Case Scenario

I had a patient whom I actively disliked, and whenever I saw his name on my list I worked to suppress my uncomfortable negative feelings. My initial problems with him had to do with his passive attitude that, at times, bordered on hostility. For example, if I suggested he make lifestyle changes to deal with his obesity, he would shrug. If I pointed out a laboratory test abnormality—his cholesterol was too high, or his kidneys were going downhill—he would say, “You're the doctor,” with an edge of aggression, as though these were problems for me alone to solve.

I felt certain he was depressed and tried to convince him that antidepressants could help him, but he refused. He never followed my advice or showed any warmth or pleasant affect. However, in what amounted to a thank you, he told me repeatedly that I was the only doctor over the years who had stuck with him.

At one of his office visits, he revealed something about himself that turned my dislike into frank aversion. During this visit, I again attempted to convince him to start a course of antidepressants. His response was to reveal to me that he has, in the past, avenged his neglected youth by publicly humiliating black persons and by having vicious confrontations with persons of other ethnic minorities.

My interpretation of this confession was that he felt it rationalized how he had dealt with feelings of depression in the past and justified his current refusal to take anti-depressants. I thought he might be telling me that his savage actions were appropriate ways of expressing hostility because they were direct and external actions, whereas antidepressants were for “sissies.” I was overcome with revulsion as he spoke and showed no interest or remorse. I asked myself how I could continue taking care of such a reprehensible man.

At the next opportunity, I discussed my distress with my colleagues, who suggested that I discharge the patient. Certainly no one else in the practice was eager to take him on. However, I did not feel that I could simply send him away, because I had the sense that my sticking with him was the only positive experience in his life; to send him away would be an act of abandonment. Therefore, I continued to care for him until he was transferred to another location, subsequently leaving my practice.

Obviously, my care meant something to this patient, although it was not anything I could interpret as medically or interpersonally meaningful. At what point is a physician no longer obligated to take care of a patient who has moral, political, or religious views that are dissonant with one's own? What if the physician considers these views reprehensible?

Commentary

Patients who present to the clinic without having followed the treatment plan endorsed at previous visits may frustrate us on both professional and personal levels. Professionally, failure to comply with a treatment plan can result in a setback in the patient's condition or in avoidable complications, which may require a different intervention because of the progression of disease. We may wonder why patients choose to seek care—or care from us in particular—if they have no intentions of engaging in their own care. In addition, we deal with the frustration of wanting to help patients (which is why many of us pursued a career in medicine in the first place) who seemingly do not want our help.

This clinical scenario raises two interrelated issues: (1) value conflicts between patients and physicians; and (2) the appropriateness of discharging a patient from one's practice. A third issue, patient adherence, also involves patient and physician behavior.

The major challenge in this case is what to do with the dissonant religious, political, and cultural views that this patient shared with the physician. Value conflicts are commonplace and, therefore, every physician must attend to them. Sometimes the difference in values may be one of preference: a Somali woman may prefer to see only female physicians, for example. However, the difference in values may be more significant, such as when a woman may request emergency contraception from a physician who is morally opposed to this intervention.

As physicians, our job places us in a position to interact with people of many different cultural, spiritual, political, and moral views, yet we are committed to caring for all. However, there are occasions when a physician may encounter a patient that pushes one's tolerance and sensitivity to the limit, as in this case. Continued contact with this racist patient may have made the physician feel complicit in the perpetuation of this patient's dubious social values, and it is to those feelings that the suggestion to discharge the patient appeals.

As for the second issue, there are at least three things that physicians should consider before taking the drastic action of dismissing a patient: (1) the patient may be feeling powerless; (2) the patient's behavior may be an attempt to regain some sense of control; and (3) the education level of the patient may be a factor.

First, no matter what the outward affect, it is important to remember that some patients may lack the knowledge and skills that physicians possess. Because of this, patients may feel that they lack power in the physician-patient relationship, regardless of the communication styles of physicians. Feelings of powerlessness can cause people to act in different ways, and therefore the undesirable behavior exhibited by the patient may be a symptom of these feelings.

