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Managing Difficult Patients
VOLUME VIII - NUMBER 6
NOVEMBER-DECEMBER, 1967
rSYCBIOSOMATICS OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE
The first tu:o papers of this issue are part of the California Symposium, "Colllprehensil;e Medical Care and the Psychiatric Consultation."
Managing Difficult Patients \VILLIAM
A.
• A difficult patient is one who in some manner upsets his physician-one who makes his doctor feel anxious or irritated or angry or overly-solicitous, too sympathetic, even erotically stimulated. It is not usually the nature of the problem, not the category of the disease, but the person of the patient which arouses these negative or positive feelingsfeelings which can interfere with the logical management of the patient. The physician's reaction to a particular patient is more than his objective appraisal of the medical problem; it is also his subjective reaction to the person of the patient. 1 A gross example of the influence of the subjective is the behavior of two senior medical students toward two patients recently. The first student had as his patient a 14-year-old shy Negro girl who weighed over 200 pounds, and who was staying at home, not attending school and not associating with other children. Her illness appeared seriously disabling. The second medical student had as his patient an attractive, blonde, white, divorcee in her late 20's who had some bodily symptoms secondary to anxiety. The first student gave his patient a reducing diet and a return appointment in
Dr. Steiger is John A. Kolmer Professor and Chairman of the Department of Community Medicine, Temple University School of Medicine, Philadelphia, Penna. Presented at the Symposium, "Comprehensive Medical Care and the Psychiatric Consultation," University of California Medical Center, San Francisco, Nov. 1965. November-December, 1967
STEIGER,
M.D.
a month. The second assured his patient that she could call him any day in the clinic if she were upset, and gave her a return appointment in a week. Most of the time and energy in medical education and in meetings such as these are devoted to dealing with the patient as an object. It was Descartes (1596-1650) who first separated conceptually the body from the soul. This permitted man to be conceived as any other object or thing in the world, allowing us to weigh him, dissect him, analyze him." Thus the performance of a blood sugar on a patient is not basically different from the analysis of the carbon concentration of a piece of steel. This is the objectification of man which allows us to use the scientific method upon him. This has been to man's great benefit, but also somewhat to his detriment, as it objectifies and depersonalizes him. You may be saying: what is wrong with that? Man is object in the world. Well I say I am also a subject in the world, looking out at the world, conceptualizing it, ordering it, fantasying about itall inside, privately and alone.· Thus I say that we can conceive of man as an object, but he is still subject. We can dichotomize him conceptually into body and soul, object and subject, soma and psyche, but in the real world he is an indivisible unity. I am pursuing this because it goes to the heart of the doctor-patient relationship. When I perform a physical examination on a patient, I am conceiving of the patient as an object, a thing, an it. When I am relating to the paTh1.s
305
One
1I1111"111~11I111~11"'III" RXHU-6EP-BSAW
11111
PSYCHOSOMATICS
tient, when I am empathic, I am relating to the patient's subjectivity with my own subjective nature. In the terms of Martin Buber, philosopher and theologian, these relationships can be called I-It and I-Thou. Thus the doctor-patient relationship is a complex one as it must be both I-It and I-Thou: both subjective and ohjective, personal and impersonal, emotional and logical, intimate and remote.;' The I-Thou relationship is generally the soul of the doctor-patient interaction, and it is this that is disturbed generally in the case of the difficult patient. Our tendency with the difficult patient is to increase I-It and diminish I-Thou and thus to diminish the anguish for ourselves. When a patient with multiple, vague complaints irritates us, we tend to prescribe a tranquilizer indicating that we conc::>ive of him as a physico-chemical thing, dismissing the patient as quickly as possible; or, we may ignore the obvious signal of anxiety and objectify this patient by performing a mllltiplicity of objective tests. In this instanc~' with the multiple complainer, our irritation generally is consequent to the anxiety