JOURNAL OF DIALYSIS, 1(8), 749-755 (1977)

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EDITORIAL

THE DOCTOR-PATIENT RELATIONSHIP AS IT PERTAINS TO PATIENTS WITH TERMZNAL RENAL FAILURE Milton Viederman, M.D. Director, Psychiatric Services Rogosin Kidney Center The New York H o s p i t a l - C o r n e l l Medical Center

It is g e n e r a l l y assumed t h a t t h e t e c h n o l o g i c a l advances i n medicine which have taken p l a c e o v e r t h e l a s t decade, w i t h t h e i r concomitant i n c r e a s e i n s p e c i a l i z a t i o n , h a s o f n e c e s s i t y l e d t o

a dehumanization of medicine and a d e c r e a s e d i n t e r e s t and concern w i t h t h e p a t i e n t as person.

Y e t when one examines t h e c a t e g o r i -

cal d i s e a s e c e n t e r , i t s e l f a p r o d u c t of i n c r e a s e d t e c h n i c a l sophist i c a t i o n . one d i s c o v e r s t h a t t h i s a n t i c i p a t e d d e p e r s o n a l i z a t i o n is no more common I n t h i s medical s e t t i n g than in any o t h e r , though problems, of c o u r s e , exist.

P h y s i c i a n s c o n f r o n t e d w i t h t h e long-

term and i n t e n s i v e care of s e r i o u s l y ill p a t i e n t s must i n some way e s t a b l i s h a modus v i v e n d i i n d e a l i n g w i t h them.

The q u a l i t y of

t h e d o c t o r - p a t i e n t r e l a t i o n s h i p w i l l depend i n p a r t upon t h e

749 Copynght @ 1977 hy Marcel Dekker. Inc All Rights Reserved Neither this work nor any pJrl may be reproduced or transmitted in any form or by any means. electronic or mechanical including photocopying, microfilming. and recording. or by any information storage and retrieval system without permwion in writing from the publaher.

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p e r s o n a l i t y o f t h e p h y s i c i a n and h i s a b i l i t y t o u t i l i z e t h e physicianly r o l e f o r the p a t i e n t ' s benefit.

T h i s i s t h e s u b j e c t of t h i s

b r i e f commentary.

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B e f o r e examining a s p e c t s of t h i s r e l a t i o n s h i p , some comments

on t h e djlemma which c o n f r o n t s t h e d i a l y s i s p a t i e n t are i n o r d e r , a l t h o u g h no a t t e m p t w i l l b e made t o d e s c r i b e t h e e x t e n s i v e l i t e r a t u r e which i s devoted t o t h i s s u b j e c t .

A p a t i e n t confronted with

t h e knowledge t h a t h e has developed a s e r i o u s i r r e v e r s i b l e i l l n e s s and m u s t undergo a c h r o n i c , demanding t r e a t m e n t which is u n l i k e l y t o f u l l y r e s t o r e him t o h i s p r e v i o u s s t a t e of v i g o r , i n e v i t a b l y e x p e r i e n c e s a crisis w i t h which h e must come t o terms i n some way. A wide a r r a y of l a t e n t a n x i e t i e s and areas of v u l n e r a b i l i t y w i l l

be evoked.

Among t h e s e are c o n f l i c t s a b o u t dependency and inde-

pendence; t h e e x p r e s s i o n of h o s t i l e f e e l i n g s ; damage t o s e l f -

esteem through l i m i t a t i o n s of work c a p a c i t y ; changes i n body image and f u n c t i o n i n g , p a r t i c u l a r l y i n t h e a r e a o f s e x u a l i t y , and physi-

c a l a c t i v i t y ; and d i s t u r b a n c e s o f c o g n i t i v e mild d e g r e e s of o r g a n i c i t y .

f u n c t i o n i n g due t o

The v e r y loss of t h e c a p a c i t y t o u r i -

n a t e , which is a developmentally a c q u i r e d f u n c t i o n o f g r e a t import a n c e , i s viewed by t h e p a t i e n t , o f t e n u n c o n s c i o u s l y , as damaging t o h i s s e n s e of m a s c u l i n i t y and potency.

