in an unfeeling and intellectual manner expressed a series of ideas which were scattered and disorganized. He had some thoughts about being unable to get along with people and gave evidence that he lived in a world of his own. He related a shocking story of having been to several doctors with complaints referable to his nose, throat and anus. A submucous resection, a rhinoplasty and 2 rectal operations
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had been done with no change in his symptoms. This man's symptoms and behavior were classically schizophrenic.
Before elective surgical procedures are advised or performed it is wise to appraise carefully the personality of the patient. If there is any doubt about the real need for the procedure when the patient's motivation seems bizarre or inappropriate, psychiatric consultation should be considered. The Severely Depressed Patient
Depression is a medical disorder commonly overlooked or misdiagnosed. It should be thought of in any illness in which fatigue, anorexia, weight loss, insomnia, constipation, and sluggishness on awakening are present. The threat of suicide in depression is ever present whether the depression is reactive to a real loss (of health, body part, function or possession) or the so-called endogenous depression of constitutional or hereditary origin. As encountered in a medical practice, a suicidal intent may be communicated to the family doctor by the patient in subtle ways. Expressions of hopelessness, extreme fatigue and self recrimination associated with the depressive triad of anorexia, constipation and early morning insomnia should prompt the physician to ask a series of graduated questions somewhat as follows: (1) Do you feel very unhappy? (2) Do you feel as if the joy is gone out of life? (3) How much have you thought of doing harm to yourself? (4) Are you considering ending your life? (5) How do you plan to do it? Affirmative answers to the first four questions indicate a serious suicidal intent whether or not the patient can spell out the means he has considered using to end his life. Tentative positive answers should not be taken lightly and psychiatric advice is indicated. The patient who is not intending suicide will answer in the negative to questions 3 and 4, but if the responses are vague, evasive, or silent we must consider the patient suicidal until proved otherwise. The restless or agitated depressed paticnt is more capable of ending his life than the apathetic, slow moving or rctarded one. A sudden improvement in a severely depressed patient may forebode a serious suicidal attempt, for the person may have settled on a "way out" of his misery. The quantity of energy which such a patient displays to the observing physician is a good measure of the possibility of a suicidal attempt when the intent exists. Constant (24 hours) observation by someone in attendance is advisable until the patient is hospitalized. The Hostile, Arrogant or Critical Patient
Difficult as this type may appear, the physician may readily manage such a patient if he remembers two cardinal rules: 1. The outward attitude usually represents an armor or veneer which the patient uses to cover up his fear of being hurt or rejected. The patientoften operates on the principle that the best defense is to be on the offensive. 2. The unpleasant hostile or carping exterior is not personally in-
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tended for the physician. Rather it represents a general regressive attitude about being needy, weak or sick. The hostile, defiant or critical patient may be exemplified in a representative vignette such as that of the hysterical patient mentioned earlier. Other examples are patients who verbally assault the physician about having to wait, about the physician's age (too old or too young), or about the anticipated expense of treatment. Such people are best handled by recognizing their anger and encouraging them to speak about their feelings. By accepting their remarks without remonstration the physician allows a corrective emotional experience. When the steam seems to be running out of the patient's comments the physician can get down to the business at hand. THE DOCTOR'S REACTIONS (RESPONSES) TO THE DIFFICULT PATIENT
In his everyday dealing with patients the physician will encounter reactions within himself which he may recognize in various ways. Fatigue, digestive disorders, palpitations, backache, headache and troubled sleep are some common symptoms which give evidence that the physician may be having difficulty in dealing with patients. In such an instance the physician may modify the old aphorism and say, "Physician, observe thy self."
Doctors Are Human \Ve are not God-like creatures even though some adoring patients regard us such. We too have our frailties, feelings and failings and must acknowledge that patients can frustrate, anger, gratify, appeal sexually or cause disgust and loathing within us. To recognize such feelings, particularly if they interfere with our professional skills or personal integrity, is of utmost importance. To detach ourselves from them requires energy and defensive processes which can be antitherapeutic for the patient and exhausting to the doctor. If wc accept ourselves as human beings we may allow ourselves to feel our reactions and then ask, "Why do I feel this way about this patient?" Very frequently such introspection gives us an understanding of or empathy with the patient which opens up vistas of the patient's feeling states that are of primary importance. Recently a 62 year old physician was under the care of one of the authors for an emotional disturbance associated with parkinsonism which impaired his surgical ability. Following the initial interview with him the author felt very oppressed, his muscles aehed and he became aware of having morbid thoughts. Taking cognizance of his own feelings he realized the intensity of the patient's depression and ordered the required therapy for this man's involutional depressive reaction.