we feel coming from the patient and making liS as ill at ease as he is. Furthermore we get feelings of therapeutic impotence from such a patient, and the patient's pessimism becomes our poor prognosis. An analysis of our own subjective feelings in such an instance allows us to be speedily aware of the patient's feelings-and to take the appropriate course of action, such as saying promptly, "I get the feeling that you are anxious, upset, feel hopeless and blue." This encourages the patient to talk openly about his real, underlying problems and concerns and to desist from his "organ recital."" Thus a key to the management of difficult patients is self-awareness, the performance of a conscious analysis of the feeling transmitted verbally and non-verbally by the patient to the physician. It is paying attention to the I-Thou interaction and not merely attending to the I-It. In the case of the difficult patient the physician must ask himself what he feels and why. Is this his problem, his prejudiceis it the patient's problem? To illustrate: A lady on the neurosurgical service was seen in consultation by an internist. He approached her bed, introduced himself and 306
explained his purpose. He noted that the lad~' looked very frightened, and he himself felt some anxiety. At this point he could have performed a number of defensive maneuvers. He could have studied her chart meticulously; he could have asked her for her complaint, quizzed her in detail (done a verbal I-It analysis) about it; he could have asked a few hrief, direct questions and plunged in to do the physical examination. The appropriate maneuver was to say sympathetically as he did: "You look scared to death." This brought about verbalization of her fears and allowed for appropriate and specific reassurance, after which the consultation could proceed efficiently. (~ote, too, in the aforementioned instance that "taking a history" and "doing a physical" can be defenses against dealing with the patient's intimate concerns.) To be this candid about what is felt is apparently not common among physicians. There is a hesitancy about heing open, and yet it is often the best way to gain rapport and to solve puzzling problems. Certainly the verbose patient is the bane of many doctors and yet it is seemingly easy to note the Vl'rhosity and the large head of pressure hehind the speech. Instead of getting irritated it is better to say something about it, such as "You are going on here at a great rate, Mrs. Doe, what's the reason for it!" You suspect, of course, that the patient is talking away from some worrisome concern that is difficult to hring up, even to the physician. Effectively encouraging patients to tell what problems are behind their symptoms is a matter of attitude and technique. The most effective attitude is one of relative passivity. It is the placing of the responsibility for giving the important historical data squarely upon the patient. This frees the physician from feeling that he must do a verbal dissection of the corpus before him and come directly to an answer. Instead he says to the patient, "Tell me all about it." He asks such questions as, "How did you feel when it happened?" "Why did you come now?" "What do you think the trouble is?" "Why are you behaving this way to me?" Such questions make the patient an active, adult part of the relationship. They show respect for the patient as a person with ideas and feelings and they encourage his coVolulIle VJII
~IANAGING
DIFFICULT PATIENTS-STEIGER
operation. Furthermore they allow the patient to express his fantasies about his disorder-his fears, his misinformation and so on, and permit specific reassurance if necessary. Global reassurance, especially when prematurely given, is rarely effective and should he avoided. Finally such questions elicit a great amount of material in a very short time. Recently a ii-year-old lady was seen with several vague complaints. The medical student who sa\\' her was congratulated by an instructor for persuading her to undergo a sigmoidoscopy, which found nothing significant. My own appraisal was that the student did not find out why the lady came with her vague complaints. Did it mean that she feared death, especially feared dying alone? Some discussion of this, including who is there to call if she becomes ill, the availability of neighhors, of a bedside telephone, etc. would likely have been more appropriate. This asking "why" (as in why she came with vagut-' complaints) is the single most significant technique in interviewing. A young, married diabetic couple hoth taking insulin asked their physician about the advisahility