Kaplan & Sadock’s Study Guide and Self Examination Review in Psychiatry
8th Edition

1
The Patient–Doctor Relationship
The patient–doctor relationship is at the core of the practice of medicine. It is of utmost concern to all physicians and should be evaluated in all cases. It is essential that all clinicians consider the nature of this relationship, the factors in themselves and their patients that influence the relationship, and the ways in which good rapport can be achieved.
Rapport is the spontaneous, conscious feeling of harmonious responsiveness that promotes the development of a constructive therapeutic relationship. It implies an understanding and trust between the doctor and patient. Medicine is an intensely human and personal endeavor, and the patient–doctor relationship itself becomes part of the therapeutic process.
The bio-psycho-social model of disease stresses an integrated approach to human behavior and disease. Each system in this model, the biological, psychological and social, affects and is affected by the others. It does not consider illness as a direct result of a person’s psychological or sociocultural makeup, but rather promotes a more comprehensive understanding of disease and treatment. This model provides a conceptual framework for dealing with disparate information and serves as a reminder that there may be important issues to consider beyond the biological.
The interactions between a doctor and patient can take different shapes, and it is helpful to be aware of the models that have been formulated to describe these interactions. The paternalistic model, the informative model, the interpretive model, and the deliberative model are guides for thinking about the patient–doctor relationship. A talented, sensitive physician uses different approaches with different patients and may have different approaches with the same patient as time and medical circumstances vary.
Doctors and patients may have divergent, distorted, and unrealistic views about each other. Transference and countertransference, terms originating in psychoanalytic theory, are hypothetical constructs that are extremely useful as organizing principles for explaining certain developments of the patient–doctor relationship that can be upsetting and that can interfere with good medical care. Students must be aware of and familiar with these concepts in order to fully understand the complexities of the patient–doctor interaction. The patient–doctor relationship is one of the most important factors in issues of treatment compliance, or adherence. Compliance decreases when communication problems arise. Doctors should be familiar with the factors that increase and decrease treatment adherence, and the clinician must explore the reasons for noncompliance rather than dismiss the patient as uncooperative.
In addition to the vast amount of knowledge and the skills required for the practice of medicine, an effective physician must also develop the capacity for balancing compassionate concern with discompassionate objectivity, the wish to relieve pain with the ability to make painful decisions, and the desire to cure and control with an acceptance of one’s human limitations. William Osler, M. D. discussed the characteristics and qualities of the physician in his book Aequanimitas. Although rarely reached, all students of medicine should be familiar with them, and strive to reach them.
Students should test their knowledge by addressing the following questions and answers.
Questions/Answers
Directions
Each of the questions or incomplete statements below is followed by five suggested responses or completions. Select the one that is best in each case.
1.1 Transference feelings
A. are based on doctors projecting their feelings to the patient
B. is a main reason for lawsuits filed by mistreated patients
C. do no occur with a highly experienced physician
D. are based on a patient projecting feelings from past relationships to the doctor
E. none of the above
1.1 The answer is D
Transference describes the process of patients unconsciously projecting feelings from their past relationships to the doctor. A patient may come to see the doctor as cold, harsh, critical, threatening, seductive, caring, or nurturing, not because of anything the physician says or does, but because that has been the patient’s experience in the past. The residue of the experience leads the patient unwittingly to “transfer” the feeling from past relationships to the doctor. The transference can be positive or negative, and it can swing back and forth—sometimes abruptly—between the two. Many a physician has become unsettled when a pleasant, cooperative, and admiring patient suddenly and for no discernible reason becomes enraged and breaks off the relationship or threatens a lawsuit. Physicians are not immune to distorted perceptions of the patient–doctor relationship. When doctors unconsciously project their feelings to the patient, the process is called countertransference, not transference.
While physicians can be sued for anything, like any other person, transference feelings are not one of the main reasons for lawsuits filed by mistreated patients.
A doctor’s level of expertise does not have any effect on whether transference feelings will occur or not.
1.2 Rapport is
A. based on doctors projecting their feelings to the patient
B. based on a patient projecting feelings from past relationships to the doctor
C. a feeling of harmony that promotes a therapeutic relationship
D. of little significance in obtaining the history
E. none of the above
1.2 The answer is C
Rapport is the spontaneous, conscious feeling of harmonious responsiveness that promotes the development of a constructive relationship. It implies an understanding and trust between the doctor and patient. With rapport, patients feel accepted with both their assets and liabilities. Frequently, the doctor is the only person to whom they can talk about things that they cannot tell anyone else. Most patients trust their doctors to keep secrets, and this confidence must not be disobeyed.