The Apostolic Function of the Physician The personality of the physician, based on his own experiences, philos-
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ophy of life and values, is a powerful influence in his everyday dealings with his patients. What the doctor believes a patient should experience and endure in his illness, even the name of the illness, is often based on some unshakeable conviction held by the physician about his patients. The physician's ability to empathize with any given patient may depend on his social class; thus social class would determine the diagnosis and management. This area has been referred to as the "apostolic function of the physician" and often operates as a constant in medical practice. The rigid, highly moralistic medical practitioner of puritanical background may deal with a young man with a case of gonorrhea quite differently than a physician who has sown his own wild oats in earlier years. The hard working, conscientious doctor who rarely takes a day off will react with indignation to a request for a certificate of disability for a week's absence from work because of a "cold." Our tendency to make our patients believe in and live up to our standards, i.e., to convert them to our way, often backfires or confuses the management of a patient's illness. The Frustrated or Rejected Physician
Emotional stress drains heavily on the energies of the busy physician. Difficult patients play upon his equanimity and tolerance during hectic office hours or while he is making hospital or home rounds. Feelings of frustration and rejection are bound to arise in some of these encounters. At such times the wise physician will pause in his professional chores, briefly introspect and ask himself why he feels as he does at such a time. His feelings may stem from encounters with certain patients, sometimes from two or three who have visited in one office session after which he has felt particularly drained. Scheduling such trying patients on different days may prevent a recurrence. An insightful and effective approach to this problem is to take note of common characteristics of certain patients who are particularly distressing to the physician. He may then avoid such patients or attempt to understand why individuals with these personality traits pose such a problem. A discussion of such difficulty with a trained colleague may be most enlightening. 'The physician may recognize that he has been trying too hard to satisfy an individual patient, to answer all the questions and respond to all the demands made at one visit. Conscientious doctors may feel obliged to hear out such torrents of demands, to appease each of the pleas for help or explain all of the urgent symptoms at one session. Just as psychiatrists regularly set limits when the clock indicates the allotted time has run out, the generalist can terminate the session by firmly and directly stating, "We will have to stop now. Let's go on with this subject next time." 'The occasional patient who rebuffs all the physician's responses may bring about a feeling of rejection in the doctor. In such an instance, direct confrontation of the patient with what he is doing may bring about a
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STELGER, HERMAN HIRSH
productive discussion and may clear the air in what can become an otherwise hopeless doctor-patient relationship. Rejection may have many meanings. In the case of a young woman who does not improve with medication there may be a desire for affection and interest, particularly when the patient acts coy and seductive. An older woman may repeatedly rebuff the physician's therapeutic attempts in order to provoke a paternal rage which to her would represent masochistic gratification. Another patient may evoke repeated therapeutic efforts by the conscientious physician to satisfy unmet dependency needs which have existed since childhood and which can never be assuaged. When the physician reviews the record (whether he is one of many physicians who have attempted to help this patient or is the sole respondent to the demands) he may perceive a hidden significant motive running through the series of encounters with the patient. A 29 year old married woman visited her internist every 4 or 6 months with complaints of epigastric pain, nausea after meals, headaches, and restless sleep. After several such experiences the physician suggested a gastrointestinal x-ray series since the patient denied any relief from various medications and slyly hinted that he was incompetent. The initial reaction was one of anger, then rejection; the physician then regained his objectivity and confronted the patient with the pattern of her unremitting symptoms and her visits at regular intervals over the previous 2 years. After a moment's pause the patient's expression changed. She related these visits to her mother's intrusion in her affairs, how she criticized the patient's husband, the way the children were being raised, etc. This process would peak out every few months when this young woman was on the point of exploding at her domineering mother. She then became sick and weak and turned to her doctor (as she had turned to her passive physician father before he died several years earlier). The rejection of the doctor could be equated to rejection of her father, who had used his overdemanding practice as an excuse for not facing up to his wife (and not helping the patient in her early attempts to liberate herself from the controlling mother). With this understanding, the physician began to encourage the patient to stand up to her mother, to ally herself with her husband's previous efforts to curb the mother's intrusions and to recognize her own adequacy as a mother and wife. The patient slowly changed her outlook during the next year and her symptoms subsided.
