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Patients and Their Obstetricians
Patients and Their Obstetricians EDMUND MIDDLETON, M.D., and VIRGINIA HUFFER, M.D.
• During the past two decades, there has been an increasing appreciation by physicians in all branches of medicine that patients should be treated as a whole and not just as organ systems. This total approach is at least theoretically accepted by most doctors although in actual practice many avoid dealing with emotional aspects of their patients. In the field of obstetrics, the patient usually presents with a clearcut clinical entity, i.e., pregnancy, with definite procedures to be followed. Therefore, it is easy to develop a rather stereotyped approach and thereby lose sight of the individuality of the patient. Every woman who comes to an obstetrician brings her own personality pattern and set of values. Also, since pregnancy is such a major milestone in a woman's life, she naturally experiences a degree of emotional upheaval and readjushnents will be necessary. Her anxieties, conflicts, aspirations and ideals will be accentuated during this phase. Since the reproductive process is such a basic part of her concept of herself as a woman, she often bestows upon her obstetrician a more special and intimate role than she assigns to physicians from whom she seeks assistance for physical disease. Probably no physician, with the exception of a psychiatrist, plays such an important part in a woman's psychological life and well being. However, the obstetrician may not effectively utilize this advantageous position to the ultimate benefit of the patient. The doctor who is able to recognize and respond to the personality needs of his patients will not only promote their emotional well being, but he will in turn benefit by having more cooperative, secure and satisfied patients. It is one of the aims of this paper to describe the various types of patient pe.rsonalities as they present to an obstetrician From the Department of Obstetrics and Gynecology and Department of Psychiatry, University of Maryland, School of Medicine, Baltimore 1, Maryland.
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and to discuss some of the factors behind the manifest behavior. Suggestions will be made as to possible ways of responding. Although emphasis has been placed on considering the emotional problems of the pregnant woman, little has been said about the effect of the personality of the obstetrician on patients' reactions. It is obvious, however, that the personality and manner of the obstetrician is of great importance to the patient. Her ability to establish a comfortable relationship with him and feel secure in this depends to a large degree on the physician himself. It is probably infrequent that an obstetrician asks himself how his attitudes affect his patients and if anything in his manner contributes to the various difficulties that may develop during the course of pregnancy. While it is impossible for a physician to obtain an ideal relationship with all of his patients, more self-awareness on the part of the doctor should aid him in recognizing how he relates to those who walk into his office. The fact that the obstetrician plays a part in setting the emotional tone of his patients can be illustrated by remarks that obstetrical nurses commonlv make. It is not unusual to hear comments' such as "that must be Dr. X's patient; she is so relaxed and cooperative", or "Dr. Y is admitting a patient. We are in for a hard night. His patients usually raise the roof." Inasmuch as it is important that the physician considers what he himself brings into the consultation room, the authors intend to categorize various personality types of obstetricians with the hope of encouraging them to be more introspective and possibly modify their reaction patterns to be suitable to the needs of the patients. Illustrations will be given of possible interactions between the personalities of physicians and patients, which demonstrate how they compliment each other or create disharmony. Volume IV
PATIENTS AND THEIR OBSTETRICIANS-MIDDLETON AND HUFFER
The following constitutes a description of various patient personalities as may be seen in an obstetrical practice. Obviously, the listing does not follow any standard nomenclature. Obstetricians will readily recognize that many patients in their own practices fall into these descriptive categories. The personality outlines are developed as they might apply to the average middle class married woman. PATIENT PERSONALITY
1. The Demanding, Controlling Woman.This is the patient who comes to the obstetrician's office with exceedingly definite ideas as to the way she thinks her pregnancy should be managed. She is opinionated on such subjects as anaesthesia, natural childbirth, rooming in, infant feeding, et cetera. She has read all of the lay literature and perhaps even some of the more technical articles concerning pregnancy and childbirth. Things must be done exactly as she wants and when she wants. Obviously, this is a difficult patient for the average obstetrician. Not only may he feel that his authority is threatened, but he also may consider her demands as incompatible with the best obstetrical care. The obstetrichili is often inclined to immediately give such a woman a lecttir~ and tell her that if she wishes him to be her doctor she will have to abide by his management. He frequently fails to recognize that the patient has developed a controlling, demanding attitude because of her own personality needs and that underneath this exterior there is a frightened woman. Her defense against her anxieties takes the form of a need to be in control. She may feel that she is' inadequate as a person and that she does not quite measure up to other people emotionally or physically. Her way of reacting against these fears is to attempt to arrange everything in a manner that she feels will make her superior to other women. The obstetrician is left with three choices: (1) to go along completely with her demands, (2) to become very aggressive himself and tell the patient that she will have to comply with his instructions or go elsewhere, or (3) be aware that this overbearing behavior reflects underlying anxieties. With the last in mind, the obstetrician may approach the patient not with the idea of wrenching all control from her immediately, but by graduMay-June, 1963
ally gaining her confidence, develop a mutually acceptable plan for her care.
2. The Scared, Modest Rabbit.-This patient will be visibly frightened, speak in a whisper and look very embarrassed. She will volunteer very little infonnation, and will give only monosyllabic answers to questions. She feels that the whole procedure is not ladylike. The physician will need to be quite gentle, and to be quietly reassuring, showing non-verbal acceptance and respect for her modesty. Direct confrontation by telling her not to be frightened and embarrassed will probably not be effective, neither will backslapping, kidding or coercive attitudes. Only time and a sustained attitude of patience will be helpful. 3. The Clinging, Complaining W oman.- The patient shows behavior which is regressive in nature, more appropriate for the small child who is ill than for the adult woman who presents with a nonnal physiologic process. This individual frequently presents a multitude of complaints. She fears any activity will hann either her or the fetus and for this reason she is constantly calling the obstetrician with one question after another. She has an endless store of complaints and queries which may cause the doctor to feel that he will never be able to get her out of his office or off the phone. These characteristics are symptoms of emotional immaturity which are accentuated during the pregnancy. This patient frequently drives her doctor to exasperation and he may become more and more curt and brusque with her to the point of being openly angry. Hostile rejection does come from the obstetrician when he can no longer bear the patient's numerous complaints. Such an intolerable situation is likely to develop if initially he did not recognize that she was a clinging, complaining person, but had accentuated her dependent behavior by constantly attempting to reassure her and answer her demands for attention. When one encounters this kind of regressive patient, a gentle, but finn approach is frequently effective. It would be preferable very early in the course of her care for the doctor to set up a definite schedule for her, leaving nothing vague or to chance. She can be encouraged to collect her questions to be presented at her next appointment rather than 14.1
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calling each time a thought occurs. Providing her with a definite schedule of activities will give her structure and therefore support to cling to between office visits.
