Friday Reflection 5: Well, That Could Have Gone Better

LB is a 70-year-old man who comes to the general medicine clinic for follow up of his multiple medical issues. He presents every three months or so for care of his hypertension, chronic lower extremity deep venous thrombosis and back pain.

LB was a long-term patient of mine with whom I was never my best. Pretty much every visit with him ended with me leaving the room thinking, “well, that could have gone better.”

After a few visits, early in our 20-plus year relationship, I realized that these visits were difficult and I tried to figure out how I could do better. I’d pause and reflect before the visits. I’d schedule the visits on days I had no other patients so there was no time pressure. I’d send a medical student in to gather information so my time with him could be more focused. Nothing really worked.

Most doctors develop a clinical persona that works with, let’s say, 90% of their patients. It includes some combination of kindness, patience, empathy, professionalism and their own, idiosyncratic personality. This persona is their bedside manner. Doctors, who excel in building rapport, subtly tailor this persona to each individual, being mindful of the how everybody in the room is reacting to each other. (Richard Epstein wrote an amazing essay on this sort of mindful practice.)

The real pros, doctors who are a pleasure to observe as well as to see as a patient, can change their approach, their persona, for the 10% of people for whom their default setting fails to connect. They recognize that the clinical relationship is a tool with which to improve the outcomes of their patients and that one needs a variety of tools. I have watched endlessly polite, deferential clinicians shift to being paternalistic, needling, demanding, or edgy if that is what they sense will work.

None of this is much different to how we all behave socially. We are always ourselves, but we are also subtly different in the variety of settings and with the array of family, friends and acquaintances with whom we live, work, and play. What is different about physicians is that, if they are to be successful, they need to excel in these interactions, 12-50 times a day, with anyone who shows up in the office. And, some of the people who show up in the office, like those you meet in your life’s travels, can be downright difficult.

Any doctor, who is being honest, can identify a handful of patients with whom they struggle to connect.

If I think of the 10 or so “well, that could have gone better” patients in my practice, they seem to fall into two groups. The first is the group of people who possess a certain combination of behaviors and traits that I’ve realized are my kryptonite. These people have high levels of health related anxiety, they have poor medical literacy, and they interact with an accusatory edge. I’m pretty good with anxiety. I’ve spent my career in medical education and I love helping people understand medical issues. I kind of the love the challenge of the combative, mistrustful, suspicious and litigious. But, combine all of these in a single person, and I struggle. This might sound like the rare type but I care for 6 or 7 of these people.

The reason for my struggles with the rest of my “well, that could have gone better” patients: countertransference. My discussion of transference and countertransference will probably make a psychotherapist squirm, but here is my internist view. Transference occurs when a patient transfers aspects of a relationship with someone else to the therapist. Countertransference, thus, is when a therapist’s own relations, emotions, attachments are transferred to the patient. With the number and array of patients we all see, there are bound to be patients that remind us friends, enemies, lovers, and family. Occasionally, the reaction is powerful.

LB bore an uncanny resemblance to my Uncle Pat. I loved Pat dearly but he could irritate me to no end. Without ever directly expressing an opinion, he made his opinions known in subtle, often barbed comments. He cloaked this skill with such self-effacement that, if ever challenged, he would claim that he had no idea to what you were referring. He would say that he was not nearly smart enough to have a real opinion on this or that topic. Pat never asked for anything; he just let you know how nice it would be to have a cup of coffee, right now. Uncle Pat was also unendingly loving and supportive, always ready on the other end of the phone to help with any situation.

LB looked a bit like Pat. He even sounded a lot like Pat -- though his accent was distinctly Chicago rather than Pat’s New York. Stoicism was unknown to LB. Any perceived ill would lead to anxious calls for immediate attention and intervention. These needs were motivated by an obvious fear of illness, which he would never acknowledge. His frequent calls each began with, “I don’t want to bother you, I know you have people with greater needs than my own.” In addition, more than one visit ended with me asking, “Is there something I can do for you?” when LB seemed to be hinting at, but not articulating, a need. He was also thoroughly polite and adored by his wife and children whom I met during his one brief hospitalization.

The fact that the “problem” with LB was my problem was never clearer than when I sent a medical student in to start a visit. Students always found him kind, cooperative, and charming. One student, with whom I shared my struggles with LB, actually noted, “It seemed like I was talking to a different person from the one you described.”

My response to LB could be visceral – I could feel my stomach tightening. It was a familiar sensation; I had felt it since I was a teenager when Uncle Pat would get under my skin. Countertransference has never been so obvious.

For years, LB was a patient who demanded little thought. He was healthy and our visits and phone conversations, though trying, were short and asked little of me beyond an effort to be patient and assuage his latest anxieties. I never considered how my feelings toward him affected the care I delivered. Until I had to.

At a visit more than a decade and half into our relationship, LB complained of hip pain. The pain was one of many concerns and certainly not the most pressing. On his exam I found nothing and did not even mention it in my visit summary. Two calls about the hip pain followed in the days after the appointment. I saw him again a week later, having overbooked him in a clinical session, and remember feeling especially put upon at the visit. I ordered an x-ray, mostly because I was busy, had little time to think, and had already expended significant energy reassuring him. The x-ray was normal but the calls (and his pain) did not stop. I sent him to an orthopedic colleague to transfer the calls to someone else. The orthopedist, immediately concerned about a femoral stress fracture, made the diagnosis on the day he met him with an MRI.

I wondered how our conversation about my 2-week delay in diagnosing his fracture would go at my next visit with LB. I knew that my reaction to him had affected the care I had provided. My energy was spent suppressing the irritation he caused me rather than on thinking about his problem. The “affective neutrality” that we all try to maintain, was lost to me during our visits. I wondered if I should have ended our relationship years earlier.

LB was gracious about the events.  He thanked me for sending him to an excellent orthopedist. I pointed out that it took me 2 weeks to refer him, delaying his diagnosis. His replay? “No harm not foul.” He told me that he remained confident in my care and was proud to call me his doctor.

I sat quietly for 10 or 15 seconds. I needed to punish myself and I needed him to participate.

“Does it seem like I am often annoyed with you even though there is nothing you do to deserve that? I worry I lose my patience with you during our visits and that my attitude affects my ability to care for you. ”

What was I looking for here? Did I think that putting my feelings on the table might help me take better care of him? Being honest, part of me hoped that my question would give LB license to express dissatisfaction, become angry. Maybe he would even end our relationship.

“No, you always seem very patient with me. I know I can be a bit of a pain in the you know-what. Most people get irritated with me at some point. I’ve stuck with you for longer than I have with any other doctor.”

I have long known that asking patients to identify their emotions is a powerful tool.  “You seem angry” or “you must be frightened by this situation” often gives license to people to be honest and move an interaction forward. It’s not often that I’ve found the needs to call out my emotions during a visit but this had a remarkable effect. I felt better having admitted my error and, while not discussing my uncle and countertransference, having opened up about what I felt was challenging about our relationship.

I left the appointment thinking, “I’m surprised how well that went.”

Our relationship did not magically improve. There were still calls and visits that I found exhausting. However, admitting my response to LB somehow made it more manageable for me. His honest expression of insight also brought about more empathy for him. I actually looked forward to our visits.

Recognizing the challenges to a patient/doctor relationship is often simple. What characteristics do we, individually perform poorly with? When is damaging countertransference present? Insight, however, does not always improve a relationship. I’ll always remember my “post fracture” visit with LB as a time when it did.