The Patient is the One with the Disease

Samuel Shem (pen name for Harvard psychiatrist Dr. Stephen Bergman) wrote The House of God in 1976; it became one the most popular medical novels of all time. Embedded in it are the Laws of the House of God, the Fat Man’s essential rules for surviving internship. The Third Law is “The patient is the one with the disease”. I invoke this Law almost every week in my clinic.

New patients are assessed initially by one of my nurse practitioners. Almost invariably I will be told that a patient is angry, crazy, obnoxious, uncommunicative, belligerent, ignorant, or simply an asshole. Patients complain about the parking, the wait to be seen, the requests for past records/scans/labs that they didn’t bring but believe we should magically possess, the repetitive reconciliation of medications and allergies that are already well documented in the medical record, and so on. Sometimes they are rude to the NP’s or won’t let them do their job. 

Despite this Sturm und Drang, most of the time when I see the family they are reasonably well behaved. Sometimes there is initial anger, suspicion, or lack of cooperation that dissipates over several minutes. What is going on?

Patients and families faced with a new diagnosis of cancer go through predictable phases of reactions described by the Kubler-Ross stages of grief: anger, denial, depression, bargaining, and acceptance. Fear is often an underlying factor -- fear of dying, fear of pain & suffering from the cancer and/or its treatment, fear of the impact of the cancer on the rest of the family. Depending upon the stage of adjustment to the diagnosis, these anxieties may be acted out in the clinic in ways that interfere with a therapeutic relationship. Physicians may receive a certain level of respect, since this vulnerable individual is placing himself in your hands, but other personnel such as secretaries and nurses often bear the brunt of patients’ anxiety-driven bad behavior.

Managing the dysphoria of patients with incurable cancer is an essential skill and requires a balance of teflon and empathy. It is key to recognize Kubler-Ross reactions but not react to them, neither getting sucked into confrontation nor walling yourself off like so many medical oncologists who become emotionally disconnected (a common complaint among my own patients). It is sufficient to verbally acknowledge the patient’s feelings (showing empathy), move rapidly into a summary of their disease course (displays knowledge and caring), then shift into a positive tone with a review of treatment options (offer hope). This will diffuse the fear and anxiety that underlies most contrary behavior. Of course, even assholes get cancer. Just remember, the patient is the one with the disease.

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