4. The Independent, Bravado Type.-No complaints and very few questions are offered by such a patient. She may state that since pregnancy is nothing but a normal process, there is no reason to pamper herself in any way. She intends to go about her usual activities which could foreseeably range from mountain climbing to deep-sea diving. She most certainly is not going to have any of those silly little neurotic complaints that other pregnant women have. She exudes the attitude that women have been having babies for centuries, so why should there be any fuss? This patient may be very refreshing to the obstetrician. However, he should keep iIi mind that perhaps "the lady does protest too much" and that all this may be a defensive show of bravery. She denies the need within herself to fon"; any dependent relationship. It may be prudent for the doctor to convey to such a patient that this is all fine, but that she may have some anxieties or symptoms and she should feel free to discuss these with him. A source of difficulty with this patient is the possibility that she may deny symptoms of a potentially serious nature, and therefore fail to infonn her obstetrician. 5. The Irresistible Female Type.-This woman trades on being coy and seductive. Her main aim in life is to have any and every man succumb to her charm. Indeed, she may be very tempting! This patient is likely to get into psychological difficulty during late pregnancy when she no longer feels attractive. This is a blow to her narcissism and may result in a degree of depression. The process of labor and delivery will be especially repugnant to her, and at this time she may appear to be a very disturbed person. No longer can she be the irresistible, beautiful creature. Not only is she experiencing discomfort, but the responsibilities and restrictions that the care of a child necessitate are imminent. Previously, she had thought of a baby as a toy or a doll that might further aggrandize her femininity. During the post-partum period, she may become seriously depressed 144
or manifest other undesirable emotional responses. Not only should the obstetrician be mindful of this, but during the course of prenatal care he may have approached her in ways to have helped her adjust to motherhood. If he has discreetly emphasized his respect for the mature, motherly woman rather than having encouraged her seductive, immature playfulness, he may have promoted emotional growth during her pregnancy.
6. The Resentful Wornan.-Even though the pregnancy was planned, this woman is not pleased. She feels that society demands that a woman should have children, but to her the whole process is a nuisance. Because of her hostility and resentment, she is likely to be very negativistic with her obstetrician even to the point of giving the impression that he, along with the rest of society, is responsible for what to her is a most unpleasant situation. As an outlet for her resentment, she will question in a hostile way everything that the physician tells her and will use many devices to place him on the defensive. However, her own conscience makes her feel that this resentful attitude is not acceptable and therefore she frequently will, by her questions and ideas, betray feelings of guilt. This patient has a deep-seated emotional conflict over the role of femininity, and the obstetrician may feel at a loss to know what he can do to make the situation more acceptable. First, he might relieve her guilt to a certain extent by pointing out that often women are not pleased with the idea of having a baby. This will allow her to feel that she is not alone in her attitude and that this is something that she can discuss with the physician. He may take steps to manage her labor and delivery so as to forestall as much as possible her feeling that she is being put in a depreciated state during the actual delivery. For example, to this woman, being put up in stirrups and having her wrists shackled during delivery would be felt by her to be degrading. If the physician can get over to her the idea that being able to have a baby is a real asset and that she is acquiring something of great value, he will have indeed accomplished a major feat. 7. The Apathetic and Irresponsible Type.This woman gives the impression of indifferVolume IV
PATIENTS AND THEIR OBSTETRICIANS-MIDDLETON AND HUFFER
ence as to what happens to her during the reproductive process. She will take no active interest in any prenatal program which her physician presents, and seldom asks questions. Instructions given her are likely to be disregarded. It would be important for the obstetrician to ascertain whether this is a lifelong pattern or a more immediate emotional response to the pregnancy. If it seems to be the latter, the emotional and social factors in her current life situation should be investigated. The patient should be encouraged to ventilate her problems and suggestions may be made for environmental changes if indicated. If, on the other hand, this is a life long pattern probably very little can be done, but the doctor needs to be aware that her neglectful behavior may be potentially dangerous to her own health or to the fetus. There is a need to see her more frequently than he would see the usual patient.
8. The Perfectionistic Patient.-In contrast to the apathetic, irresponsible patient just described, this individual characteristically follows every instruction to the letter. Even having done this, she will doubt whether she really is doing exactly the right thing. She will call and repeatedly question the physician to make certain that she is making no mistakes and is doing everything in the most exemplary manner. This may become exasperating to the obstetrician who will find that the more he reassures her, the more questions and doubts are forthcoming. This woman has a need to do everything perfectly to hide from herself and others unconscious impulses that would be to her far from "perfect." Therefore, reassurance will be of little benefit because it will not approach the areas of conflict that are hidden by her obsessive manifestations. Perhaps the most helpful method with such a woman would be to take a matter-of-fact attitude which would avoid reinforcing her doubts. Excessive reassurance accentuates uncertainties by giving them status. 9. The Withdrawn Woman.-It will be very difficult to establish communication with this person. The more aggressive the doctor becomes in trying to draw her out the more she will retreat, leaving the physician rather puzzled. He will not have complaints from her May-June, 1963
but he will have an uneasy feeling that there is more to be known about this woman. She probably has been reticent to communicate most of her life. If there are symptoms of emotional or physical complications he probably won't hear about them until they are advanced. When such a patient is recognized, the most effective way of establishing a useful relationship is for the physician to say little except to indicate that he is interested in hearing her problems. At each visit, she should be afforded an opportunity to bring forth her thoughts. The quietly accepting manner of the physician should give her confidence to express herself.
