I knew my blog criticising zero tolerance wouldn’t be popular. But as Churchill said: ‘You have enemies? Good. That means you’ve stood up for something, sometime in your life.’
For me there is a bigger issue at stake here than how we treat abusive patients, and that is the therapeutic relationship between doctor and patient – something I would stand up for again and again.
Too often I hear patients being denigrated, blamed, laughed at and generally moaned about. The more stress we are under, the more commonplace it seems to be. I don’t think it does our profession any credit. Patients are not the enemy, they are the reason why we get up in the morning and go to work.
However, there’s no doubting that patients can be difficult – some are even hateful. I use the word very deliberately, because there are times when we can actually come to hate certain patients – to resent them, dread seeing them, despise them even. When that happens, what should we do?
In 1978 James E Groves wrote an excellent article titled ‘Taking care of the hateful patient’.¹ He doesn’t mince his words and talks in detail about the feelings of anger and frustration that certain patients will invoke in the doctor – and the usefulness of recognising, expressing and naming such feelings.
And I agree with him. What I am not arguing is that GPs should ignore these feelings and just try to be more cuddly so that difficult patients can walk all over us.
Groves talks about the ‘entitled demander’ (most of our abusive patients will come from this group). He notes the natural desire in the doctor to counterattack such patients, but also how such an approach can make the doctor more vulnerable since this sort of patient will hit back, and does have the power to really hurt us.
In fact, he says: ‘The most helpful therapeutic strategy with the entitled demander is to support the entitlement, but to rechannel it in the (right) direction.’
GPs have always had to deal with the negative emotions inherent to our role, and it’s not just abusive patients that can be challenging – there are issues of dependency, manipulation, self-rejection and more. We need to have a constructive way of dealing with these emotions, for our own sake, as well as for our patients.
The influential psychologist Carl Rogers described the therapeutic value of holding patients in ‘unconditional positive regard’, and if it were always easy for doctors to do then he would not have had to stress its importance.
It’s for the challenging patients that positive regard is so vital, so difficult, and yet so valuable both for the doctor and patient. As we listen to their story and try to understand, we find a way of dealing with our negative emotions, as well as helping the patient to develop more positive behaviours.
Rogers stresses the contrast with the potentially destructive ‘conditional positive regard’ – there are echoes here of the modern right wing concept of the deserving and undeserving poor.
In the past we had Balint groups to help us gain insight, find new approaches and generally keep ourselves going. Such groups could be demanding, and time-consuming, but then again complex problems can take time to solve.
But has the modern-day equivalent of a Balint group now become an online forum where we just moan about our patients? I sincerely hope not.
Let’s try to be more positive than that. To quote Rogers: ‘When I look at the world I’m pessimistic, but when I look at people I am optimistic.’
Dr Martin Brunet is a GP in Guildford. You can tweet him @DocMartin68.
1 Groves, J. E. Taking Care of the Hateful Patient. NEnglJMed 298, 883–887 (1978).