of having a child. He knowledgeahly quoted them the bleak statistics on childbearing in diabetics when the lady began to sob-already three months pregnant. If only he had asked "u;hy" do you ask? Being sought for advice can be so 8attering that we will answer without first carefully seeking from the patient all the relevant data-at which point advice is seldom needed. In this regard, it is worthwhile to be aware that the patient who is seductive to you, or who excessively flatters you, or is hostile to you or suspicious of you-is this way with everyone. You, the physician, are not special. It is not really personal. This is usually the patient's way of handling his anxiety over interpersonal relationships. The microcosm of your doctor-patient relationship usually reflects the macrocosm of their relationships with people in the world.~ An engineer was a precise, mathematical person who never trusted his subordinates very far, staying in the office at night and checking up on their figures. He treated his physicians with the same distrust. He questioned them endlessly about the effects their l'\ovember-December, 1967
medications would have on him, fearing always that they would harm him. Finally his physician had to deal with this. He said, "Mr. Patient, you don't trust me." The patient denied this at first but the physician calmly pointed out his repetitive behavior to him. Thereafter whenever the patient became too difficult, the physician could remind him of his need for trust and their business could proceed. Suspicious people are not uncommon these days. You can often sense their wariness and need for psychological distance as they come in the office. Often they don't want to tell you what previous doctors said. Instead they want your independent opinion. "All you cloctors stick together, anyway." Or they read up in books about their disorder and slip you a few sly questions to check up on your knowledge. If this suspiciousness does not interfere with their management it is no problem. If it does interfere, then it must be dealt with out in the open before successful management can proceed. Again the suspiciousness is not personal, so the discussion need not be recriminatory. Patients who do not do as we say can be upsetting. Thus the woman with a breast mass who refuses surgery tends to make us anxious and angry. In our zeal to help her we may threaten her with death and suffering, instead of realizing her underlying, subjective fears of the surgery, its disfigurement, its threat to her femininity and her life. This is a frightened woman who needs understanding, needs to be encouraged to talk about her fears. Her behavior is irrational and it is this that needs to be dealt with. Often, instead, the rational approach is used and it is explained to her that the lump may not be cancer, that only a small biopsy incision will be made first, that it won't hurt because of the anesthesia. This rational explanation only frightens her more and is followed by persuasion, exhortation and finally threat. In all of these the doctor is too active, explaining, persuading, etc. It is a time to take the patient's hand, to ask her understandingly why she refuses surgery when she knows it is right, why is it so fearful, what previous experience she had with this type of thing, and so on. A patient in the ward refused a liver biopsy after both the interne and the resi307
PSYCHOSmlATICS
dent had carefully explained the procedure and the need for it. The Ward Chief on his rounds said to her, "I understand you aren't going to let us do the liver biopsy." "Why is that?" After a pause, she replied, "It is a minor operation, isn't it?" "Yes, it is," he answered. "Does that have a special meaning to you?" "Well," she said, "my mother went to the hospital for a minor operation and died." The emphasis again is in getting the patient to do the explaining. Some physicians who are not compatible with this approach use the rationalization that they don't have the time for it. In reality, with practice, it often takes very little time. Let me illustrate with two brief examples. A middle-aged woman spent a week in a hospital because of dysphonia of six months duration with nothing found. Examination by the Jackson Clinic disclosed normal vocal cords and cord function. The psychosomaticist was called in. He said promptly, "No one can find an explanation for your hoarseness." "What is really causing it in your opinion?" At first she said she didn't know. He persisted in pressing her for her opinion. Finally she said, "It came on after my daughter came home from the hospital with her baby." "My