…or is it doctor dependency?
How and why do patients become dependent?
Consider
- The patient’s role
- Why are patients reliant on their doctor? Consider positive and negative aspects to this.
- Emotional attachment to the doctor
- The doctor’s role
- Why do doctors “need” patients? Where does this need come from?#
- Emotional attachment to the patient
- The role of family and friends
- Societal influences
Other issues to consider
- “Doctor shopping”
- Dependency on medication eg analgesics
- The “analgesic headache”
- The “quiet prescription”
- The role of complementary therapy
- Making the wrong diagnosis (or even a very clever diagnosis)
- Trust
Responding to dependency
- Recognising that it is happening
- Regular appointments for minor illness or minor trauma
- Regular appointments with little content or repeated content. So why is the patient here?
- The patient won’t see another doctor, or presents with problems more logically dealt with by the nurse
- Refusal to terminate treatment
- Gifts
- Inappropriate positive feedback
- Collusion (see Balint)
- No faith in external advice eg specialist advice
- Genuine symptoms without any identifiable pathology or aetiology despite extensive examination and investigations.
- Addressing the issue
- Self awareness for the doctor
- Where are your feelings coming from? Are you stuck in the comfort zone? In denial? “Why do I look forward to seeing this patient?” “Why do I dread seeing Mr X?” “Why do I mind if this patient likes me?” “Why do I feel good after seeing this patient?”
- Emotional intelligence
- Mindfulness
- Support mentoring/co-mentoring
- Parent-child transactions –transactional analysis
- Flagging up the problem
- Defining the observed behaviour in a factual, non-judgmental way – “I have noticed that…”
- Exploring the reasons behind the behaviour
- Negotiating – “I wonder if…” “perhaps…”
- Moving forward
- Sharing responsibility with the patient for the problem (this may have to start with the doctor accepting some responsibility first)
- Ideas, concerns and expectations
- Psychodynamic thinking
- Motivational interviewing
- Narrative based medicine
- Spotting sabotage attempts
- Patient-centred feelings-based communication, moving from passive, doctor-centred care to active patient-centred care
- Self awareness for the doctor
- Preventing dependency
- Planning and agreeing to specific goals and if possible a timeframe
- Identifying what is possible and what is unrealistic
- Keeping adult-adult, avoiding parent-child and the child hook
The Bottom line?
Ideas, concerns and expectations right at the beginning, and taking a process route to the problem with the patient rather than a task-based one, including giving something of your own feelings (and wondering aloud why they are there).