Love, hate and commitment

“How do you feel about your patients, doctor Tomlinson?”

I was being intereviewed by a medical student about the resiliance of doctors working in challenging areas.When she introduced her project she talked about the effect that patients have on their doctors and how hard it can be for doctors to cope with patients who repeatedly present with problems the doctor cannot solve. The effects that patients have on their doctors has been examined most famously in detail by psychiatrist Michael Balint. The impact can be profound, provoking feelings not just of frustration, confusion and exhaustion, but even hate. The 1978 paper, Taking Care of the Hateful Patient examines this rarely acknowledged and often denied emotion. In seeking an explanation, the author divided patients into ‘dependent clingers’, ‘entitled demanders’, ‘manipulative help rejecters’ and ‘self-destructive deniers’.

Negative feelings about medical and surgical patients constitute important clinical data about the patient’s psychology. When the patient creates in the doctor feelings that are disowned or denied, errors in diagnosis and treatment are more likely to occur. Disavowal of hateful feelings requires less effort than bearing them. But such disavowal wastes clinical data that may be helpful in treating the “hateful patient.”

Since Balint’s time, many GPs have met in small Balint groups to discuss their most difficult patients. Eleven years since my GP training post I still meet every 3 weeks with members of the same group I attended as a trainee. As the years have passed, we have all become increasingly concerned with the relationships we have with our patients and we have all developed deep and enduring interests in what are sometimes called heartsink patients and heartsink problems like medically unexplained symptoms, chronic pain, fatigue, addiction, loneliness, and so on. This deep and serious engagement with the patients and conditions that challenge us most of all was beautifully described by John Berger in his book, A Fortunate Man, ‘still the most important book about general practice ever written’. 

We were all like the central character, Dr Sassall,

… thriving on medical emergencies, impatient with non-specific symptoms and the absence of clear-cut physical diagnoses and underlying pathology. He moves gradually towards an empathic listening and companionship with his patients and their families, striving to recognise who they are and the meaning of their illness to them. Physical and psychological intimacy is central to his relationship to his patients.

We are trained in detachment and objectivity, and are afraid of intimacy. We are afraid of our patients being dependent on us, or becoming dependent ourselves on our patients. We are afraid of crossing professional boundaries, of becoming over-involved, of being paternalistic or meddling. Part of this fear is a fear of vulnerability and a denial that as social beings, we actually do depend on each other.  If it is hard for us doctors to come to terms with actually hating our patients, it is even harder to admit that we need our patients to love, respect, care about and depend on us.

My reply to Rebecca, the medical student who asked how I felt about my patients was to say, “I love my patients”. We both paused, allowing a moment for this to sink in. “Really?” she asked.

I don’t think ‘love’ is too strong a word. Love entails risk; we need to be prepared to withhold judgement and care unconditionally, we care for our patients whether they take their medication, come to their appointments, drink, smoke, binge, self-harm, take drugs, disregard our advice and argue with us. This doesn’t mean that we are without any boundaries, indeed many of our most challenging patients have suffered from a lack of boundaries, or a wildly inconsistent enforcement of boundaries, particularly in childhood, but it does mean that we are committed to working with them. For these patients most of all, continuity of care matters.

Medicine reflects our ‘post-political, liberal-permissive society’ in which commitment is social deviance. This is why the NHS reforms force us to choose a good GP or hospital, because, we are told, through a steady media tide of bad NHS news stories, we can trust none of them. A sustained therapeutic relationship is counter-neoliberal-cultural, so long term NHS staff contracts are being torn up and GP surgeries are being franchised to Virgin and other multinationals, undermining the possibility of building up long-term relationships with care givers. The social determinants of health such as poverty, poor diet, smoking, addiction, lack of education, fresh air and exercise are being re-framed as ‘lifestyle choices’ and there are growing calls from think tanks and politicians for patients to take more responsibility and do more self care.

The relationship between doctors and patients is a challenge to this contemporary orthodoxy and fundamentally reflects how we all relate to eachother. To engage with the endless struggle that challenging relationships demand is harder than withdrawing and calling for patients to take more responsibility or giving up altogether. Without the insights of Balint and the support of our peers, the challenges of intimacy and care can be too much to bear. Dr Sassall, the central character in A Fortunate Man, eventually committed suicide. If we are to build the resilience necessary to care deeply, we need to come to terms with the emotions we are afraid of and put kindness, love and compassion at the heart of healthcare,

It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat. Theodore Roosevelt. Man in the Arena.

The Logic of Care and the Problem of Patient Choice. Mol

You May! Slavoj Žižek writes about the Post-Modern Superego

Resilience in Doctors who work in Challenging Areas. A Qualitive Study