Transference describes the process of patients unconsciously projecting feelings from their past relationships to the doctor. When doctors unconsciously project their feelings to the patient, the process is called countertransference; these feelings are not directly related to rapport.
1.3 What percent of patients comply with treatment in the medical setting at any given time?
A. 90 percent
B. 75 percent
C. 50 percent
D. 30 percent
E. 10 percent
1.3 The answer is C
An overall figure derived from a number of studies indicates that 54 percent of patients comply with treatment at any given time. One study found that up to 50 percent of patients with hypertension do not comply at all with treatment and that 50 percent of those who do leave treatment within 1 year.
1.4 Illness behavior refers to
A. the role society ascribes to the sick person
B. being excused from responsibilities
C. the influence of culture on illness
D. the way the condition presents itself
E. all of the above
1.4 The answer is E (all)
The term illness behavior describes patients’ reactions to the experience of being sick. Aspects of illness behavior have sometimes been termed the sick role, the role that society ascribes to people when they are ill. The sick role can include being excused from responsibilities and the expectation of wanting to obtain help to get well. Illness behavior and the sick role are affected by people’s previous experiences with illness and by their cultural beliefs about disease. The influence of culture on reporting and manifestation of symptoms must be evaluated. For some disorders this varies little among cultures, whereas for others the way a person deals with the disorder may strongly shape the way the condition presents itself. The relation of illness to family processes, class status, and ethnic identity is also important. The attitudes of peoples and cultures about dependency and helplessness greatly influence whether and how a person asks for help, as do such psychological factors as personality type and the personal meaning the person attributes to being ill.
1.5 Which of the following models guides us in thinking about the patient–doctor relationship?
A. The paternalistic model
B. The deliberative model
C. The informative model
D. The interpretive model
E. All of the above
1.5 The answer is E (all)
In thinking about the patient–doctor relationship, it is helpful to formulate models of interaction. In a paternalistic model between doctor and patient, it is assumed that the doctor knows best. The doctor prescribes the treatment, and the patient is expected to comply. In this model, the doctor asks most of the questions and generally dominates the interaction. This approach may be of value in an emergency situation, when the doctor needs to take control and make potentially life-saving decisions without long deliberation. In the deliberative model, the physician acts as a counselor to the patient, actively advocating a particular course of action. It is used commonly to modify injurious behaviors like trying to get patients to stop smoking or to lose weight. In the informative model, the doctor dispenses information. All available data are freely given, but the choice is left wholly up to the patient. This model may be appropriate for certain one-time consultations where the patient will be returning to the regular care of a known physician. The interpretive model is used by doctors who have come to know their patients better and understand something of the circumstances of their lives, their families, their values and their hopes and aspirations, and are better able to make recommendations that take into account the unique characteristics of an individual patient.
1.6 Which of the following statements about transference is true?
A. Transference reactions may be strongest with psychiatrists.
B. Transference is a conscious process.
C. Transference occurs only in patient interactions with psychiatrists, not with clinicians from other disciplines.
D. Transference toward physicians is exclusively positive because patients know doctors are trying to help them.
E. Transference implies that the way a clinician interacts with their patient has no direct bearing on the emotional reactions of the patient.
1.6 The answer is A
Transference describes the process of patients unconsciously attributing to their doctors aspects of important past relationships, especially those with their parents. Transference is ubiquitous, and plays a role in the interaction of all patients with all clinicians. The transference can be positive or negative, and it can swing back and forth between the two. Transference reactions may be strongest with psychiatrists, especially when the therapeutic modality used requires the psychiatrist to be more neutral. The more neutral the psychiatrist is, the more transferential fantasies and concerns are mobilized in the patient and transferred onto the doctor. The words and deeds of doctors have powerful effects on their patients because of the unique authority the doctor has, and the patients’ dependence on them. How a particular physician behaves and interacts has a direct bearing on the emotional, and even the physical, reactions of the patient.
