Impact when relationships break down

A HYPOTHETICAL case illustrating a breakdown in the relationship between a breast cancer patient and her oncologist in a country town highlights what can go wrong when patient expectations are not met, according to cancer and psychology experts.

The case, published in the Ethics and law section of the MJA, outlines a scenario where an oncologist is frustrated when his patient does not attend appointments and does not follow his medical advice, apparently valuing the recommendations of a naturopath over his counsel. (1)

The patient is described as feeling frightened and unheard while dealing with persisting symptoms and several features indicating an increased risk of psychosocial distress.

The case study authors wrote that the oncologist’s focus on anticancer treatment and limited attention to the patient’s persisting symptoms and psychosocial distress compromised the therapeutic relationship, leading the patient to seek other practitioners and other means to address her concerns.

They said leaving the patient without any access to specialist oncological skills in a small rural community was not an acceptable option clinically. “Either the doctor needs to provide realistic suggestions as to how the patient can be managed by another practitioner or both parties need to make the effort to work together as the patient adjusts to her diagnosis and circumstances and the doctor accepts that, in this case, he is but one member of the patient’s team”, they wrote.

Professor Stewart Dunn, professor of psychological medicine at Sydney Medical School, told MJA InSight communication issues between doctors and patients were increasing as a common source of patient complaints.

“There are always new challenges for doctors and patients communicating that evolve out of technology and patients having more access to information”, Professor Dunn said. “[Patients] expect doctors to be able to talk to them realistically about alternative medications and their role and, in the cancer ward, the advent of high cost drugs which aren’t available freely creates a huge problem for doctors communicating with patients.”

Associate Professor Rosemary Harrup, head of medical oncology and haematology at Royal Hobart Hospital, said there were several areas in medicine that were prone to a breakdown in the doctor–patient relationship.

She said relationships could become troubled when the doctor and the patient had different cultural or linguistic perspectives. There could also be aspirational differences, where a patient’s expectations were unable to be fulfilled.

“In that case, it is very important to be able to support the patient, but without destroying their hope”, said Professor Harrup, who is also chair of the Medical Oncology Group of Australia.

Professor Dunn said the way in which a doctor dealt with an adverse event could make or break a doctor–patient relationship.

He said open disclosure — the discussion of incidents that involve harm to the patient — could help to prevent a relationship breakdown. If something did go wrong, patients wanted a clear explanation of what had happened.

However, he said, doctors could also feel “horrified and traumatised” when an adverse event occurs. “Doctors go into medicine to do good and to heal, and the thought that you’ve harmed somebody touches you to your soul. Doctors can be traumatised, just like patients, and want to be away from that situation.”

Professor Dunn said the key factor in maintaining a good relationship with patients through difficulties such as adverse events and delivering bad news, was for the doctor to remain in touch with their humanity.

“If doctors try to pretend that they are bulletproof and don’t have feelings about the situation and are just doing a professional job, it’s not going to work nearly as effectively as when the doctor acknowledges that they find this news devastating too”, he said, adding that research shows that doctors’ heart rates increase when breaking bad news to patients. (2)

A related paper published in the MJA by Professor Loane Skene, of the University of Melbourne’s Law School, discussed the legal issues that may arise when the doctor–patient relationship breaks down. (3)

“The legal duties of a doctor attending a ‘difficult’ patient with a serious condition do not end at the last consultation, especially in a small rural community”, she wrote.

Professor Harrup said in instances where the philosophies of a patient and a physician didn’t align at all, it was best to discuss alternative care arrangements for a patient.

“If a doctor and a patient have very different philosophies they should try to talk those over and if they can’t come to an agreement, then it may be appropriate to say that ‘our philosophies are quite different, which might mean that we’re never going to be satisfied with each other. Can we agree that we will seek an alternative practitioner for you as a patient?’”

Professor Harrup said in rural and remote areas, where alternative medical professionals and specialist services might not be available, this presented an additional challenge.

However, she said investigating telemedicine options or attending the consultation with another trusted health professional, such as a specialist or a GP, could help to preserve the doctor–patient relationship.

1. MJA 2014; 201: 347-349
2. Med Rev 2013; 92: 13-24
3. MJA 2014; 201: 350-351

(Photo: Alex Raths, Thinkstock)