Overidentification with the Patient The loss of objectivity through overidentification with the patient can eause the physician difficulty. The most effective attitude is one of empathy, a flexible and reversible splitting of the doctor's psyche into an identifying part and an observing part. The function of feeling with the patient (identification) is limited by an observational, reality-oriented aspect (cognition) of the doctor's ego. Too much identification with a decrease or loss of objectivity leads to overinvolvement in the patient's life. The young, earnest tyro is particularly prone to this tendeney, which often leads to embarrassment and ineffectiveness over the long term. At the least, it encourages the patient to exaggerated expectations of the physician, with subsequent disillusionment and disruption of the doctor-patient relationship.
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One of the common manifestations of this type of difficulty is the physician who is carried away by the appeal of an attractive, intelligent young woman whose illness has not evoked sympathy and a kindly response from spouse or family. An inappropriate overinvolvement may ensue in which the physician may take sides with and shower the young woman with care and attention far out of proportion to that given to other patients. Objectivity is lost so that the patient is seen as a maiden in distress or an unhappy child. What ensues depends on the physician's ability to extricate himself and regain his professional status. In general, overidentification should be suspected when the physician finds himself having fantasies or dreaming about a patient.
Intellectualization and the Use of Professional Terminology It is not unusual for the physician to use scientific terminology in his communication with a patient and then need to reword his questions or statements in understandable terms after he meets with a blank stare or a puzzled expression. In time the experienced physician avoids such semantic entanglements by using common phrases suited to the socioeconomic level of his patient. Persistent use of medical lingo must be viewed as a defense on the part of the doctor which may be necessitated by his need to compensate for feelings of inadequacy, his inability to cope with feelings in the patient, or his need to cling to the manner of a senior physician, with whom he has identified and idealized so that the human traits of his God-like father image have been forgotten.
Treatment of the Manifest Complaint The red herring complaint can divert the physician from the real reason for the patient's visit. It is wise to let the patient talk, to listen carefully and look for cues, key words (see below), and not jump to hasty conelusions. Particularly, when a patient has had a certain symptom of long standing it is advisable to ask, "What made you come now?" In addition to long-standing symptoms, rE~latively mild, bizarre or seemingly contrived symptoms are viewed with suspicion by the astute physician. It is often helpful to ask "Is there anything else you'd like to tell me about?" or "Are there any other problems on your mind?" and then allow a brief silenee to intervene before moving on with the next part of the examination.
Treatment of the Chance Objective Finding There are times when no biologic evidence of disease can be found to account for a patient's symptoms but there may be an incidental physical finding. Because of the physician's need to do something for the patient, he may treat what he finds rather than look farther for what may be less accessible.
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A.
S'Y8IGER, HERMAN HmsH
A 42 year old postman complained of tiredness in the lower part of his body. The physician discovered some maceration between the toes of his patient but was unable to correlate any other physical findings with the patient's symptoms. He explained at length the cause and management of the patient's itching feet and was about to dismiss him with a prescription for foot powder, etc., but was advised to reopen the interview and ask about the patient's work and home situation. He discovered that the postman had two sons, one in college and one a delinquent adolescent who was in repeated trouble with the law. He was ever weighed down with helping to support the former and trying to keep the latter out of jail.
Premature Reassurance and Advice Giving In the face of distressing illness or an outburst of emotion the physician may feel impelled to offer the patient hasty comfort and words of advice about an as yet poorly defined clinical picture. The physician may well question himself at such a time: "Whom am I reassuring, the patient or myself?" A 46 year old woman had been referred from the Gynecology Clinic for medical evaluation 2 years after a total hysterectomy. She had been in good health and had gained some weight during this time. The physician commented upon her harassed expression and was told that she worried a lot at home. Enlarging on this she stated that she worried about seeing blood in the toilet bowl after stool. She started to cry and became very emotional. The doctor hastened to tell her that she was iust upset and her concern was unnecessary. "I'm sure you're all right. You probably have hemorrhoids, that's all," he added reassuringly. The tears subsided momentarily as the patient blurted out, "How do you know, you haven't even examined me yet?" She continued on with a story of neglect by a physician many years previously when her mother's breast lump was ignored until it was too late. When the physician repeated his previous reassurance based on his objective findings after the physical examination, the patient was satisfied and grateful.
