When I first met Ms. Miller (name changed), quite frankly, I couldn’t wait to get out of the room. I’m sure she couldn’t either. A woman in her 40s with systemic lupus erythematosus, poorly controlled asthma and fibromyalgia, she seemed to have every conceivable symptom. And, worse than that, due to a long history of unfortunate encounters with the healthcare system, including disjointed care, adverse effects of medications and repeated hospitalizations, she was a self-described “difficult” patient who remained reserved and was quite suspicious of me. Every other sentence she uttered was followed by a not-so-subtle loud sigh or a roll of the eyes.
Two years after that first meeting, I could hardly believe she would be smiling widely, enthusiastically extending her hand to shake mine and showing me photos of her children and nephews. In turn, I’ve been eager to see her at our visits and discuss the ways we can address her medical problems.
That repartee did not come easily. There was a lot of give-and-take over the months and years. We mutually engaged in a lot of diplomacy and negotiation over a long period of time, sometimes over large topics and sometimes over relatively minor aspects of care.
This is the common experience of rheumatologists, who are experts in managing chronic conditions. Indeed, how to deal with difficult patients is a core, often unspoken, theme throughout fellowship education. Because we, as rheumatologists, are in the unusual spot of being deeply invested in virtually every aspect of physical and mental health without actually being primary care providers, we have to carefully and relentlessly hone our skills in dealing with difficult patients. More specifically, to be successful in our craft, we have to foster and nurture what psychologists term the therapeutic alliance.1
For both new and experienced rheumatologists, identifying the principles of successful alliances may help us hone strategies to decrease frustration and improve the sense of satisfaction while in the clinic.
This can lead to patient activation, as well as better adherence, health and well-being. Individual strategies to achieve strong therapeutic alliances vary and are dictated by a number of structural and cultural norms, but certain principles can guide the way.
The first, and most elemental, aspect of the therapeutic alliance is commitment. As physicians, we have to be committed to our patients. That means letting them know their well-being is the most important aspect of our relationship. Certain patients are under the impression, based on previous experiences, that healthcare providers are providing a transactional service.
Refuting the notion that physicians just dispense drugs in exchange for money is extremely important. In fact, it’s vital that we demonstrate how much we value personal relationships and that we actively engage with the utmost sincerity and honesty. Empathic conversation that goes beyond simple documentation of tasks can help patients realize that our role isn’t just to dispense medication but to help them recover well-being.
The use of the golden minute at the beginning of the patient encounter, when the electronic medical record and computers are deliberately ignored in favor of face-to-face conversation is one strategy that has been articulated and studied.2
Other strategies include deliberate articulation of joint responsibilities, using words like “we,” “together” and “cooperate.” At the end of sessions, I often use the phrase, “does that sound fair?” to demonstrate the bilateral nature of our commitment rather than dictation from a doctor.
It is just as important to reinforce that our commitment lasts long after our face-to-face encounters are over. The use of after-visit summaries has become commonplace. Consider including contact information, along with information for self-management of chronic disease. When used to their maximal effect, after-visit summaries can advance our commitment once we are no longer face to face. Additionally, if the patient is amenable, more frequent follow-up, at least initially, can also help reduce barriers in management once the patient is out of the room.
There’s a misconception in the general public that doctors are ‘in the pocket of big pharma,’ to quote Ms. Miller. We should take every opportunity to demonstrate what is true—that we are in the pocket of our patients.