daughter had to stay in bed with a kidney infection." "I had to care for her, for the baby, and my husband, for the house," and then proceeded to spill out a lifetime of martyrdom with all the consequent rage and resentment that she had not been able to express. Another lady complained of a chronic bellyache. She said she'd been to two other doctors. The first had given her a red medicine which made her sick; the second a green medicine that made her vomit. One immediately suspects that she thinks those medicines poisoned her. When asked what she did about the medicines, she admitted having taken them to an analytical chemist! The lady is obviously paranoid. Both of these ladies had been frustrating, puzzling and difficult to their physicians. The approach of what do you think is the cause of your trouble in the first case and what did you do about the medicines in the second
308
allowed for rapid elucidation. There is more to this, however. In the first lady the physician could see the serious mien, could feel the sadness and resignation. In the second, her damning of previous physicians made one bristle from her hostility, her lack of trust. The subjective messages, once recognized, led to appropriate questioning. CO:"CLUSIO:"
I have tried to convey through the use of conceptual models and through clinical vignettes some of the strategy and tactics that we have found useful in dealing with difficult patients. Principal attention has been paid to the use (for diagnostic and therapeutic purposes) of the feelings aroused in the physician by those patients. This requires a considerable self-awareness, a conscious mastering of his own feelings by the physician. It means that interviewing involves data collection from self as well as from patient. Involved is the underlying assumption that patients do arouse feelings in physicians, both positive and negative. To expect the physician to love all his patients is unrealistic and impossible. It is expected that he be aware of his feelings so that he does not allow them to interfere with logical scientific patient care. REFERE:"CES
1. Steiger, \V. A. and Hansen, A. Victor: Patients Who Trouble You. Boston: Little, Brown and Co., 1964. 2. Steiger, W. A.: Remarks on ~[anaging the Difficult Patient. Psychosvmatics, 3/2, ~larch-April 1962. 3. Steiger, W. A.: Is Science Basic? ]. -'led. EdIlC., 38/9, September 1963. 4. Mlmn, A. ~f.: Free WiU and Determinism. University of Toronto Press, 1960, p. 197. 5. Steiger, W. A. and Hirsh, H.: The .\ledical Student. Teaching of Psychotherapy. Boston: Little, Brown and Co., 1964, p. 294. 6. Steiger, W. A. and Hirsh, H.: The Difficult Patient in Everyday ~Iedical Practice. .\ledical Clin. N. Amer. 49:1449, September 1985.
Temple Unit;ersity Hospital 3401 North Broad Street Philadelphia, Pennsy!mnia 19140
Volume VIII
NOVEMBER-DECEMBER, 1967
rSYCBIOSOMATICS OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE
The first tu:o papers of this issue are part of the California Symposium, "Colllprehensil;e Medical Care and the Psychiatric Consultation."
Managing Difficult Patients \VILLIAM
A.
• A difficult patient is one who in some manner upsets his physician-one who makes his doctor feel anxious or irritated or angry or overly-solicitous, too sympathetic, even erotically stimulated. It is not usually the nature of the problem, not the category of the disease, but the person of the patient which arouses these negative or positive feelingsfeelings which can interfere with the logical management of the patient. The physician's reaction to a particular patient is more than his objective appraisal of the medical problem; it is also his subjective reaction to the person of the patient. 1 A gross example of the influence of the subjective is the behavior of two senior medical students toward two patients recently. The first student had as his patient a 14-year-old shy Negro girl who weighed over 200 pounds, and who was staying at home, not attending school and not associating with other children. Her illness appeared seriously disabling. The second medical student had as his patient an attractive, blonde, white, divorcee in her late 20's who had some bodily symptoms secondary to anxiety. The first student gave his patient a reducing diet and a return appointment in
Dr. Steiger is John A. Kolmer Professor and Chairman of the Department of Community Medicine, Temple University School of Medicine, Philadelphia, Penna. Presented at the Symposium, "Comprehensive Medical Care and the Psychiatric Consultation," University of California Medical Center, San Francisco, Nov. 1965. November-December, 1967
STEIGER,
M.D.