Avoidance of the Sexual Area of the Patient's Life Many physicians are reluctant to question patients about intimate matters relating to their personal lives, especially to ask objectively about sexual relations. The noncommittal "How are things at home?" to which the patient responds with an indifferent "O.K." is often the substitute for meaningful questioning and the key is lost to understanding many patient's problems. 1he use of "May I ask you something personal?" will often allow a physician and patient to enter this area without undue embarrassment to either.
OVERCOMING THE DIFFICULTIES IN THE DOCTOR-PATIENT RELATIONSHIP; HISTORY-TAKING
In an active daily teaching program with senior medical students we have introduced some practical modifications in interviewing technique which may enable the physician to avoid or surmount obstacles encountered in the difficult doctor-patient relationship. In essence, the patient is re-
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garded as a whole person rather than an object to be questioned, measured and dosed. Buber has described this philosophically in terms of an I-Thou relationship rather than an I-It confrontation. The patient as a person is given more responsibility in relating the history; the disadvantages of a structured questionnaire type of anamnesis with its mechanical computer-like characteristics are avoided. Our suggestions for modifications in history-taking follow. NONVERBAL COMMUNICATION. The first moments of an interview, before any words are spoken, can be very informative. Initial hunches of the experienced physician often prove correct. The sixth sense of men like OsIer was based on skillful perception similar to that of Sherlock Holmes as he demonstrated his remarkable observational powers to his friend Dr. Watson. Some points of observation are as follows: Who comes with the patient to the doctor's office? How is the patient dressed? Does the patient relate to others in the waiting room, or does he seem detached? Does the patient, blanch or flush when spoken to? Does he tremble or seem restless? What does he do with his hands'? How about facial expression; is it animated, eager, sad? Are the patient's eyes bright, dull, listless, restless, sleepy? Are the hands well kept, are the nails chewed down, are there any sears on the wrists? An endless series of such details may be listed. All may contribute to an understanding of the patient's illness. Does the patient seem shy, arrogant, humorous, dejected, argumentative, circumstantial? The attitude evidenced by the patient may prepare the physician for tactful and skillful questions. Does the patient wait to be asked, need to be prompted for details of the illness or does he take the initiative? Does the patient ramble, does he answer the question relevantly or arc his thoughts scattered, profuse or evasive'? Many disorders can be detected by noting these points and considerable time and effort can be saved if the physician uses the information he can gain by observing and listening to his patient. THE PHYSICIAN'S FEELINGS ABOUT THE PATIEN'l' (EMPATHY). One of the unfortunate consequences of scientific medical training is the tendency to overlook the human quality of feelings. The essence of the doctorpatient relationship is rapport based on the empathetic ability of the physician. When the doctor empathizes with his patient he allows himself to become involved to the degree that he puts himself in the patient's shoes. He imagines or fantasies what it must be like to be and feel as does this person before him. He then detaches himself by deliberately breaking the identification, and with the cognitive, reasoning part of his mind he examines the feelings which he has transiently experienced while he was "feeling with" the patient. Many difficulties are avoided by paying heed to this nonverbal frequency band as messages come through just below the levels of words and concepts. If the doctor feels anxious, embarrassed, guilty, depressed, attracted or repelled, angered or experiences any other emotion during the interview he is probably tuning in via empathy. Know-
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W lLLIAM A.