10. The Normal Patient.-A description of the normal pregnant woman has purposely been left for last. One might facetiously remark that to the obstetrician the normal woman is one who has no complaints, makes no demands, and has no anxieties. However, such a patient is not really likely to be "normal." As was stated earlier, since pregnancy is a period of dynamic emotional readjustment, it is expected that a woman will have some anxiety and questions about her own physiology, what labor and delivery are like and whether she is in satisfactory physical condition to bear a healthy child. She looks for a moderate degree of warmth and acceptance from her obstetrician and wants to feel free to ask him questions, even though she herself may consider some of them a little silly, and to be able to express a usual amount of apprehension. She will call the physician at times during her pregnancy concerning certain symptoms or activities and on occasion may even be tearful and show signs of indecisiveness. She seeks acceptance in return for the confidence and respect she has for her physician. She prefers a warm, gentle but firm and decisive obstetrician. Since doctors, as well as patients, are distinct individuals, each will vary in the personality and habit patterns displayed in dealing with patients. Obstetricians inspecting the following categories will have little difficulty in recognizing many of their colleagues, but perhaps few will be introspective enough to accurately place themselves. However, many may find certain of their own traits in several of these descriptions. 145
PSYCHOSOMATICS OBSTETRICIAN'S PERSONALITIES
1. The Authoritarian Doctor.-Many physicians present themselves to patients in a manner which is best labeled as authoritarian. As the term implies, such an individual is characterized by his dogmatic way of making statements and giving instructions. He is often brusque or overbearing and will certainly not offer· the patient any opportunity for selfexpressipn. The patient will be told what she must or must not do, but will never be offered any option or choice in regard to either important or inconsequential matters. He will brush aside desires and suggestions expressed by the patient. The authoritatrian manner will limit the patient's ability to communicate with the doctor and she will hesitate to mention doubts, concerns or even symptoms. Some patients respond to this physician with a mixture of fear and worship. Women who have difficulty in making decisions and those who feel more secure when they are rigidly controlled will ?ften be best managed by a physician who IS able to assume a dominant role. Others, resenting a dictatorial manner, will find occasion to flaunt this control. An authoritarian approach is particularly unsuitable for the emotionally mature woman who expects advice and information rather than dictation from the obstetrician. 2. The Permissive Obstetrician.-In contrast to the authoritarian personality, there are obstetricians who are excessively permissive in their doctor-patient relationships. Their patients develop the impression that they can do as they please and may feel that they themselves are directing modes of management. Permissiveness in areas that do not involve the health of the mother and child is often desirable, especially if the patient is mature and well informed. There has been a recognition of this in the modern prenatal programs which allow the mothers to select for themselves an overall approach to prenatal care and delivery. Examples include allowing the patients to participate in elective programs such as natural childbirth and rooming-in plans. However, the physician who is habitually permissive may appear indecisive, disinterested or lacking in professional ability. Ideally, permissiveness should not be free of 146
mutually understood responsibility and authority. Placing the responsibility for a decision on the patient when a real matter of health is concerned is highly undesirable. An illustration .is that of a patient who has symptoms suggesting threatened abortion, to whom the doctor responds, "You can go to bed if you wish, or I could give you some hormones, but I doubt that anything will make much difference." While this may be medically sound, it produces conflict and insecurity in the patient. If she does abort, she will feel that she herself made the wrong decision and blame herself. The habitually permissive physician who cannot season his approach with a show of strength when necessary will he given a workout by his patients who will hecome insecure and demanding.
3. The Aloof Physician.-Patients may regard the aloof physician with awe. He appears to be concerned with matters far heyond the everyday complaints of a mere woman. Questions or doubts expressed by the patient are usually ignored or dealt with in a manner which suggests their unimportance. When information or explanation is advanced by this doctor, it probably will be too technical for the average patient to understand and therefor increases the remoteness of the relationship. When a patient calls the aloof physician, she may speak to him if she succeeds in penetrating the gauntlet of those who protect the doctor's precious time. This doctor may be popular with patients who tend to regard their physician as a symbol of mysterious knowledge and skill rather than as a warm, understanding, and wise person. '''hen suggestion is used by the aloof physician, it may result in symtomatic relief in much the same manner as does a placebo, but as in the case of the authoritarian physician there will be a barrier to desirahle communication between patient and doctor. 4. The Histrionic Healer.- The histrionic doctor sells drama as well as healing. To a patient, he is the image of the hero physician saving lives and averting disaster in the nick of time. Patients who present unusual or moderately complicated courses will get plenty Volume IV
PATIENTS AND THEIR OBSTETRICIANS-MIDDLETON AND HUFFER
of ammunition for the "My doctor told me" kind of bridge table conversation. Unfortunately, unguarded exaggeration originating with the doctor will be re-exaggerated to sensational proportions by the patient. All of us wonder at times about the source of strange statements elicited during history taking, such as "Another doctor told me that if I got pregnant again I would probably die." Yet careful evaluation turns up nothing more threatening than a retroverted uterus. In spite of awareness concerning the effect of illadvised comments to patients, this physician cannot resist the temptation to impress. Let him best satisfy his ego by telling clinical drama stories to his colleagues, for they can listen with judgment as well as amusement. All too often patients are encountered who have been needlessly concerned for years as a result of some distorted idea related to their reproductive function which can be found to originate in an incautious remark by a physician.
5. The Charmer.- This doctor is characterized by the use of many devices of familiarity or intimacy as a "bedside manner." Patients are usually addressed by him in terms of endearment, such as "Honey" or "Dear". Hand holding or similar acts may be frequently employed. The charmer's approach is used with the presumption that the patient will feel that her doctor is expressing sympathy, interest and concern. Actually, this technique encourages the natural tendency of many patients to regress to a dependent child-like state. In this state, since the doctor would be regarded as an omnipotent figure, the patient is shorn of many of her defenses and the physician finds it easy to dominate and control her. However, the physician who habitually uses the endearing approach may discover to his dismay that a number of patients will respond not by becoming the "good" child but by behaving as a "spoiled" one who is querulous and demanding. Other patients, resenting an unwarranted familiarity, will become more distant and cool toward their physician. It should be added that doctors sometimes cloak attitudes of condescension and irritation towards patients with a brusque form of familiarity. May-June, 1963
6. The Gossip.-As the name implies, this doctor talks too much. He has the habit of making his patient's visits more like social calls. If the patient should divulge something quite intimate to the physician, he may either show undue interest, or respond by revealing choice items of a personal nature which often are about other physicians, nurses, patients, wives or secretaries. This may temporarily reassure the patient that she is not alone in some area of experience or that she has an inside track with her obstetrician. On later reflection, she will realize that confidential material has been disclosed, and she will be confronted with the deduction that another person will soon hear about her own private story. Needless to say, this patient will have less respect and confidence in her doctor and will be certain to hecome more reticent with him. 7. The Fussbudget.- This individual is so recognizable in any situation that little description is necessary. As a physician, he is prone to nag patients, nurses, house officers and secretaries. Understandably, he is likely to become unpopular with all of these. With patients, he may give the impression of great attention to detail, thereby cloaking himself with an appearance of being thorough and conscientious. The fussbudget, by his nature, is expressing a great deal of insecurity and anxiety. There is a probability that this will be perceived by patients, with the result that similar feelings will be aroused. Such a relationship creates an atmosphere conducive to childbirth with fear. 8. The Harassed Doctor.-Being rushed is a real situation often encountered in the practice of medicine, but the physician who appears harassed as a behavior pattern will seem to be under considerable pressure for haste most of the time, even where there is no existing need. He is chronically disorganized and consequently scatters himself in many directions at the same time. To his patients, he may appear irritable and seldom has time to give them much personal attention. An attitude of haste often causes forgetfulness on the part of the doctor, and this is the physician who is most often embarrassed by having patients confront him with a contradiction in what he has told 147
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them on different occasions. His work-up of patients tends to be repetitious and fragmented.