1.7 Which of the following patient factors is associated with treatment compliance?
A. Socioeconomic status
B. Educational level
C. Subjective feelings of distress
D. Intelligence
E. All of the above
1.7 The answer is C
A highly significant factor associated with treatment compliance is the patients’ subjective feelings of distress or illness, as opposed to doctors’ often objective medical estimates of the disease and required therapy. Patients who believe they are ill tend toward compliance. Asymptomatic patients, such as those with hypertension, are at greater risk for noncompliance than are patients with symptoms. There is no clear association between compliance and a patient’s sex, marital status, race, religion, socioeconomic status, intelligence, or educational level.
Table 1.1 Checklist for Clinicians
The following checklist allows clinicians to rate their skills in establishing and maintaining rapport. It helps them detect and eliminate weaknesses in interviews that failed in some significant way. Each item is rated “yes,” “no.” or “not applicable.”
  Yes No N/A
1. I put the patient at ease. _________ _________ _________
2. I recognized the patient’s state of mind. _________ _________ _________
3. I addressed the patient’s distress. _________ _________ _________
4. I helped the patient warm up. _________ _________ _________
5. I helped the patient overcome suspiciousness. _________ _________ _________
6. I curbed the patient’s intrusiveness. _________ _________ _________
7. I stimulated the patient’s verbal production. _________ _________ _________
8. I curbed the patient’s rambling. _________ _________ _________
9. I understood the patient’s suffering. _________ _________ _________
10. I expressed empathy for the patient’s suffering. _________ _________ _________
1.8 Which of the following doctor factors is associated with treatment compliance?
A. Positive physician attitude
B. Short waiting room time
C. Older doctors with experience
D. Increased frequency of visits
E. All of the above
1.8 The answer is E (all)
Compliance increases when physicians have a positive attitude and are enthusiastic and nonpunitive. Older doctors with experience, the amount of time spent talking to patients, a short waiting room time, and increased frequency of visits are also associated with high compliance rates. The patient–doctor relationship, or match, is one of the most important factors in compliance issues. When a doctor and patient have different priorities and beliefs and different styles of communication (including a different understanding of medical advice and different medical expectations), compliance decreases.
1.9 Which of the following is considered important in establishing rapport with a patient?
A. Putting the patient at ease
B. Expressing compassion
C. Evaluating a patient’s insight
D. Showing expertise
E. All of the above
1.9 The answer is E (all)
Establishing rapport is the first step of a psychiatric interview. It encompasses six strategies, as defined by Ekkhard and Sieglinde Othmer: putting patients at ease, finding patient’s pain and expressing compassion, evaluating patient’s pain and expressing compassion, evaluating patient’s insight and becoming an ally, showing expertise, establishing authority and balancing the roles of empathic listener, expert, and authority. As part of a strategy for increasing rapport, Othmer and Othmer developed a checklist that enables interviewers to recognize problems and refine their skills in establishing rapport. The first ten questions in the checklist are shown in Table 1.1.
1.10 Which of the following is true about the techniques used when interviewing a patient?
A. Confrontation is used to test a patient’s ability to remain calm.
B. Reflection allows the doctor an opportunity to share with the patient his or her personal feelings.
C. Silence is used as a way of withholding empathy.
D. Interpretations should be made early and as often as possible.
E. Clarification is away for the doctor to get further details about what has already been revealed.
1.10 The answer is E
In clarification, doctors attempt to get details from patients about what they have already said. Confrontation is meant to point out to a patient something that the doctor thinks the patient is not paying attention to, is missing, or is in some way denying. Confrontation must be done skillfully so that patients are not forced to become hostile and defensive. The confrontation is meant to help patients face whatever needs to be faced in a direct but respectful way. In the technique of reflection, a doctor repeats to the patient, in a supportive manner, something that the patient has said. The goal of reflection is twofold: to assure the doctor that he or she has correctly understood what the patient is trying to say and to let the patient know that the doctor perceives what is being said. It is an empathic response meant to let the patient know that the doctor is both listening to the patient’s concerns and understanding them. Silence may be used to allow patients to contemplate, cry, or just sit in an accepting, supportive environment in which the doctor makes it clear that not every moment must be filled with talk. Interpretation is most often used when a doctor states something about a patient’s behavior or thinking that the patient may not be aware of. The technique is a sophisticated one and should generally be used only after the doctor has established some rapport with the patient and has a reasonably good idea of what some inter-relationships are.
