Playing the part

Authority

In residency, I was taught to engage patients in decision making—to involve them as full partners in their health. To my surprise, I found early in my clinical practice that some patients were not interested in partnering with me. They simply didn’t want to know what was wrong with them or to understand treatment options. I was to be the authority. “Tell me what to do. You fix it, Doctor.”

Employee

In the Canadian health care system, it is easy to forget the financial side of the patient-physician relationship. Because there is generally no overt exchange of money for services rendered, discussing payment for services not covered by provincial plans can seem sordid and petty. Some patients reinforce this line of thinking. They seem affronted at the idea of paying for camp forms or travel immunizations. Others take the role of employer to an extreme and demand unreasonable access.

Necessary evil

Some patients come to see me under protest. I am in league, they think, with Big Pharma. I vaccinate. I medicate. I am against the body healing itself. Sometimes, however, these patients have worrisome symptoms that won’t go away. They need me, but they want me to know that they disdain the medical model of health care.

Friend

Other patients want to be my friend. These patients call me by my first name, inquire into my personal life, and extend social invitations. They like to use the word “we” in discussion, implying an “us against them” mentality.

Servant

Several patients have thought that I should take the role of servant. My job was to do as they wished. If they wanted full-body imaging, I should order it. If they wanted to take habit-forming sleep aids, I should provide prescriptions with plentiful refills. A retroactive sick note, massage therapy “just because,” unnecessary referral—that should be no problem.

Enemy

I’ve had a few patients who had had terrible experiences with physicians in the past. Abuse. Misdiagnosis. Harmful or inappropriate treatment. These patients have initially seen me as the enemy—the embodiment of the evil they have experienced. Fortunately, most of these relationships have become healthier and more balanced over time. Sadly, some patients have gone the other way. Despite frequent attempts to restore and rebuild the patient-physician relationship, these patients gradually developed animosity toward me. It is interesting how long these patients will stay with physicians they regard as the enemy.

Advisor

For many, a physician is a trusted advisor. Someone honest and compassionate.3 Someone who considers first their patients’ well-being.4 Someone who respects their patients’ autonomy and looks out for their best interests.5 Reilly ( page 834) emphasizes the importance of trust in the patient-physician relationship, particularly with adolescent patients.

I am most comfortable with the role of advisor. That is the model of patient-physician interaction I was trained for. Sometimes, however, I have to adapt my preferred model to better meet the needs of my patients. A sprinkling of friend. A soupçon of authority. A dab of employee. But, thankfully, mostly advisor.