9. The Ideal Obstetrician.-An ideal obstetrician, like all perfection, does not exist. Physicians know that to practice most effectively, they need attributes other than professional competence. The woman seeking care for pregnancy is not in a position to evaluate an obstetrician's skill, but will respond to his attitudes and manner. Perhaps, without being aware of it, the patient is seeking certain attributes which when perceived will enable her to feel that she is receiving the best care. It is necessary for a woman to feel that her obstetrician is interested in her as an individual. She .welcomes evidence that he has respect for her and is concerned for her feelings as well as her blood pressure. His accepting manner allows her to express qualms and questions. At the same time, a straightforward and matter-of-fact attitude will reassure her that nothing mysterious or threatening is taking place. He explains various aspects of her pregnancy and his management in such a way that misgivings tend to be dispelled by the knowledge of what to expect. He allows her freedom of choice in many areas but is definite in his instructions about items of major importance. The obstetrician who has these qualities cannot help but have a good understanding of his patients. Therefore, he is in an excellent position to individualize his supervision of labor and delivery so that it will be optimal for a patient. The ideal obstetrician never allows his patients to develop the feeling that they are being deserted during labor. This does not mean that he is in constant attendance at the bedside, but that after an initial examination soon after the onset of labor, he follows her as closely as is necessary for her. The best physician is one who is flexible enough to vary his attitudes and approaches as best suits the needs of his patients. If, as a result of the obstetrician's approach and attitude, the patient develops the feeling that at this time she is experiencing a wonderful and important moment of her life, her obstetrician for her has been ideal. 148
EXAMPlES OF DOCTOR-PATIENT INTERACTION
1. Undesirable.-Mrs. X, an aggressive demanding woman, goes to Dr. Y, who is exceedingly permissive and in general allows his patients to do as they wish. During her initial visit, Mrs. X states in no uncertain terms that she wants no sedation during her labor, nor will she accept any general or spinal anesthesia. She also wishes her husband to be with her throughout her labor and delivery. She plans not to gain a pound during pregnancy and asks for a diet that will give her all the nutriments, but which will allow her to maintain only her current weight of 120 pounds. Dr. Y agrees to all of this, even before examining her, and gives her a 1,200 calorie diet. The patient leaves triumphantly. At the next visit, examination reveals evidence of borderline pelvic capacity, but the obstetrician, in view of his agreement to the patient's demands, attempts to avoid thinking about the possible implications. The woman talks on and on about how wonderful she feels and how much she is looking forward to her delivery. The obstetrician fails to observe that "the lady doth protest too much", and that under this euphoric facade there is much anxiety. During the third month, the patient who has had slight intermittent cramping, calls the obstetrician and asks if it is all right for her to go dancing. She is told she may do so, if she feels like it. Early the next day, she appears at the office, saying her cramps are worse. Although examination reveals nothing of Significance, he suggests she may stay in bed if she wishes. She then requests medication, to which he complies. The following day, she calls complaining that the medication is no good and asks for something else. He again complies. By now, the patient is controlling the situation and the obstetrician is her pawn. While this is not comfortable for either, the obstetrician is unable to recognize that she is looking for limits and firmness from him in order that she may feel secure. Her controlling attitude is her own way of attempting to create security. During the remainder of her pregnancy this patient will find more and more requests to make, such as changing her appointments for her own convenience and then failing to keep them. Volume IV
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When Mrs. X goes into labor, she will probably have little confidence in herself and no security in her doctor whom she has controlled. She demands his constant attendance. If he attempts to leave the room, she screams for him to come back, but while he is there she verbally abuses him. Neither he nor her husband can calm her. The situation is now definitely out of control. The obstetrician, both in desperation and retaliation, gives her a large dose of sedation and then a general anesthesia at the time of delivery. The obstetrical outcome is satisfactory, but the overall doctorpatient relationship is a fiasco. 2. Desirable.-If Mrs. X had consulted the "ideal physician," who can recognize the insecurity beneath the demanding attitude and who is flexible enough to vary his approach, he would have responded to her in a more firm and direct manner. He would indicate willingness to follow her wishes insofar as there is no compromise of her safety and comfort, but would firmly convey an understanding that if at any time one procedure offers a
definite advantage, he reserves the privilege to recommend this. He would assure her that anything about which she feels extremely apprehensive would be avoided unless it becomes a medical necessity. She responds favorably in that her requests have been acknowledged and respect shown them, but she is relieved by knowing that the doctor is in control. It probably would be unnecessary for the patient to call asking about the advisability of dancing as she would have already been informed as to what activities are permissible. Should she call concerning questions or complaints, the obstetrician would be definite in his instructions, and not make additions or subtractions at the suggestion of the patient. Her awareness that she cannot manipulate him will in itself be reassuring, so that her need to pressure and demand will gradually lessen. At the time of labor, she will feel secure enough in her relationship with him that this will result in a cooperative venture, satisfying to both the physician and the patient.