1.11 All of the following statements about illness behavior are correct except
P.3

A. It is affected by a person’s cultural beliefs about disease.
B. It always involves the experience of illness as a loss.
C. It involves the sick role that society ascribes to people when they are ill.
D. It is affected by prior illness episodes of standard severity.
E. It can be affected by psychological factors such as personality.
1.11 The answer is B
The term illness behavior describes patients’ reactions to the experience of being sick. Aspects of illness behavior have sometimes been termed the sick role, the role that society ascribes to people when they are ill. The sick role can include being excused from responsibilities and the expectation of wanting to obtain help to get well. Illness behavior and the sick role are affected by people’s previous experiences with illness and by their cultural beliefs about disease. The influence of culture on reporting and manifestation of symptoms must be evaluated. For some disorders this varies little among cultures, whereas for others the way a person deals with the disorder may strongly shape the a condition presents itself. The relation of illness to family processes, class status, and ethnic identity is also important. The attitudes of peoples and cultures about dependency and helplessness greatly influence whether and how a person asks for help, as do such psychological factors as personality type and the personal meaning the person attributes to being ill. People react to illness in different ways, which depend on their habitual modes of thinking, feeling, and behaving. Some people experience illness as an overwhelming loss; others see in the same illness a challenge they must overcome or a punishment they deserve. Mack Lipkin, Jr. created a list of essential areas to be addressed in the assessment of illness behavior, which included questions about prior illness episodes, especially illnesses of standard severity (childbirth, renal stones, surgery); cultural degree of stoicism; cultural beliefs concerning the specific problem; personal meaning of or beliefs about the specific problem; and several questions to ask to elicit the patient’s explanatory model.
1.12 In which instance is an autocratic patient–doctor relationship most appropriate?
A. A patient who has a life-threatening illness with various treatment options.
B. A woman who is a carrier of the gene for cystic fibrosis consults her doctor about whether she and her husband should conceive.
C. A 54-year-old woman with hypertension wishes to monitor her own blood pressure at home.
D. A 22-year-old man is brought into the emergency room with a gunshot wound to the chest.
E. A young woman confides in her doctor about wanting to have an abortion.
1.12 The answer is D
In a paternalistic, or autocratic, patient–doctor relationship, it is assumed that the doctor knows best. He or she will prescribe treatment, and the patient is expected to comply without questioning. Moreover, the doctor may decide to withhold information when it is believed to be in the patient’s best interests. In this model, the physician asks most of the questions and generally dominates the interview.
There are circumstances in which an autocratic approach is desirable. In emergency situations the doctor needs to take control and make potentially life-saving decisions without long deliberation. In addition, some patients feel overwhelmed by their illness and are comforted by a doctor who can take charge. In general, however, the paternalistic autocratic approach risks a clash of values, especially in situations with many alternatives and potentially life-changing decisions in which the patient must play a role, such as a life-threatening illness like cancer, or issues concerning high-risk conception or abortion. In most instances, illnesses which can be monitored and controlled by the combined efforts of the doctor and patient, such as hypertension, should also not be treated autocratically.
1.13 Compared to nonpsychiatric medical patients, psychiatric patients
A. do not have to deal with the stigma attached to being a patient
B. are more likely to tolerate a traditional interview format
C. are twice as likely to visit a primary care physician
D. exhibit a higher degree of compliant behavior
E. never need family members or friends to provide medical histories
1.13 The answer is C
Psychiatric patients must often contend with stresses and pressures that differ from those suffered by patients who do not have a psychiatric disorder. These stresses include stigma attached to being a psychiatric patient (it is more acceptable to have a medical or surgical problem than a mental problem); communication difficulty because of disorders of thinking, and oddities of behavior and impairments of insight and judgment that might make compliance with treatment difficult. Because psychiatric patients often find it difficult to describe fully what is going on, physicians must be prepared to obtain information from other sources. Family members, friends, and spouses can provide critical data such as past psychiatric history, responses to medication, and precipitating stresses that patients may not be able to describe themselves.
