1 Managing the Difficult Patient and Boundary Issues

Introduction This is a lecture about the vicissitudes of the doctor-patient relationship; especially how psychological and contextual factors may impact upon it. Discussions of the "Difficult Patient" and boundary issues, especially boundary violations, share the common element of being examples of the doctor-patient relationship gone awry. The discussion of these two topics will bring out issues of defense mechanisms, character style, and personality disorder. The idea of a difficult patient rests upon the assumption of an ideal doctor-patient relationship, in which there is mutual respect and cooperation in an effort to heal the patient. The patient is expected to be open, honest, obedient, and motivated to get better, displaying gratification and pleasure at improvement. The physician, on the other hand, is expected to be thoughtful, to listen, to be empathic, to be non-judgmental, to do no harm, and to be competent. As physicians we strive for this ideal and are often upset when we fall short. While the ideal can be approached at times, it usually varies from this, and unfortunately, but not rarely, deviates greatly from this ideal. There are two general types of deviation from the ideal – situations in which there is marked conflict and situations that are inappropriately close. Both of these are potentially quite destructive, but potentially preventable. We will look at various attempts to understand these deviant situations and then at general means to handle or avoid them.