Healing With the Needles

To the editor:

We read the recent essay titled “Healing with the Needles” by Dr. Guerrera with hopeful anticipation [1]. As medical educators and clinicians, we appreciate efforts to articulate the nature of the doctor-patient relationship. We concur that as family physicians we are given remarkable opportunities to play a profoundly important role in the lives of our patients. We also concur that competing factors such as insurance coverage, public demand, and the like are making it increasingly difficult to focus on using the doctor-patient relationship in a clinically meaningful manner.

Despite these points of agreement with Dr. Guerrera, it is our sense that she failed to recognize some subtle and profoundly important issues with regard to the doctor-patient relationship. To be fair, missing such points is easy to do based upon the various demands faced by family physicians within the clinical arena. It is no easy task to recognize complex psychosocial issues for what they are in “real time” and then to act in a clinically accurate manner with the goal of serving the “best interest” of the patient.

In our view, this essay explores one doctor’s attempt to hold herself to high standards of medical professionalism. While existing definitions of medical professionalism are multidimensional [2-4], we believe that the concept of “staying in role” (i.e., the professional role of physician) is paramount. The doctor is called on to use his or her empathic skills in order to create a trusting atmosphere within which the patient can share their problems. Based on the patient’s natural behavioral tendencies (transference) the physician may be drawn towards either disdain or fondness for the patient (countertransference) [5]. Either feeling state represents an inevitable loss of objectivity by the physician. At best such an enterprise yields suboptimal results; at worst, the doctor may unintentionally reinforce self-defeating patterns within the patient’s life.

It is our sense that the author became overly fond of her patient based on what she viewed as admirable qualities (e.g., tries multiple modalities, makes good effort, means well, etc.). This fondness for her patient (countertransference) may have resulted in not optimally managing what appears to be a classic example of triangulation. By triangulation we mean, “...when the doctor and patient have in common a relation to a third person or issue that colors the quality of their contact.[6]” Within this family group, at least two “triangles” appear most prominent (grandmother-patient-doctor and patient-doctor-daughter). Did the doctor act to “first do no harm” with respect to these various relationships and in particular the impact that these relationships might have upon the identified patient?

Our impression is that the physician in this essay was confronted with an enmeshed family system (Is it not odd that a 30 year old patient has both her mother and an 8 year old child present for a somewhat invasive procedure?). The patient’s passivity and poor self-image (labeled “chronic depression”) were probably learned through experience. Her mother was likely reinforcing (whether purposeful or not) within the patient a sense of incompetence. An alternative view of having an 8 year-old girl join the doctor in caring for her disabled mother is that reinforcing this pattern is unhealthy for both the mother (patient) and the child. Could the mother’s chronic depression reflect a sense of humiliation at having forced her child into an inappropriate care giving role towards her? Could the child eventually become “depressed” herself (angry and resentful) that she was not the one who received age-appropriate nurturance? Are we actually witnessing how children are taught to be chronically depressed by the roles that we adults force them into?

We don’t pretend to have the answers for our questions in the prescriptive sense. However, our point is that we should not romanticize the doctor-patient relationship. From the standpoint of medical professionalism, our goal must be to remain in the role of doctor despite whatever distractions we face to digress. In this sense, either distain or fondness for a patient, is essentially equivalent in that both represent a form of countertransference that serve to distract from the physician’s professional role to act in an accurate manner to serve that patient’s best interests. We do advocate empathy in an attempt to best understand our patient’s needs. We believe that empathy will be most accurate when we engage in a healthy (and at times painful) amount of self-reflection and introspection re: what is motivating our behavior towards patients. Does my patient’s behavior reflect a form of transference with the potential to engender a certain reaction from others (including the doctor)? Do my feelings reflect a form of countertransference causing me to digress from an approach that is best for the patient? As physicians, our professionalism depends on our ability to answer such difficult questions.

References
1. Guerrera, MP. Healing with the needles. Ann Fam Med 2008; 6(2): 173-74.
2. Harris, GD. Professionalism part I: Introduction and being a role model. Fam Med 2004; 36(5): 314-15.
3. Harris, GD. Professionalism part II: Teaching and assessing the learner’s professionalism. Fam Med 36(6): 390-92.
4. Swick, HM. Toward a normative definition of medical professionalism. Acad Med 2000; 75(6): 612-16.
5. Campbell, RJ. Psychiatric Dictionary, 6th ed. New York: Oxford University Press, 1989.
6. Johnson, AH, and Brock, CD. Exploring triangulation as the foundation for the family system thinking in the Balint group process. Fam Syst Health 2000; 18: 469-78.

Respectfully submitted,
John R. Freedy, MD, PhD and Clive D. Brock MD
Department of Family Medicine
Medical University of South Carolina
Charleston, South Carolina

Competing interests:   None declared