Studies show that 60 percent of all patients with mental disorders visit a nonpsychiatric physician during any 6-month period and that patients with mental disorders are twice as likely to visit a primary care physician as are other patients. Nonpsychiatric physicians should be knowledgeable about the special problems of psychiatric patients and the specific techniques used to treat them. One such problem is compliance with treatment. In general, psychiatric patients exhibit a higher degree of non-compliant behavior than do medical patients. Compliance increases when physicians have such characteristics as enthusiasm and a nonpunitive attitude, and when physicians explain to patients the value of a particular treatment outcome and emphasize that following the recommendation will produce this outcome.
1.14 Which of the following is not considered a necessary part of a psychiatric patient–doctor relationship?
A. Discussion of payment
B. The understanding that confidentiality may be broken in some situations
C. Awareness of the consequences for missed appointments
D. The patient’s familiarity with the doctor’s personal life
E. Clarification of the doctor’s availability between scheduled appointments
1.14 The answer is D
Before psychiatric clinicians can establish an ongoing relationship with patients, it is necessary to address certain issues. For example, they must openly discuss payment of fees. Discussing these issues and any other questions about fees from the beginning of the relationship can minimize misunderstanding later. Psychiatrists should also discuss the extent and limitations of confidentiality with patients, so that patients are clear about what can and cannot remain confidential. As much as physicians must legally and ethically respect patients’ confidentiality, it may be wholly or partially broken in some specific situations. For example, if a patient makes clear that he or she intends to harm someone, the doctor has a responsibility to notify the intended victim.
Patients need to be informed about a doctor’s policies for missed appointments. Some doctors ask patients to give 24 hours’ notice to avoid being billed for a missed session. Others bill for missed sessions regardless of advance notification. Still others decide on a case-by-case basis or perhaps state a 24-hour rule but make exceptions when warranted. Some doctors state that if they receive advance notice and can fill the appointment time, they won’t charge for missed sessions; others do not charge for missed appointments at all. The choice is up to the individual physician, but patients must know in advance to make an informed decision about whether to accept the doctor’s policy or to choose another doctor. Though a clinician may choose to reveal aspects of his or her personal life when appropriate, it is not necessary to the patient–doctor relationship that the patient be familiar with the doctor’s personal life. Limited, discreet self-disclosure, or self-revelation, by physicians may be useful in certain situations, and physicians should feel at ease and should communicate a sense of self-comfort. Conveying this sense may involve answering a patient’s questions about whether a physician is married and where he or she comes from. A doctor who practices self-revelation excessively, however, is using a patient to gratify unfulfilled needs in his or her own life and is abusing the role of the physician. If a doctor feels that a piece of information will help a patient be more comfortable, the doctor can decide in each case whether to be self-revealing. The decision depends on whether the information will further a patient’s care or if it will provide nothing useful.
Directions
Each set of lettered headings below is followed by a list of numbered words or statements. For each numbered word or statement, select the one lettered heading most closely associated with it. Each lettered heading may be selected once, more than once, or not at all.
Questions 1.15–1.18
1.15 Intent of question is vague
1.16 May invite yes or no answers
1.17 Low time efficiency
1.18 Patient selects topic
A. Open-ended questions
B. Closed-ended questions
Answers 1.15–1.18
1.15 The answer is A
1.16 The answer is B
1.17 The answer is A
1.18 The answer is A
Interviewing any patient involves a fine balance between allowing the patient’s story to unfold at will and obtaining the necessary data for diagnosis and treatment. Most experts on interviewing agree that the ideal interview is one in which an interviewer begins with broad, open-ended questioning, continues by becoming more specific, and closes with detailed direct questioning.
The early part of the interview is generally the most open ended, in that physicians allow patients to speak as much as possible in their own words. A closed-ended, or directive, question is one that asks for specific information and that allows a patient few options in answering. Too many closed-ended questions, especially in the early part of an interview, can lead to a restriction of the patient’s responses. Sometimes, directive questions are necessary to obtain important data, but when used too often, a patient may think that information is to be given only in response to direct questioning by the doctor. An example of an open-ended question is, “Can you tell me more about that? Closed-endeded questions, however, can be effective in generating quick responses about a clearly delineated topic. Closed-ended questions have been shown to be useful in eliciting information about the absence of certain symptoms (for example, auditory hallucinations and suicidal ideation). Closed-ended questions have also been found to be effective in assessing such factors as frequency, severity, and duration of symptoms.With open-ended questions, the intent is purposefully vague, the patient is allowed to select the topic, and they tend by their nature to be of lower time efficiency than closed-ended questions. Table 1.2 summarizes some of the pros and cons of open-ended and closed-ended questions.
