DISLIKE:

REACTION, RESPONSE AND CONTINUING TO CARE

There are countless reasons why a physician may "dislike" a patient. In light of personal and professional expectations of physicians as tolerant, welcoming healers, what is the internal experience of recognizing and grappling with such "dislike?"

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In 1978, psychiatrist James Groves penned an article entitled "Taking Care of the Hateful Patient" in the New England Journal of Medicine (1). In it, he calls attention to the fact that physicians may occasionally “dislike” their patients, feeling anything from mild frustration to more intense animosity for a variety of reasons (1). This is hardly a revelation; physicians are human, and humans have emotions. But historically and socially, medical providers are expected to behave a certain way—to comport themselves proficiently and patiently. They are tasked with keeping their "heart[s] soft and tender" in the face of "suffering humanity," seeing “dignity and perhaps even a divine spark in every patient" (2). They are "idealized [as] compassionate, intelligent healer[s]" who remain "objective and just" in their work (3,4). In this context, the idea of a physician feeling aversion, revulsion, rage—or any negative emotion—towards a patient seems distasteful at best (1,5).


In an effort to improve both patient care and physician wellbeing, recent academic discourse has stressed "acceptance and awareness" of such negative emotions as "prerequisite to the self-knowledge and self-control required [for a strong] professional patient-physician relationship" (6). Indeed, countertransference—the psychoanalytic concept of a provider’s unconscious or conscious reactions to patients—plays a critical role in decision making and care management (7,8). Its disregard or denial has the potential to harm patients and clinicians alike, leading to “distraction from effective care, waste of physician energy, complaints from patients and staff, and continued health problems for the patient,” among other issues (9). Any semblance of "dislike" in clinical practice should thus be acknowledged and examined, remembering that factors associated with a) the physician themselves (e.g., mental health struggles, past experiences, values, biases, blame); b) the patient (e.g., the same, plus anxiety or fear around their condition, family dynamics); and c) the "system" (e.g., disparities in healthcare access, time constraints) may all play a role (5,9,10,*).

*Notably, while Groves identifies a host of patient-side factors in his 1978 NEJM publication (e.g., pessimism, repeated self-destructive behavior), he does not elaborate as extensively on physician-side and system-related contributors to negative emotions in providers (1). In reality, this triad (patient, provider, system) is inseparable, and should be considered together, as an interlinking whole, whenever a negative emotion is encountered.

Illustrative scenarios:

  • A patient in the emergency room requests a different physician (e.g., a man rather than a woman, a different ethnicity, etc.). The original physician considers the situation and her options. 

  • A patient reminds her physician of the physician’s mother. This physician had a tumultuous relationship with her mother, and finds herself easily frustrated with the patient’s questions and concerns.

  • A physician feels exhausted caring for a patient who constantly seeks reassurance about her health status, contacting the physician daily via multiple avenues.

  • A patient has committed a severe crime (an extreme example).

 

References

  1. Groves JE. Taking Care of the Hateful Patient. N Engl J Med. 1978;298:883-887

  2. Gunderman RB and Gunderman PR. Forty Years since “Taking Care of the Hateful Patient.” AMA J Ethics. 2017;19(4):369-373.

  3. Sazima G. The “Hateful Patient” Revisited: A Transactional View of Difficult Physician-Patient Relationships. Psychiatric Times. 2015;32(6).

  4. Yurkiewicz I. Countertransference is a reality that must be grappled with. KevinMD. January 29, 2013.

  5. Gordon S. Suzanne Gordon on the difficult patient. BMJ Opinion. March 22, 2016.

  6. Meier DE, Back AL and Morrison S. The Inner Life of Physicians and Care of the Seriously Ill. JAMA. 2001;286(23):3007-3014.

  7. Park DB, Berkwitt AK, Tuuri RE et al. The hateful physician: the role of affect bias in the care of the psychiatric patient in the ED. American Journal of Emergency Medicine. 2014;32(5):483-85.

  8. American Psychological Association. https://dictionary.apa.org/countertransference 

  9. Haas LJ, Leiser JP, Magill MK et al. Management of the Difficult Patient. Am Fam Physician. 2005 Nov 15;72(10):2063-2068.

  10. Hahn SR, Kroenke K, Spitzer RL et al. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996;11(1):1-8.