Second, given what this patient disclosed about his childhood, it seems reasonable that he developed unhealthy coping mechanisms as he matured. Although most people find detestable what this patient described as ostensibly appropriate outlets for anger, it is not uncommon for those who were oppressed to then oppress others when presented with the opportunity. Rather than indicating deep-seated hatred, this behavior more often demonstrates a response to a loss of control in one's life that may have produced a feeling of, “I can't control what happens to me, but I can control what I do to others.”

Something like this may have been going on with this patient; he may have felt as though his kidney function or his cholesterol level was “out of his control,” and yet going to the doctor was something he could manage to accomplish. Therefore, this offensive disclosure may have been a way for the patient to assert to the doctor that he could take control when it was warranted, but did not view his depression in this way. To address this issue, it may have been useful to simply ask the patient what his treatment goals were.

Finally, the third consideration is that all patients may not have the level of general or medical education that physicians do. Whereas medical professionals understand the connection between obesity, eating habits, and cholesterol level, not all patients do. A failure to understand or appreciate the information that physicians give them may lead patients to think that their condition is out of their control. Similarly, different cultural backgrounds and family systems give rise to persons who have different world views. In medical school, physicians are taught respect, sensitivity, and empathy for others; however, patients may not go through such training. Some families emphasize these features of human interaction, whereas others exploit them. As a result, behavior varies greatly from patient to patient, and it is unrealistic to expect the same level of tolerance of diversity from our patients that we exhibit as physicians.

The real problem presented by this patient may not have been his offensive views, but instead may have been related to physicians' expectations of patient behavior. Suppose that this patient still held these “morally reprehensible” views, but was compliant with treatment (i.e., he began a diet-management program and agreed to try antidepressants). Would the physician still have found this patient so reprehensible?

What compounded the frustration in this case was that the patient continually returned for appointments, but would take no responsibility for his health situation or its management. It is possible that the trust the patient had for the physician—expressed as repeated visits to the physician and by the disclosures he made while there—might have worked against his participation in his own care. One study has shown that patients felt their participation in decision-making about care was less important when they trusted their physician.¹ Knowing that this physician would “stick with him” may have made it acceptable, in his mind, to put his entire fate into the hands of his physician.

Sometimes just expressing to our patients that we have different personal views and agreeing to disagree may be a solution. Perhaps the physician in this case could have told the patient, “I am appalled by your racism and aggressive acts of prejudice, and if I am to continue to be your physician you will not express those views in my office.”

This way, the physician would have attended to these views without endorsing them, and the patient would have known where he stood with the physician. The physician then might be able to continue to see this patient without getting the feelings of “frank aversion” when he saw this patient on his schedule.

However, in the end, if the issues of compliance and variant viewpoints grow to become a real obstacle in the care of the patient, then it is in the best interests of both physician and patient to discharge the patient. Physicians may inadvertently not provide the same care if they continue to see a patient they dislike. For example, physicians may refrain from ordering a particular test because they have let their disgust of the patient get in the way of their medical judgment. As a result, sometimes discharging a patient is the right thing to do.²

However, the patient deserves an explanation for the discharge. For example, a letter to the patient could state that, because of the patient's noncompliance and conf lict of values, the patient is being discharged. Many professional practice groups have developed protocols for discharging patients.³ This helps physicians be consistent with identifying and executing the discharge process. For example, in the clinic of one author, if the reason for discharge is along the lines of dissonant physician-patient relationship styles, the patient is allowed to switch to another physician at the clinic. If the reason for discharge is nonadherence or immoral or unethical behavior, the patient is discharged from the entire clinic—the patient is given the discharge letter and will receive 30 days of emergency care until he or she finds a new physician.

Cases like the one presented here raise the question of what it means to say that all patients deserve competent, compassionate care. We must remember that our obligation to provide care does not just apply to the easy patients, or the patients with whom we can clearly separate religious or political commitments from care (e.g., we don't discharge patients with radically different political views, even if we find their views to be questionable). In fact, if we could dismiss patients that easily, we would be compounding the access problem by only caring for patients who are like us: a small portion of the population, indeed. Despite this obligation, we must also practice medicine that we can feel good about at the end of the day. Perhaps, by focusing on our moral commitments rather than those of our patients, we begin to understand why it is important to find ways to work with even those patients who pose the biggest challenges to our professionalism.