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Flatterer patient

Grateful patients are one thing, but what should you do if you suspect

a manipulative flatterer? Dr Melanie Wynne-Jones advises

The desire to help people is a significant driver for doctors. We would not be human if we didn't feel pleased when our efforts are appreciated.

But sooner or later we come across the patient who seems to have an unusually high opinion of us for reasons that are not entirely clear.

This often surfaces in consultation with overt compliments and deep gratitude. 'You're so kind, doctor ­ no one listens to me/ understands me like you do.'

If this is said at the end of a successful series of consultations, you are entitled to enjoy the warm glow of appreciation. But if the praise is disproportionate to your achievements, or if the patient is a frequent consulter with symptoms that are multiple, vague, dispiriting and impossible to resolve, then it's time to reflect.

You may have fantastic communication skills, you may indeed exude empathy. However, this instant rapport may say more about the patient than it says about you.

We are trained to be patient-centred. This model implies that the patient shares responsibility on an adult-adult basis. But there is another model, the transactional analysis model, which describes a relationship akin to parent and child1,2.

The GP as authority figure can sometimes be appropriate when the patient is in serious trouble. Someone who is in the throes of a myocardial infarction or who has discovered a breast lump may need to be the 'child' relying on the 'parent' doctor for practical help and reassurance.

But once the immediate threat has been dealt with, both doctor and patient will probably prefer to revert to the adult-adult model.

Generally speaking paternalism in the doctor-patient relationship is frowned upon these days.

The 'you're so understanding' patient may be adopting the child role, not necessarily consciously, in an attempt to pass over ongoing responsibility for their welfare to the doctor/parent, who must keep them safe. Using flattery to push our 'caring' button helps to achieve this.

An alternative motive, again not necessarily conscious, may be that the patient is manipulating the doctor into providing whatever the patient is looking for, be it support, attention and reassurance, or more practical things

such as medication, referral or a sicknote. In effect, the child manipulating the parent.

Recognising that we are being assigned the role of parent may give us insight into the consultation or into the patient's possible modus operandi with other people in their lives. We may find ourselves enticed into playing games in which our role is to offer solutions that are gratefully welcomed, but dismissed as unworkable. Insight may suggest a way forward, but reflecting this back to the patient carries risks, so talk to your trainer first.

The transactional analysis model can also explain another type of flatterer patient.

This time you, the doctor, are cast as the child, and the praise is a reward for behaving as the patient wants.

Again, if you find yourself feeling uncomfortable by a patient's dominant attitude or overfamiliar attempts at rapport, reflect on what is going on.

Consider whether the patient's approach is deliberate or subconscious, whether their requests and demands are reasonable, and what effect they are having on you or the consultation.

At times even the most adult of us can show signs of becoming the child who immediately says 'no' because they don't like being told what to do.

Most people have a preferred way of behaving, and ideally most consultations will proceed along adult-adult lines. But all of us, including GPs, switch to parent or child mode occasionally, either from choice or because we feel pushed into it. It's useful to be aware when this is happening, but it's important not to get too cynical.

After all, many of our patients genuinely like us ­ and most of the time we genuinely deserve it!

References

1 Games People Play: the psychology of human relationships. Eric Berne (1973). Penguin. ISBN 0140027688

2 The International Transactional Analysis Association

www.itaa-net.org

Melanie Wynne-Jones is a GP in Marple, Cheshire

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