Table 1.2 Pros and Cons of Open-Ended and Closed-Ended Questions
Aspect Broad, Open-Ended Questions Narrow, Closed-Ended Questions
Genuineness High
They produce spontaneous formulations.
Low
They lead the patient.
Reliability Low
They may lead to nonreproducible answers.
High
Narrow focus, but they may suggest answers.
Precision Low
Intent of question is vague.
High
Intent of question is clear.
Time efficiency Low
Circumstantial elaborations.
High
May invite yes or no answers.
Completeness of diagnostic coverage Low
Patient selects topic.
High
Interviewer selects topic.
Acceptance by patient Varies
Most patients prefer expressing themselves freely; others feel guarded and insecure.
Varies
Some patients enjoy clear-cut checks; others hate to be pressed into a yes or no format.
Reprinted with permission from Othmer E., Othmer SC. The Clinical Interview Using DSM-IV. Washington, DC: American Psychiatric Press; 1994.
Questions 1.19–1.23
1.19 A patient is admitted to the hospital with a sudden onset of altered mental status when found thrashing about in bed. After a workup, a physician restrains him to perform a lumbar puncture.
1.20 A 64-year-old woman with diabetes mellitus visits her physician after repeatedly drawing high blood glucose levels during home monitoring.
1.21 After a patient’s complete recovery from illness, her physician continues to phone and visit her—and declares his love for her.
1.22 Three days after abdominal surgery, a 32-year-old man has mild basal rales by auscultation. His surgeon tells him to ambulate.
1.23 The doctor of a 16-year-old girl with persistent abdominal problems tells her that she must go for a lower gastrointestinal (GI) series.
A. Active–passive model
B. Teacher–student model
C. Mutual participation model
D. “Friendship” model
Answers 1.19–1.23
1.19 The answer is A
1.20 The answer is C
1.21 The answer is D
1.22 The answer is B
1.23 The answer is B
The patient–doctor relationship has a number of potential models. Often, neither the physician nor the patient is fully conscious of choosing one or another model. The models derive most often from the personalities, expectations, and needs of both the physician and the patient. The fact that their personalities, expectations, and needs are largely unspoken and may differ can lead to miscommunication and disappointment for both participants, physician and patient, in the relationship. The physician must be consciously aware of which model is operating with which patient and should be able to shift models, depending on the particular needs of specific patients and on the treatment requirements of varying clinical situations. Models of the patient–doctor relationship include the active–passive model, the teacher–student (or parent–child or guidance–cooperation) model, the mutual participation model, and the “friendship” (or socially intimate) model.
The active–passive model implies passivity on the part of the patient and the taking over by the physician that necessarily results. In this model, patients assume no responsibility for their own care and play no active role in treatment. The model is appropriate when a patient is unconscious, immobilized, or delirious. The sudden onset of the patient’s altered mental status can be a potentially life-threatening situation. Possible causes of the profoundly changed mental status are trauma, vascular disorders, brain tumors, meningitis, encephalitis, and toxicological, metabolic, endocrine, and psychiatric disorders. For some patients with an altered mental status, a lumbar puncture is necessary and should be performed, as long as increased intracranial pressure, which can cause brainstem herniation, is not suspected. A computed tomographic (CT) scan or an eye examination that checks for papilledema may aid in the assessment before a lumbar puncture is performed.
In the teacher–student model the physician’s dominance is assumed and emphasized. The physician is paternalistic; the patient is essentially dependent and accepting. The model is often observed after surgery and before such diagnostic tests as a GI series.
The mutual participant model implies equality between the physician and the patient: both participants in the relationship require and depend on each other’s input. The need for a patient–doctor relationship based on a model of mutual, active participation is most obvious in the treatment of such chronic illnesses as renal failure and diabetes, in which a patient’s knowledge and acceptance of treatment is critical to success. The model may also be effective in more subtle situations—for example, in pneumonia.
The “friendship” model of the patient–doctor relationship is generally considered dysfunctional, and can lead to unethical behavior. It is most often prompted by an underlying psychological problem in the physician, who may have an emotional need to turn the care of the patient into a relationship of mutual sharing of personal information and love. The model often involves a blurring of boundaries between professionalism and intimacy and an indeterminate perpetuation of the relationship, rather than an appropriate ending and termination of treatment.