STEIGER, HERMAN HIRSH
ingly or not, he has identified with the patient and is experiencing what the patient feels. Such feeling, when its significance is understood, eonfirms the initial impressioIl gained through initial observations and is then utilized by making simple direct statements such as, "You seem sad," "I get the feeling that you're seared," "You really are worried, aren't you?" "Do you feel guilty about something?" A brief silence following sueh remarks will usually lead to a eonfirmatory response and initiate a salutary doctorpatient relationship. KEY WORDS AND LOADED PIIRASES. An excellent due to the patient's feelings is the frequent appearance of emotionally tinged words and phrases in the early, unguarded moments of the medieal interview. Anxiety is denoted by such words as "jittery," "on edge," "restless," "bad nerves," "butterflies in the stomach," "pounding" or "jumping" in the chest. "Tightness," "doubled up," "a knot in my stomach," "it grabs me" usually denote tension and worry. Phrases such as "weighed down," "tired," "heaviness," "emptiness," "ehoked up," "can't cry," "haven't cried in years" frequently are heard from depressed patients. These expressions can be put to prompt use by repeating them and asking the patient to tell you more about the phrase or word used. This often leads to more explicit expressions of feeling, more informative material, and often an indicatioll that the patient appreciates the physician's understanding and interest. OPEN-END QUESTIONING AND LISTENING TO THE PATIENT. Hearing what is on the patient's mind rather than attending only to that which the physician is formulating in his own mind is the purpose of open-end questioning. The perceptive physician will use his powers of observation early in the interview, listening to and encouraging the patient to talk about symptoms and about himself as a person. While he listens, the physician tunes in OIl the multiple dues coming through on the other wave length previously described. The doctor ean be relatively teIlsioIl-free at this time and convey a feeling of relaxation and calm which puts the patient at ease. Phrases such as "Tell me about it," "Mm-hm, I understand," "How did you feel about it?" and "How did that affect you?" keep the interview open, and flowing. Silences following such questions are often productive after the patient learns that he is being given a chance to express himself. CIRCUMSTANCES OF ONSET OF AN ILLNESS. Distress and pain often lead to chronological eonfusioIl as patients give the history of an illness. Logieal thought and temporal eonnectioIls are pushed aside by the need for help. The physician's responsibility is to restore some order in the historical details. THE PATIENT'S FANTAsn;s ABOUT HIS SYMPTOMS. Any physician who has been ill may recall his fanciful (often terrifying) ideas of what might have been wrong with him. "Second year medical student's disease" is ample confirmation that the mind plays strange tricks on one who has a
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little bit of knowledge. Patients too have ideas about their illnesses which may be useful clues to their state of mind and identification with family members, and often will reveal guilt, anxiety and significant emotional ties. There is a technique in interviewing which we have found useful in getting to the base of a patient's fears and worries. By asking "\Vhat do you think about (the symptom)'?" or "What do you imagine (the symptom) might mean'?" we elieit answers which may seem absurd or have no scientific validity, but wc do learn what agonizing fantasies might be keeping the patient irritable, sleepless, dejeeted, or away from the doctor's office until the present time. In asking the patient for his innermost thoughts about his illness we n:cognize him as a person who is entitled to assume some responsibility in describing the illness. \Ve also are showing him that we are interested in him and his ideas as well as the symptoms he has. This is another example of I-Thou rather than I-It. Occasionally, the patient will point directly to some facts which he might not have revealed if the doctor had not asked him what his ideas are about his symptom. Some of the common fantasies which are expressed by patients are of cancer, heart disease, incipient strokes, brain tumors, anticipation of mutilative operations, and infertility or sterility. Bizarre fantasies such as "My insides are rotting," "There are people in my chest talking to me," "Worms are crawling in my skin," "The spirit of God is in me," "I'm turning into a woman" (or into a man, if the patient is a woman) should alert the physician to the existence of a psychotic disorder. Following up the non psychotic fantasy is often revealing. By asking a patient why she at 31 years of age thinks she might have a stroke, the physician may release a guilty confession about some sinful thought. Questioning the patient who thinks he has heart disease often leads to an identification with a parent who died from coronary thrombosis. Such clues not only circumvent many difficulties in interviewing; they often lead directly to significant material and save much of the busy physician's time. DREAMS. There are times when even skillful interviewing with the application of the above suggested modifications does not reveal the contents of the patient's emotional conflict. A glimpse of this material may be obtained through a dream. It is not the province of the medical physician to analyze dreams; however, when a patient makes reference to troubled sleep, tossing and turning at night or early morning awakening, the curiosity of the physician may well be aroused. By asking if the patient dreams and then requesting him to describe a recent dream the physician allows for an expression from a deeper layer of the patient's mind which may be quite revealing. Nervous states can sometime be differentiated by a dream. Characteristically, depressed patients have morbid dreams regarding death, dead relatives, holes in the ground and caskets, and the dreams are often set in somber tones, with purple, black or grey backgrounds. Anxiety and anger often appear in dreams of fighting, violence, fire, explosions, or clashing
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WILLIAM
A.