A t t h e same t i m e , one

cannot i g n o r e t h e s t a g e of t h e l i f e c y c l e i n which t h e p a t i e n t f i n d s h i m s e l f when t h e i l l n e s s f i r s t a p p e a r s .

One can e a s i l y

imagine t h a t an a d o l e s c e n t s t r u g g l i n g f o r independence w i l l behave i n a d i f f e r e n t way from t h e young head of a f a m i l y o r a r e t i r e d person w i t h o r w i t h o u t a s u r v i v i n g s p o u s e , t o name b u t a few s i t -

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uations.

Ultimately, t h e p a t i e n t ' s response t o t h i s c r i s i s w i l l

be determined by t h e n a t u r e and degree of defenses a g a i n s t p a i n f u l f e e l i n g s evoked by t h i s s i t u a t i o n and by t h e a v a i l a b i l i t y and development of c e r t a i n coping mechanisms t o d e a l with h i s dramatiRen Fail Downloaded from informahealthcare.com by Chulalongkorn University on 01/08/15 For personal use only.

c a l l y changed new r e a l i t y .

Factors such as a s o l i d , profoundly

valued sense of s e l f , r i c h and g r a t i f y i n g human r e l a t i o n s h i p s which can withstand t h e stress of i l l n e s s , t h e absence of excessive conf l i c t a b o u t dependency coupled with a capacity t o t r u s t , are among the f a c t o r s which w i l l h e l p t h e p a t i e n t t o weather t h e c r i s i s of chronic i l l n e s s and treatment. There are a number of ways i n which poor r e s o l u t i o n of t h i s c r i s i s may manifest i t s e l f i n i n d i v i d u a l p a t i e n t s .

Nephrologists

working with t h e s e p a t i e n t s a r e r e g u l a r l y confronted with such manifestations.

P s y c h i a t r i c c o n s u l t a t i o n is f r e q u e n t l y requested

when p a t i e n t s manifest o v e r t psychotic r e a c t i o n s ( o f t e n with some degree of o r g a n i c i t y ) , when p a t i e n t s f a i l t o adhere t o t h e rudiments of a reasonable treatment program and manifest oppositional-

i s m and o f t e n o v e r t aggression, o r when they e x h i b i t moderate-tosevere anxiety o r depression. of so-called

However, t h e r e are a l a r g e number

" s i l e n t s u f f e r e r s " who do not d i r e c t l y c a l l t h e a t t e n -

t i o n of t h e physician t o t h e degree of i n n e r s u f f e r i n g and pain which they experience. The physician is i n a unique p o s i t i o n i n many c a s e s t o i n f l u ence t h e outcome of t h e p a t i e n t ' s response t o c r i s i s i n e i t h e r p o s i t i v e o r negative ways.

Regression i s a normal and expected

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response in any patient confronted with a severe illness.

Hem-

dialysis in particular evokes such responses in a generally more intense way because of the very special symbolic meaning of being dependent upon a machine for life and because of the severe diRen Fail Downloaded from informahealthcare.com by Chulalongkorn University on 01/08/15 For personal use only.

etary restrictions imposed.

This regressive state places the

physician in a particularly unique position because the patient endows him with wishful, omnipotent and omniscient qualities. The patient's predicament with its uncertainty and danger evokes strong wishes in him for the security and protection reminiscent of vhat children under normal circumstances receive from their parents. Those patients who did not receive such protection and care as children are most vulnerable when confronted with serious illness and have the greatest difficulty in establishing trusting relationships with their physicians. In summary, one of the fundamental paradigms of the doctorpatient relationship is the parent-child relationship.

Though

this is usually experienced by the patient on an unconscious level, it can be consciously utilized by the physician to solidify his relationship with the patient. At this point, it would be useful to introduce a concept which has been utilized extensively in psychiatric thinking and has broad application to medicine in general. cept of the therapeutic alliance.