Questions 1.24–1.28
1.24 The ability to maintain calm and steadiness
1.25 The ability to handle stressful situations with an even temper
1.26 Forming standards, and living under their influence
1.27 Calmness of mind, bearing, and appearance
1.28 The capacity to face or endure events with courage
A. Composure
B. Equanimity
C. Imperturbability
D. Idealism
E. Bravery
Answers 1.24–1.28
1.24 The answer is C
1.25 The answer is B
1.26 The answer is D
1.27 The answer is A
1.28 The answer is E See Table 1.3.
Table 1.3 Character and Qualities of the Physician As Described by William S. Osler, M.D., in Aequanimitas
Imperturbability The ability to maintain extreme calm and steadiness
Presence of mind Self-control in an emergency or embarrassing situation so that one can say or do the right thing
Clear judgment The ability to make an informed opinion that is intelligible and free of ambiguity
Ability to endure frustration The capacity to remain firm and deal with insecurity and dissatisfaction
Infinite patience The unlimited ability to bear pain or trial calmly
Charity toward others To be generous and helpful, especially toward the needy and suffering
The search for absolute truth To investigate facts and pursue reality
Composure Calmness of mind, bearing, and appearance
Bravery The capacity to face or endure events with courage
Tenacity To be persistent in attaining a goal or adhering to something valued
Idealism Forming standards and ideals and living under their influence
Equanimity The ability to handle stressful situations with an undisturbed, even temper
Questions 1.29–1.32
1.29 Can be upsetting and interfere with good medical care
1.30 A patient sees her doctor as overly critical because her mother had always criticized her life choices
1.31 May be encouraged as integral to some intensive psychiatric treatment
1.32 A doctor is hostile to a patient who he assumes will be “difficult” and non-compliant because she reminds him of his ex-wife
A. Transference
B. Countertransference
C. Both transference and countertransference
Answers 1.29–1.32
1.29 The answer is C
1.30 The answer is A
1.31 The answer is A
1.32 The answer is B
Doctors and patients may have divergent, distorted, and unrealistic views about each other, about what happens during a clinical encounter, and about what the patient has a right to expect. Transference and countertransference are terms originating in psychoanalytic theory. They are purely hypothetical constructs, but they have proved extremely useful as organizing principles for explaining certain developments of the patient–doctor relationship that can be upsetting and that can interfere with good medical care.
Transference describes the process of patients unconsciously attributing to their doctors aspects of important past relationships, especially those with their parents. A patient may come to see the doctor as cold, harsh, critical, threatening, seductive, caring, or nurturing, not because of anything the physician says or does, but because that has been the patient’s experience in the past. The residue of the experience leads the patient to unwittingly “transfer” the feeling from past relationships to the doctor. The transference can be positive or negative, and it can swing back and forth—sometimes abruptly—between the two.
Transference reactions may be strongest with psychiatrists, for a number of reasons. For example, as part of intensive, insight-oriented psychotherapy, the encouragement of transference feelings is an integral part of treatment. In some types of therapy, a psychiatrist is more or less neutral. The more neutral or less information the patient has about the psychiatrist, the more transferential fantasies and concerns are mobilized and projected onto the doctor. Once the fantasies are stimulated and projected, the psychiatrist can help patients gain insight into how these fantasies and concerns affect all the important relationships in their lives.
Physicians themselves are not immune to distorted perceptions of the patient–doctor relationship. When doctors unconsciously ascribe motives or attributes to patients that come from the doctor’s past relationships, the process is called countertransference. Countertransference may take the form of negative, disruptive feelings, but it may also encompass disproportionately positive, idealizing, or even eroticized reactions. Just as patients have expectations for physicians—for example, competence, objectivity, comfort, and relief—physicians often have unconscious or unspoken expectations of patients. Most commonly patients are thought of as “good” patients if their expressed severity of symptoms correlates with an overtly diagnosable biological disorder, if they are compliant and generally nonchallenging with treatment, if they are emotionally controlled, and if they are grateful. If these expectations are not met, even if this is a result of the unconscious unrealistic needs on the part of the physician, the patient may be blamed and considered unlikable, untreatable, or “difficult.”