STEIGER, HERMAN HIRSH
between opposing forces. Guilt is frequently represented by the common dream of death of loved ones followed by their coming alive later in the dream. Recurrent distressing dreams of snakes, being pursued by men, threatening animals or monsters should alert the physician to the possibility of sexual anxiety. He may question the patient tactfully, when such dreams are reported, about the existence of sexual difficulties by asking, "Do you have any fears or worries about sexual matters?" To ignore such dream material would be like avoiding the anxiety of a spinster about finding a man under her bed. The dream is an informative clue to the emotional status of a patient which may be adventitiously reported during a medical history. EARLIEST MEMORIES. An interesting and rewarding query which may easily be introduced in medical history taking is "What is the earliest thing you can remember in your life?" When one considers the many events which occur in a person's childhood, due weight must be given the one or two recollections which may be given in response to this question. Such recall can be considered as summarizing the life-style or principal method of adaption to life stresses. The request for an early memory has often yielded a valuable clue to an otherwise obscure problem. It is not intended that this question be used in every medical history. However, it may be a fruitful source of information when the physician is puzzled about the patient. WHY DOES 'I'HE PATIENT ASK THAT QUESTION? When the patient brings up a question during an interview, the physician tends to respond as an authority from whom the patient is seeking information and advice. It is advisable to pause for a moment and consider before answering. Is this a loaded question? Is the patient trying to put you over a barrel? Is the question relevant to what has been under discussion? Is this truly a quest for your knowledge, or is the patient testing you to check on your values and attitudes? If in doubt, turn the question back to the patient and respond, 'Why do you ask?" The answers are usually informative and sometimes reveal hidden attitudes. One type of question which should always be parried as above is the personal one about the physician. Before a doctor reveals any information about himself he might well wonder why the patient wants it. OPENING AND CLOSING REMARKS. The first words whieh a patient utters may often be very revealing, offering an immediate opportunity to appraise the patient's mood, attitude toward the doctor and reaction to be anticipated during the rest of the session. Equally significant are the parting shots whieh a patient makes on leaving the doctor's office. Some of these are subsumed as "by the way" diseases mentioned under The Red Herring. Other remarks may be personal grievances or expressions of anxiety, rejection or anger which the patient may have been too timid to express when seated. It is not unusual to find that the most important statement made during a visit is the parting remark. Rather than overlook
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such a parting shot, it is often advisable to make a note of it and introduce it at an opportune time on the next visit of the patient.
SUMMARY Difficulties in medical interviewing are considered according to what the patient offers and the responses of the physieian. Ten of the common types of difficult patients are described. Nine of the usual difficulties encountered by physicians in developing the doctor-patient relationship are covered. Several suggestions are offered for overeoming these difficulties by skillful medical interviewing modifications which have been found useful in fostering an optimal doctor-patient relationship.
REFERENCES 1. Balint, M.: The Doctor, His Patient and the Illness. New York, International Uni-
versities Press, Inc., 1957. 2. Hirsh, H.: The general practitioner and the depressed patient. Pennsylvania M. J. 65.· 1467-1471, 1962. 3. Hirsh, H.: The general practitioner and the former mental hospital patient. GP 27: 113-118, 1963. 4. Hirsh, H.: Red herrings in the doctor's office. GP 27: 82-88, 1963. 5. Hirsh, H.: Psychologic clues in the medical history. GP 29: 106-112, 1964. 6. Hirsh, H., Hoffman, F. H. and Steiger, W. A.: Self-awareness in the physician. Pennsylvania M. J. 64: 1140-1143, 1\)61. 7. Katz, R. L.: Empathy. New York, Free Press of Glencoe, Inc., 1963. 8. Steiger, W. A.: Remarks on managing the difficult patient. Psychosomatics 3: 134136, 1962. 9. Steiger, W. A. and Hansen, A. V., Jr.: Patients Who Trouble You. Boston, Little, Brown & Co., 1964. 3401 North Broad Street Philadelphia, Pennsylvania 19140 (Dr. Steiger)