a month. The second assured his patient that she could call him any day in the clinic if she were upset, and gave her a return appointment in a week. Most of the time and energy in medical education and in meetings such as these are devoted to dealing with the patient as an object. It was Descartes (1596-1650) who first separated conceptually the body from the soul. This permitted man to be conceived as any other object or thing in the world, allowing us to weigh him, dissect him, analyze him." Thus the performance of a blood sugar on a patient is not basically different from the analysis of the carbon concentration of a piece of steel. This is the objectification of man which allows us to use the scientific method upon him. This has been to man's great benefit, but also somewhat to his detriment, as it objectifies and depersonalizes him. You may be saying: what is wrong with that? Man is object in the world. Well I say I am also a subject in the world, looking out at the world, conceptualizing it, ordering it, fantasying about itall inside, privately and alone.· Thus I say that we can conceive of man as an object, but he is still subject. We can dichotomize him conceptually into body and soul, object and subject, soma and psyche, but in the real world he is an indivisible unity. I am pursuing this because it goes to the heart of the doctor-patient relationship. When I perform a physical examination on a patient, I am conceiving of the patient as an object, a thing, an it. When I am relating to the paTh1.s
305
One
1I1111"111~11I111~11"'III" RXHU-6EP-BSAW
11111
PSYCHOSOMATICS
tient, when I am empathic, I am relating to the patient's subjectivity with my own subjective nature. In the terms of Martin Buber, philosopher and theologian, these relationships can be called I-It and I-Thou. Thus the doctor-patient relationship is a complex one as it must be both I-It and I-Thou: both subjective and ohjective, personal and impersonal, emotional and logical, intimate and remote.;' The I-Thou relationship is generally the soul of the doctor-patient interaction, and it is this that is disturbed generally in the case of the difficult patient. Our tendency with the difficult patient is to increase I-It and diminish I-Thou and thus to diminish the anguish for ourselves. When a patient with multiple, vague complaints irritates us, we tend to prescribe a tranquilizer indicating that we conc::>ive of him as a physico-chemical thing, dismissing the patient as quickly as possible; or, we may ignore the obvious signal of anxiety and objectify this patient by performing a mllltiplicity of objective tests. In this instanc~' with the multiple complainer, our irritation generally is consequent to the anxiety we feel coming from the patient and making liS as ill at ease as he is. Furthermore we get feelings of therapeutic impotence from such a patient, and the patient's pessimism becomes our poor prognosis. An analysis of our own subjective feelings in such an instance allows us to be speedily aware of the patient's feelings-and to take the appropriate course of action, such as saying promptly, "I get the feeling that you are anxious, upset, feel hopeless and blue." This encourages the patient to talk openly about his real, underlying problems and concerns and to desist from his "organ recital."" Thus a key to the management of difficult patients is self-awareness, the performance of a conscious analysis of the feeling transmitted verbally and non-verbally by the patient to the physician. It is paying attention to the I-Thou interaction and not merely attending to the I-It. In the case of the difficult patient the physician must ask himself what he feels and why. Is this his problem, his prejudiceis it the patient's problem? To illustrate: A lady on the neurosurgical service was seen in consultation by an internist. He approached her bed, introduced himself and 306
explained his purpose. He noted that the lad~' looked very frightened, and he himself felt some anxiety. At this point he could have performed a number of defensive maneuvers. He could have studied her chart meticulously; he could have asked her for her complaint, quizzed her in detail (done a verbal I-It analysis) about it; he could have asked a few hrief, direct questions and plunged in to do the physical examination. The appropriate maneuver was to say sympathetically as he did: "You look scared to death." This brought about verbalization of her fears and allowed for appropriate and specific reassurance, after which the consultation could proceed efficiently. (~ote, too, in the aforementioned instance that "taking a history" and "doing a physical" can be defenses against dealing with the patient's intimate concerns.) To be this candid about what is felt is apparently not common among physicians. There is a hesitancy about heing open, and yet it is often the best way to gain rapport and to solve puzzling problems. Certainly the