This is the con-

Simply stated, the therapeutic

alliance implies that the physician, utilizing specific modes of intervention, attempts to establish an alliance with the patient which is directed toward a common goal, namely, 1. the shared per-

EDITORIAL.

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c e p t i o n of t h e d i s e a s e and i t s a s s o c i a t e d problems ( i n c l u d i n g t h o s e i n t h e psycho-social a r e a ) , and 2. t h e implementation of a r a t i o n a l p l a n of t r e a t m e n t i n which

both p a t i e n t

and d o c t o r p a r t i c i p a t e .

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The f a i l u r e t o e s t a b l i s h t h i s t y p e of r a p p o r t o f t e n l e a d s t o s t r u g g l e s between p h y s i c i a n and p a t i e n t o v e r what a r e obviously n o t shared goals.

The bedrock on which t h e t h e r a p e u t i c a l l i a n c e is

c o n s t r u c t e d is c o m u n i c a t e d understandinq.

The p h y s i c i a n ' s i n t e r -

est i n t h e p a t i e n t ' s emotional state and h i s w i l l i n g n e s s t o e x p l o r e w i t h t h e p a t i e n t t h e s o u r c e s of h i s a n x i e t y and d e p r e s s i o n i n such

a way a s t o c l a r i f y ( f o r t h e p a t i e n t ) t h e s o u r c e s of h i s a n x i e t y i s of g r e a t importance i n s o l i d i f y i n g t h e r e l a t i o n s h i p .

Often t h e

p a t i e n t f e e l s p a i n f u l l y a l o n e w i t h t h e a n x i e t i e s and f e a r s evoked by h i s new predicament.

The knowledge t h a t t h e p h y s i c i a n i s both

aware o f , and concerned about, t h e s e r e a c t i o n s and t h e impact of t h e i l l n e s s on t h e p a t i e n t ' s l i f e diminish h i s s e n s e of l o n e l i n e s s and o f f e r some modicum of s a f e t y and s e c u r i t y , which, i n h i s e a r l y l i f e , was 'associated w i t h t h e f e e l i n g t h a t h e was understood. e x p l o r a t i o n of t h e anxious f a n t a s i e s which t h e p a t i e n t develops about t h e s o u r c e s of h i s i l l n e s s and h i s e x p e c t a t i o n s about t h e impact of t r e a t m e n t may permit r e a s s u r a n c e .

A b r i e f case anecdote w i l l i l l u s t r a t e t h i s p o i n t . A negro man who experienced much suppressed anger and d i s t r u s t of w h i t e s had adapted very poorly t o d i a l y s i s . A f t e r t r a n s p l a n t a t i o n , he w a s very anxious and expressed concern t h a t " t h e kidney w i l l reject me." He a l s o res e n t e d t h e r i g o r o u s p o s t - t r a n s p l a n t medical regimen, s t a t i n g t h a t he f e l t l i k e ''a s l a v e t o t h e d o c t o r s . " His p a n i c about l o s i n g t h e kidney w a s q u i t e overwhelmi n g u n t i l h e r e v e a l e d t h e f a n t a s y t h a t he had r e c e i v e d t h e kidney from a w h i t e woman. C l e a r l y , h e expected

The

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r e j e c t i o n by h e r . H i s c o n t i n u e d resentment r e f l e c t e d h i s f e e l i n g t h a t h e w a s s t i l l e n s l a v e d by h i s b l a c k n e s s and had n o t e x p e r i e n c e d t h e freedom o f r e b i r t h . Nonet h e l e s s , t h e p a t i e n t experienced considerable r e l i e f when i t w a s p o i n t e d o u t t h a t t h e kidney had come from a b l a c k woman.

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Although t h i s b r i e f commentary cannot d e a l w i t h t h e wide arr a y of p e r s o n a l i t i e s who r e q u i r e c h r o n i c h e m o d i a l y s i s and t h e spec i a l a t t i t u d e s of p h y s i c i a n s which can f a c i l i t a t e management, r e f e r e n c e w i l l b e made t o two p e r s o n a l i t y t y p e s and d i f f e r e n c e s i n management which are s u g g e s t e d by t h e knowledge of t h e i r p e r s o n a l i t y needs.