There are signs of retrenchment in both research and practice (of psychosomatic medicine). The psychiatrist and even the psychoanalyst are becoming humble in the face of their failure to make a breakthrough in either the study or the treatment of these disorders.... It remains for the future to enguU the hull and perhaps hollowness of what was psychosomatics and use it in medicine generally. The family doctor is in the best position to do this. ERIC WITrKOWER, M.D., Third World Congress of Psychiatry, Montreal, June 4-10, 1961 (Quoted by Documenta Geigy)
May·June, 1963
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• During the past two decades, there has been an increasing appreciation by physicians in all branches of medicine that patients should be treated as a whole and not just as organ systems. This total approach is at least theoretically accepted by most doctors although in actual practice many avoid dealing with emotional aspects of their patients. In the field of obstetrics, the patient usually presents with a clearcut clinical entity, i.e., pregnancy, with definite procedures to be followed. Therefore, it is easy to develop a rather stereotyped approach and thereby lose sight of the individuality of the patient. Every woman who comes to an obstetrician brings her own personality pattern and set of values. Also, since pregnancy is such a major milestone in a woman's life, she naturally experiences a degree of emotional upheaval and readjushnents will be necessary. Her anxieties, conflicts, aspirations and ideals will be accentuated during this phase. Since the reproductive process is such a basic part of her concept of herself as a woman, she often bestows upon her obstetrician a more special and intimate role than she assigns to physicians from whom she seeks assistance for physical disease. Probably no physician, with the exception of a psychiatrist, plays such an important part in a woman's psychological life and well being. However, the obstetrician may not effectively utilize this advantageous position to the ultimate benefit of the patient. The doctor who is able to recognize and respond to the personality needs of his patients will not only promote their emotional well being, but he will in turn benefit by having more cooperative, secure and satisfied patients. It is one of the aims of this paper to describe the various types of patient pe.rsonalities as they present to an obstetrician From the Department of Obstetrics and Gynecology and Department of Psychiatry, University of Maryland, School of Medicine, Baltimore 1, Maryland.
142
and to discuss some of the factors behind the manifest behavior. Suggestions will be made as to possible ways of responding. Although emphasis has been placed on considering the emotional problems of the pregnant woman, little has been said about the effect of the personality of the obstetrician on patients' reactions. It is obvious, however, that the personality and manner of the obstetrician is of great importance to the patient. Her ability to establish a comfortable relationship with him and feel secure in this depends to a large degree on the physician himself. It is probably infrequent that an obstetrician asks himself how his attitudes affect his patients and if anything in his manner contributes to the various difficulties that may develop during the course of pregnancy. While it is impossible for a physician to obtain an ideal relationship with all of his patients, more self-awareness on the part of the doctor should aid him in recognizing how he relates to those who walk into his office. The fact that the obstetrician plays a part in setting the emotional tone of his patients can be illustrated by remarks that obstetrical nurses commonlv make. It is not unusual to hear comments' such as "that must be Dr. X's patient; she is so relaxed and cooperative", or "Dr. Y is admitting a patient. We are in for a hard night. His patients usually raise the roof." Inasmuch as it is important that the physician considers what he himself brings into the consultation room, the authors intend to categorize various personality types of obstetricians with the hope of encouraging them to be more introspective and possibly modify their reaction patterns to be suitable to the needs of the patients. Illustrations will be given of possible interactions between the personalities of physicians and patients, which demonstrate how they compliment each other or create disharmony. Volume IV
PATIENTS AND THEIR OBSTETRICIANS-MIDDLETON AND HUFFER
The following constitutes a description of various patient personalities as may be seen in an obstetrical practice. Obviously, the listing does not follow any standard nomenclature. Obstetricians will readily recognize that many patients in their own practices fall into these descriptive categories. The personality outlines are developed as they might apply to the average middle class married woman. PATIENT PERSONALITY
1. The Demanding, Controlling Woman.This is the patient who comes to the obstetrician's office with exceedingly definite ideas as to the way she thinks her pregnancy should be managed. She is opinionated on such subjects as anaesthesia, natural childbirth, rooming in, infant feeding, et cetera. She has read all of the lay literature and perhaps even some of the more technical articles concerning pregnancy and childbirth. Things must be done exactly as she wants and when she wants. Obviously, this is a difficult patient for the average obstetrician. Not only may he feel that his authority is threatened, but he also may consider her demands as incompatible with the best obstetrical care. The obstetrichili is often inclined to immediately give such a woman a lecttir~ and tell her that if she wishes him to be her doctor she will have to abide by his management. He frequently fails to recognize that the patient has developed a controlling, demanding attitude because of her own personality needs and that underneath this exterior there is a frightened woman. Her defense against her anxieties takes the form of a need to be in control. She may feel that she is' inadequate as a person and that she does not quite measure up to other people emotionally or physically. Her way of reacting against these fears is to attempt to arrange everything in a manner that she feels will make her superior to other women. The obstetrician is left with three choices: (1) to go along completely with her demands, (2) to become very aggressive himself and tell the patient that she will have to comply with his instructions or go elsewhere, or (3) be aware that this overbearing behavior reflects underlying anxieties. With the last in mind, the obstetrician may approach the patient not with the idea of wrenching all control from her immediately, but by graduMay-June, 1963
ally gaining her confidence, develop a mutually acceptable plan for her care.
2. The Scared, Modest Rabbit.-This patient will be visibly frightened, speak in a whisper and look very embarrassed. She will volunteer very little infonnation, and will give only monosyllabic answers to questions. She feels that the whole procedure is not ladylike. The physician will need to be quite gentle, and to be quietly reassuring, showing non-verbal acceptance and respect for her modesty. Direct confrontation by telling her not to be frightened and embarrassed will probably not be effective, neither will backslapping, kidding or coercive attitudes. Only time and a sustained attitude of patience will be helpful. 3. The Clinging, Complaining W oman.- The patient shows behavior which is regressive in nature, more appropriate for the small child who is ill than for the adult woman who presents with a nonnal physiologic process. This individual frequently presents a multitude of complaints. She fears any activity will hann either her or the fetus and for this reason she is constantly calling the obstetrician with one question after another. She has an endless store of complaints and queries which may cause the doctor to feel that he will never be able to get her out of his office or off the phone. These characteristics are symptoms of emotional immaturity which are accentuated during the pregnancy. This patient frequently drives her doctor to exasperation and he may become more and more curt and brusque with her to the point of being openly angry. Hostile rejection does come from the obstetrician when he can no longer bear the patient's numerous complaints. Such an intolerable situation is likely to develop if initially he did not recognize that she was a clinging, complaining person, but had accentuated her dependent behavior by constantly attempting to reassure her and answer her demands for attention. When one encounters this kind of regressive patient, a gentle, but finn approach is frequently effective. It would be preferable very early in the course of her care for the doctor to set up a definite schedule for her, leaving nothing vague or to chance. She can be encouraged to collect her questions to be presented at her next appointment rather than 14.1
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calling each time a thought occurs. Providing her with a definite schedule of activities will give her structure and therefore support to cling to between office visits.