verbose patient is the bane of many doctors and yet it is seemingly easy to note the Vl'rhosity and the large head of pressure hehind the speech. Instead of getting irritated it is better to say something about it, such as "You are going on here at a great rate, Mrs. Doe, what's the reason for it!" You suspect, of course, that the patient is talking away from some worrisome concern that is difficult to hring up, even to the physician. Effectively encouraging patients to tell what problems are behind their symptoms is a matter of attitude and technique. The most effective attitude is one of relative passivity. It is the placing of the responsibility for giving the important historical data squarely upon the patient. This frees the physician from feeling that he must do a verbal dissection of the corpus before him and come directly to an answer. Instead he says to the patient, "Tell me all about it." He asks such questions as, "How did you feel when it happened?" "Why did you come now?" "What do you think the trouble is?" "Why are you behaving this way to me?" Such questions make the patient an active, adult part of the relationship. They show respect for the patient as a person with ideas and feelings and they encourage his coVolulIle VJII
~IANAGING
DIFFICULT PATIENTS-STEIGER
operation. Furthermore they allow the patient to express his fantasies about his disorder-his fears, his misinformation and so on, and permit specific reassurance if necessary. Global reassurance, especially when prematurely given, is rarely effective and should he avoided. Finally such questions elicit a great amount of material in a very short time. Recently a ii-year-old lady was seen with several vague complaints. The medical student who sa\\' her was congratulated by an instructor for persuading her to undergo a sigmoidoscopy, which found nothing significant. My own appraisal was that the student did not find out why the lady came with her vague complaints. Did it mean that she feared death, especially feared dying alone? Some discussion of this, including who is there to call if she becomes ill, the availability of neighhors, of a bedside telephone, etc. would likely have been more appropriate. This asking "why" (as in why she came with vagut-' complaints) is the single most significant technique in interviewing. A young, married diabetic couple hoth taking insulin asked their physician about the advisahility of having a child. He knowledgeahly quoted them the bleak statistics on childbearing in diabetics when the lady began to sob-already three months pregnant. If only he had asked "u;hy" do you ask? Being sought for advice can be so 8attering that we will answer without first carefully seeking from the patient all the relevant data-at which point advice is seldom needed. In this regard, it is worthwhile to be aware that the patient who is seductive to you, or who excessively flatters you, or is hostile to you or suspicious of you-is this way with everyone. You, the physician, are not special. It is not really personal. This is usually the patient's way of handling his anxiety over interpersonal relationships. The microcosm of your doctor-patient relationship usually reflects the macrocosm of their relationships with people in the world.~ An engineer was a precise, mathematical person who never trusted his subordinates very far, staying in the office at night and checking up on their figures. He treated his physicians with the same distrust. He questioned them endlessly about the effects their l'\ovember-December, 1967
medications would have on him, fearing always that they would harm him. Finally his physician had to deal with this. He said, "Mr. Patient, you don't trust me." The patient denied this at first but the physician calmly pointed out his repetitive behavior to him. Thereafter whenever the patient became too difficult, the physician could remind him of his need for trust and their business could proceed. Suspicious people are not uncommon these days. You can often sense their wariness and need for psychological distance as they come in the office. Often they don't want to tell you what previous doctors said. Instead they want your independent opinion. "All you cloctors stick together, anyway." Or they read up in books about their disorder and slip you a few sly questions to check up on your knowledge. If this suspiciousness does not interfere with their management it is no problem. If it does interfere, then it must be dealt with out in the open before successful management can proceed. Again the suspiciousness is not personal, so the discussion need not be recriminatory. Patients who do not do as we say can be upsetting. Thus the woman with a breast mass who refuses surgery tends to make us anxious and angry. In our zeal to help her we may threaten her with death and suffering, instead of realizing her underlying, subjective fears of the surgery, its disfigurement, its threat