N e p h r o l o g i s t s have been v e r y s u c c e s s f u l i n d e c i d i n g which

p a t i e n t s r e q u i r e d i a l y s i s I n a r e g u l a r d i a l y s i s u n i t and which a r e amenable t o s e l f - d i a l y s i s or home d i a l y s i s t r a i n i n g . d i c t i o n s are o f t e n made on an i n t u i t i v e b a s i s .

T h e i r pre-

Certain patients

who have a s t r o n g i n v e s t m e n t i n t h e i r own a b i l i t y t o i n f l u e n c e t h e i r l i v e s and who have a s t r o n g need t o c o n t r o l t h e i r own enviroment, do b e s t when they are i n c o n t r o l o f t h e i r cwn d i a l y s i s and when they can, t o a r e a s o n a b l e d e g r e e , p a r t i c i p a t e i n t h e s t r u c t u r i n g of t h e i r own t r e a t m e n t .

These p a t i e n t s do b e s t on home d i a l y s i s .

O t h e r s who are markedly dependent, e x p e r i e n c e themselves as p a s s i v e and u n a b l e t o c o n t r o l t h e i r own lives. dialyzed."

They f i n d i t easier " t o b e

I t is t h e n e p h r o l o g i s t who must make t h e s e d e c i s i o n s .

To d e a l p r o p e r l y w i t h t h e f i r s t t y p e of p a t i e n t , t h e n e p h r o l o g i s t m u s t be w i l l i n g t o r e l i n q u i s h c o n s i d e r a b l e c o n t r o l i n o r d e r t o e s t a b l i s h an alliance i n which t h e p a t i e n t sees h i m s e l f as a res p o n s i b l e and active p a r t i c i p a n t i n t h e treatment s i t u a t i o n .

In

t h e l a t t e r s i t u a t i o n , t h e p h y s i c i a n , u n d e r s t a n d i n g t h e wishes f o r

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p a s s i v e dependency, m u s t p r o t e c t i v e l y t a k e c o n t r o l t o d i r e c t t h e t r e a t m e n t and t o l e r a t e what may be a c l i n g i n g dependency. P h y s i c i a n s vary enormously i n t h e f l e x i b i l i t y which they m a n i f e s t i n approaching a p a t i e n t .

I f t h e p h y s i c i a n is t o o r i g i d

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and needs a b s o l u t e c o n t r o l over t h e medical s i t u a t i o n , h e may react w i t h r a g e o r h o s t i l e detachment toward t h a t p a t i e n t who experiences a need t o be an important d i r e c t o r of h i s own t r e a t m e n t .

Other

p h y s i c i a n s may demand a degree of independence of which t h e p a t i e n t i s n o t capable.

The myth t h a t t h e s p e c i a l i s t involved i n t e r t i a r y care is l i k e l y t o become t h e "pure s c i e n t i s t ,I' i n t e r e s t e d only i n l a b o r a t o r y v a l u e s and pathophysiology, is d i s p e l l e d when one observes t h e funct i o n i n g of a kidney c e n t e r .

P r e s s u r e s of time, t h e need t o t r e a t

many people, o f t e n act a g a i n s t t h e o p t i m a l d o c t o r - p a t i e n t r e l a t i o n ship.

Rigid p e r s o n a l i t i e s capable of t r e a t i n g only one t y p e of

p a t i e n t do exist i n t e r t i a r y care c e n t e r s as they exist throughout t h e whole of medicine.

Impressive, however, is how much t h e need

t o r e g u l a r l y c o n f r o n t t h e v e r y s i c k p a t i e n t over many months and y e a r s f o r c e s t h e p h y s i c i a n t o a t t e n d t o t h e m u l t i p l i c i t y of psychos o c i a l f a c t o r s which i n f l u e n c e t h e p a t i e n t ' s c o u r s e and t o modify h i s approach accordingly.