4. The Independent, Bravado Type.-No complaints and very few questions are offered by such a patient. She may state that since pregnancy is nothing but a normal process, there is no reason to pamper herself in any way. She intends to go about her usual activities which could foreseeably range from mountain climbing to deep-sea diving. She most certainly is not going to have any of those silly little neurotic complaints that other pregnant women have. She exudes the attitude that women have been having babies for centuries, so why should there be any fuss? This patient may be very refreshing to the obstetrician. However, he should keep iIi mind that perhaps "the lady does protest too much" and that all this may be a defensive show of bravery. She denies the need within herself to fon"; any dependent relationship. It may be prudent for the doctor to convey to such a patient that this is all fine, but that she may have some anxieties or symptoms and she should feel free to discuss these with him. A source of difficulty with this patient is the possibility that she may deny symptoms of a potentially serious nature, and therefore fail to infonn her obstetrician. 5. The Irresistible Female Type.-This woman trades on being coy and seductive. Her main aim in life is to have any and every man succumb to her charm. Indeed, she may be very tempting! This patient is likely to get into psychological difficulty during late pregnancy when she no longer feels attractive. This is a blow to her narcissism and may result in a degree of depression. The process of labor and delivery will be especially repugnant to her, and at this time she may appear to be a very disturbed person. No longer can she be the irresistible, beautiful creature. Not only is she experiencing discomfort, but the responsibilities and restrictions that the care of a child necessitate are imminent. Previously, she had thought of a baby as a toy or a doll that might further aggrandize her femininity. During the post-partum period, she may become seriously depressed 144
or manifest other undesirable emotional responses. Not only should the obstetrician be mindful of this, but during the course of prenatal care he may have approached her in ways to have helped her adjust to motherhood. If he has discreetly emphasized his respect for the mature, motherly woman rather than having encouraged her seductive, immature playfulness, he may have promoted emotional growth during her pregnancy.
6. The Resentful Wornan.-Even though the pregnancy was planned, this woman is not pleased. She feels that society demands that a woman should have children, but to her the whole process is a nuisance. Because of her hostility and resentment, she is likely to be very negativistic with her obstetrician even to the point of giving the impression that he, along with the rest of society, is responsible for what to her is a most unpleasant situation. As an outlet for her resentment, she will question in a hostile way everything that the physician tells her and will use many devices to place him on the defensive. However, her own conscience makes her feel that this resentful attitude is not acceptable and therefore she frequently will, by her questions and ideas, betray feelings of guilt. This patient has a deep-seated emotional conflict over the role of femininity, and the obstetrician may feel at a loss to know what he can do to make the situation more acceptable. First, he might relieve her guilt to a certain extent by pointing out that often women are not pleased with the idea of having a baby. This will allow her to feel that she is not alone in her attitude and that this is something that she can discuss with the physician. He may take steps to manage her labor and delivery so as to forestall as much as possible her feeling that she is being put in a depreciated state during the actual delivery. For example, to this woman, being put up in stirrups and having her wrists shackled during delivery would be felt by her to be degrading. If the physician can get over to her the idea that being able to have a baby is a real asset and that she is acquiring something of great value, he will have indeed accomplished a major feat. 7. The Apathetic and Irresponsible Type.This woman gives the impression of indifferVolume IV
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ence as to what happens to her during the reproductive process. She will take no active interest in any prenatal program which her physician presents, and seldom asks questions. Instructions given her are likely to be disregarded. It would be important for the obstetrician to ascertain whether this is a lifelong pattern or a more immediate emotional response to the pregnancy. If it seems to be the latter, the emotional and social factors in her current life situation should be investigated. The patient should be encouraged to ventilate her problems and suggestions may be made for environmental changes if indicated. If, on the other hand, this is a life long pattern probably very little can be done, but the doctor needs to be aware that her neglectful behavior may be potentially dangerous to her own health or to the fetus. There is a need to see her more frequently than he would see the usual patient.
8. The Perfectionistic Patient.-In contrast to the apathetic, irresponsible patient just described, this individual characteristically follows every instruction to the letter. Even having done this, she will doubt whether she really is doing exactly the right thing. She will call and repeatedly question the physician to make certain that she is making no mistakes and is doing everything in the most exemplary manner. This may become exasperating to the obstetrician who will find that the more he reassures her, the more questions and doubts are forthcoming. This woman has a need to do everything perfectly to hide from herself and others unconscious impulses that would be to her far from "perfect." Therefore, reassurance will be of little benefit because it will not approach the areas of conflict that are hidden by her obsessive manifestations. Perhaps the most helpful method with such a woman would be to take a matter-of-fact attitude which would avoid reinforcing her doubts. Excessive reassurance accentuates uncertainties by giving them status. 9. The Withdrawn Woman.-It will be very difficult to establish communication with this person. The more aggressive the doctor becomes in trying to draw her out the more she will retreat, leaving the physician rather puzzled. He will not have complaints from her May-June, 1963
but he will have an uneasy feeling that there is more to be known about this woman. She probably has been reticent to communicate most of her life. If there are symptoms of emotional or physical complications he probably won't hear about them until they are advanced. When such a patient is recognized, the most effective way of establishing a useful relationship is for the physician to say little except to indicate that he is interested in hearing her problems. At each visit, she should be afforded an opportunity to bring forth her thoughts. The quietly accepting manner of the physician should give her confidence to express herself.