to her femininity and her life. This is a frightened woman who needs understanding, needs to be encouraged to talk about her fears. Her behavior is irrational and it is this that needs to be dealt with. Often, instead, the rational approach is used and it is explained to her that the lump may not be cancer, that only a small biopsy incision will be made first, that it won't hurt because of the anesthesia. This rational explanation only frightens her more and is followed by persuasion, exhortation and finally threat. In all of these the doctor is too active, explaining, persuading, etc. It is a time to take the patient's hand, to ask her understandingly why she refuses surgery when she knows it is right, why is it so fearful, what previous experience she had with this type of thing, and so on. A patient in the ward refused a liver biopsy after both the interne and the resi307
PSYCHOSmlATICS
dent had carefully explained the procedure and the need for it. The Ward Chief on his rounds said to her, "I understand you aren't going to let us do the liver biopsy." "Why is that?" After a pause, she replied, "It is a minor operation, isn't it?" "Yes, it is," he answered. "Does that have a special meaning to you?" "Well," she said, "my mother went to the hospital for a minor operation and died." The emphasis again is in getting the patient to do the explaining. Some physicians who are not compatible with this approach use the rationalization that they don't have the time for it. In reality, with practice, it often takes very little time. Let me illustrate with two brief examples. A middle-aged woman spent a week in a hospital because of dysphonia of six months duration with nothing found. Examination by the Jackson Clinic disclosed normal vocal cords and cord function. The psychosomaticist was called in. He said promptly, "No one can find an explanation for your hoarseness." "What is really causing it in your opinion?" At first she said she didn't know. He persisted in pressing her for her opinion. Finally she said, "It came on after my daughter came home from the hospital with her baby." "My daughter had to stay in bed with a kidney infection." "I had to care for her, for the baby, and my husband, for the house," and then proceeded to spill out a lifetime of martyrdom with all the consequent rage and resentment that she had not been able to express. Another lady complained of a chronic bellyache. She said she'd been to two other doctors. The first had given her a red medicine which made her sick; the second a green medicine that made her vomit. One immediately suspects that she thinks those medicines poisoned her. When asked what she did about the medicines, she admitted having taken them to an analytical chemist! The lady is obviously paranoid. Both of these ladies had been frustrating, puzzling and difficult to their physicians. The approach of what do you think is the cause of your trouble in the first case and what did you do about the medicines in the second
308
allowed for rapid elucidation. There is more to this, however. In the first lady the physician could see the serious mien, could feel the sadness and resignation. In the second, her damning of previous physicians made one bristle from her hostility, her lack of trust. The subjective messages, once recognized, led to appropriate questioning. CO:"CLUSIO:"
I have tried to convey through the use of conceptual models and through clinical vignettes some of the strategy and tactics that we have found useful in dealing with difficult patients. Principal attention has been paid to the use (for diagnostic and therapeutic purposes) of the feelings aroused in the physician by those patients. This requires a considerable self-awareness, a conscious mastering of his own feelings by the physician. It means that interviewing involves data collection from self as well as from patient. Involved is the underlying assumption that patients do arouse feelings in physicians, both positive and negative. To expect the physician to love all his patients is unrealistic and impossible. It is expected that he be aware of his feelings so that he does not allow them to interfere with logical scientific patient care. REFERE:"CES
1. Steiger, \V. A. and Hansen, A. Victor: Patients Who Trouble You. Boston: Little, Brown and Co., 1964. 2. Steiger, W. A.: Remarks on ~[anaging the Difficult Patient. Psychosvmatics, 3/2, ~larch-April 1962. 3. Steiger, W. A.: Is Science Basic? ]. -'led. EdIlC., 38/9, September 1963. 4. Mlmn, A. ~f.: Free WiU and Determinism. University of Toronto Press, 1960, p. 197. 5. Steiger, W. A. and Hirsh, H.: The .\ledical Student. Teaching of Psychotherapy. Boston: Little, Brown and Co., 1964, p. 294. 6. Steiger, W. A. and Hirsh, H.: The Difficult Patient in Everyday ~Iedical Practice. .\ledical Clin. N. Amer. 49:1449, September 1985.
Temple Unit;ersity Hospital 3401 North Broad Street Philadelphia, Pennsy!mnia 19140
Volume VIII