10. The Normal Patient.-A description of the normal pregnant woman has purposely been left for last. One might facetiously remark that to the obstetrician the normal woman is one who has no complaints, makes no demands, and has no anxieties. However, such a patient is not really likely to be "normal." As was stated earlier, since pregnancy is a period of dynamic emotional readjustment, it is expected that a woman will have some anxiety and questions about her own physiology, what labor and delivery are like and whether she is in satisfactory physical condition to bear a healthy child. She looks for a moderate degree of warmth and acceptance from her obstetrician and wants to feel free to ask him questions, even though she herself may consider some of them a little silly, and to be able to express a usual amount of apprehension. She will call the physician at times during her pregnancy concerning certain symptoms or activities and on occasion may even be tearful and show signs of indecisiveness. She seeks acceptance in return for the confidence and respect she has for her physician. She prefers a warm, gentle but firm and decisive obstetrician. Since doctors, as well as patients, are distinct individuals, each will vary in the personality and habit patterns displayed in dealing with patients. Obstetricians inspecting the following categories will have little difficulty in recognizing many of their colleagues, but perhaps few will be introspective enough to accurately place themselves. However, many may find certain of their own traits in several of these descriptions. 145
PSYCHOSOMATICS OBSTETRICIAN'S PERSONALITIES
1. The Authoritarian Doctor.-Many physicians present themselves to patients in a manner which is best labeled as authoritarian. As the term implies, such an individual is characterized by his dogmatic way of making statements and giving instructions. He is often brusque or overbearing and will certainly not offer· the patient any opportunity for selfexpressipn. The patient will be told what she must or must not do, but will never be offered any option or choice in regard to either important or inconsequential matters. He will brush aside desires and suggestions expressed by the patient. The authoritatrian manner will limit the patient's ability to communicate with the doctor and she will hesitate to mention doubts, concerns or even symptoms. Some patients respond to this physician with a mixture of fear and worship. Women who have difficulty in making decisions and those who feel more secure when they are rigidly controlled will ?ften be best managed by a physician who IS able to assume a dominant role. Others, resenting a dictatorial manner, will find occasion to flaunt this control. An authoritarian approach is particularly unsuitable for the emotionally mature woman who expects advice and information rather than dictation from the obstetrician. 2. The Permissive Obstetrician.-In contrast to the authoritarian personality, there are obstetricians who are excessively permissive in their doctor-patient relationships. Their patients develop the impression that they can do as they please and may feel that they themselves are directing modes of management. Permissiveness in areas that do not involve the health of the mother and child is often desirable, especially if the patient is mature and well informed. There has been a recognition of this in the modern prenatal programs which allow the mothers to select for themselves an overall approach to prenatal care and delivery. Examples include allowing the patients to participate in elective programs such as natural childbirth and rooming-in plans. However, the physician who is habitually permissive may appear indecisive, disinterested or lacking in professional ability. Ideally, permissiveness should not be free of 146
mutually understood responsibility and authority. Placing the responsibility for a decision on the patient when a real matter of health is concerned is highly undesirable. An illustration .is that of a patient who has symptoms suggesting threatened abortion, to whom the doctor responds, "You can go to bed if you wish, or I could give you some hormones, but I doubt that anything will make much difference." While this may be medically sound, it produces conflict and insecurity in the patient. If she does abort, she will feel that she herself made the wrong decision and blame herself. The habitually permissive physician who cannot season his approach with a show of strength when necessary will he given a workout by his patients who will hecome insecure and demanding.
3. The Aloof Physician.-Patients may regard the aloof physician with awe. He appears to be concerned with matters far heyond the everyday complaints of a mere woman. Questions or doubts expressed by the patient are usually ignored or dealt with in a manner which suggests their unimportance. When information or explanation is advanced by this doctor, it probably will be too technical for the average patient to understand and therefor increases the remoteness of the relationship. When a patient calls the aloof physician, she may speak to him if she succeeds in penetrating the gauntlet of those who protect the doctor's precious time. This doctor may be popular with patients who tend to regard their physician as a symbol of mysterious knowledge and skill rather than as a warm, understanding, and wise person. '''hen suggestion is used by the aloof physician, it may result in symtomatic relief in much the same manner as does a placebo, but as in the case of the authoritarian physician there will be a barrier to desirahle communication between patient and doctor. 4. The Histrionic Healer.- The histrionic doctor sells drama as well as healing. To a patient, he is the image of the hero physician saving lives and averting disaster in the nick of time. Patients who present unusual or moderately complicated courses will get plenty Volume IV
PATIENTS AND THEIR OBSTETRICIANS-MIDDLETON AND HUFFER
of ammunition for the "My doctor told me" kind of bridge table conversation. Unfortunately, unguarded exaggeration originating with the doctor will be re-exaggerated to sensational proportions by the patient. All of us wonder at times about the source of strange statements elicited during history taking, such as "Another doctor told me that if I got pregnant again I would probably die." Yet careful evaluation turns up nothing more threatening than a retroverted uterus. In spite of awareness concerning the effect of illadvised comments to patients, this physician cannot resist the temptation to impress. Let him best satisfy his ego by telling clinical drama stories to his colleagues, for they can listen with judgment as well as amusement. All too often patients are encountered who have been needlessly concerned for years as a result of some distorted idea related to their reproductive function which can be found to originate in an incautious remark by a physician.
5. The Charmer.- This doctor is characterized by the use of many devices of familiarity or intimacy as a "bedside manner." Patients are usually addressed by him in terms of endearment, such as "Honey" or "Dear". Hand holding or similar acts may be frequently employed. The charmer's approach is used with the presumption that the patient will feel that her doctor is expressing sympathy, interest and concern. Actually, this technique encourages the natural tendency of many patients to regress to a dependent child-like state. In this state, since the doctor would be regarded as an omnipotent figure, the patient is shorn of many of her defenses and the physician finds it easy to dominate and control her. However, the physician who habitually uses the endearing approach may discover to his dismay that a number of patients will respond not by becoming the "good" child but by behaving as a "spoiled" one who is querulous and demanding. Other patients, resenting an unwarranted familiarity, will become more distant and cool toward their physician. It should be added that doctors sometimes cloak attitudes of condescension and irritation towards patients with a brusque form of familiarity. May-June, 1963
6. The Gossip.-As the name implies, this doctor talks too much. He has the habit of making his patient's visits more like social calls. If the patient should divulge something quite intimate to the physician, he may either show undue interest, or respond by revealing choice items of a personal nature which often are about other physicians, nurses, patients, wives or secretaries. This may temporarily reassure the patient that she is not alone in some area of experience or that she has an inside track with her obstetrician. On later reflection, she will realize that confidential material has been disclosed, and she will be confronted with the deduction that another person will soon hear about her own private story. Needless to say, this patient will have less respect and confidence in her doctor and will be certain to hecome more reticent with him. 7. The Fussbudget.- This individual is so recognizable in any situation that little description is necessary. As a physician, he is prone to nag patients, nurses, house officers and secretaries. Understandably, he is likely to become unpopular with all of these. With patients, he may give the impression of great attention to detail, thereby cloaking himself with an appearance of being thorough and conscientious. The fussbudget, by his nature, is expressing a great deal of insecurity and anxiety. There is a probability that this will be perceived by patients, with the result that similar feelings will be aroused. Such a relationship creates an atmosphere conducive to childbirth with fear. 8. The Harassed Doctor.-Being rushed is a real situation often encountered in the practice of medicine, but the physician who appears harassed as a behavior pattern will seem to be under considerable pressure for haste most of the time, even where there is no existing need. He is chronically disorganized and consequently scatters himself in many directions at the same time. To his patients, he may appear irritable and seldom has time to give them much personal attention. An attitude of haste often causes forgetfulness on the part of the doctor, and this is the physician who is most often embarrassed by having patients confront him with a contradiction in what he has told 147
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them on different occasions. His work-up of patients tends to be repetitious and fragmented.
9. The Ideal Obstetrician.-An ideal obstetrician, like all perfection, does not exist. Physicians know that to practice most effectively, they need attributes other than professional competence. The woman seeking care for pregnancy is not in a position to evaluate an obstetrician's skill, but will respond to his attitudes and manner. Perhaps, without being aware of it, the patient is seeking certain attributes which when perceived will enable her to feel that she is receiving the best care. It is necessary for a woman to feel that her obstetrician is interested in her as an individual. She .welcomes evidence that he has respect for her and is concerned for her feelings as well as her blood pressure. His accepting manner allows her to express qualms and questions. At the same time, a straightforward and matter-of-fact attitude will reassure her that nothing mysterious or threatening is taking place. He explains various aspects of her pregnancy and his management in such a way that misgivings tend to be dispelled by the knowledge of what to expect. He allows her freedom of choice in many areas but is definite in his instructions about items of major importance. The obstetrician who has these qualities cannot help but have a good understanding of his patients. Therefore, he is in an excellent position to individualize his supervision of labor and delivery so that it will be optimal for a patient. The ideal obstetrician never allows his patients to develop the feeling that they are being deserted during labor. This does not mean that he is in constant attendance at the bedside, but that after an initial examination soon after the onset of labor, he follows her as closely as is necessary for her. The best physician is one who is flexible enough to vary his attitudes and approaches as best suits the needs of his patients. If, as a result of the obstetrician's approach and attitude, the patient develops the feeling that at this time she is experiencing a wonderful and important moment of her life, her obstetrician for her has been ideal. 148
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1. Undesirable.-Mrs. X, an aggressive demanding woman, goes to Dr. Y, who is exceedingly permissive and in general allows his patients to do as they wish. During her initial visit, Mrs. X states in no uncertain terms that she wants no sedation during her labor, nor will she accept any general or spinal anesthesia. She also wishes her husband to be with her throughout her labor and delivery. She plans not to gain a pound during pregnancy and asks for a diet that will give her all the nutriments, but which will allow her to maintain only her current weight of 120 pounds. Dr. Y agrees to all of this, even before examining her, and gives her a 1,200 calorie diet. The patient leaves triumphantly. At the next visit, examination reveals evidence of borderline pelvic capacity, but the obstetrician, in view of his agreement to the patient's demands, attempts to avoid thinking about the possible implications. The woman talks on and on about how wonderful she feels and how much she is looking forward to her delivery. The obstetrician fails to observe that "the lady doth protest too much", and that under this euphoric facade there is much anxiety. During the third month, the patient who has had slight intermittent cramping, calls the obstetrician and asks if it is all right for her to go dancing. She is told she may do so, if she feels like it. Early the next day, she appears at the office, saying her cramps are worse. Although examination reveals nothing of Significance, he suggests she may stay in bed if she wishes. She then requests medication, to which he complies. The following day, she calls complaining that the medication is no good and asks for something else. He again complies. By now, the patient is controlling the situation and the obstetrician is her pawn. While this is not comfortable for either, the obstetrician is unable to recognize that she is looking for limits and firmness from him in order that she may feel secure. Her controlling attitude is her own way of attempting to create security. During the remainder of her pregnancy this patient will find more and more requests to make, such as changing her appointments for her own convenience and then failing to keep them. Volume IV
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When Mrs. X goes into labor, she will probably have little confidence in herself and no security in her doctor whom she has controlled. She demands his constant attendance. If he attempts to leave the room, she screams for him to come back, but while he is there she verbally abuses him. Neither he nor her husband can calm her. The situation is now definitely out of control. The obstetrician, both in desperation and retaliation, gives her a large dose of sedation and then a general anesthesia at the time of delivery. The obstetrical outcome is satisfactory, but the overall doctorpatient relationship is a fiasco. 2. Desirable.-If Mrs. X had consulted the "ideal physician," who can recognize the insecurity beneath the demanding attitude and who is flexible enough to vary his approach, he would have responded to her in a more firm and direct manner. He would indicate willingness to follow her wishes insofar as there is no compromise of her safety and comfort, but would firmly convey an understanding that if at any time one procedure offers a
definite advantage, he reserves the privilege to recommend this. He would assure her that anything about which she feels extremely apprehensive would be avoided unless it becomes a medical necessity. She responds favorably in that her requests have been acknowledged and respect shown them, but she is relieved by knowing that the doctor is in control. It probably would be unnecessary for the patient to call asking about the advisability of dancing as she would have already been informed as to what activities are permissible. Should she call concerning questions or complaints, the obstetrician would be definite in his instructions, and not make additions or subtractions at the suggestion of the patient. Her awareness that she cannot manipulate him will in itself be reassuring, so that her need to pressure and demand will gradually lessen. At the time of labor, she will feel secure enough in her relationship with him that this will result in a cooperative venture, satisfying to both the physician and the patient.
There are signs of retrenchment in both research and practice (of psychosomatic medicine). The psychiatrist and even the psychoanalyst are becoming humble in the face of their failure to make a breakthrough in either the study or the treatment of these disorders.... It remains for the future to enguU the hull and perhaps hollowness of what was psychosomatics and use it in medicine generally. The family doctor is in the best position to do this. ERIC WITrKOWER, M.D., Third World Congress of Psychiatry, Montreal, June 4-10, 1961 (Quoted by Documenta Geigy)
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