Most healthcare workers would describe their ideal patients as independent, hardworking, and self-sufficient individuals who are logical and rational in their thinking. These individuals want to be helped, and they respond in a mature fashion to their doctors and care providers. They follow advice without overreacting or becoming overly emotional. Good patients recognize that the clinician has imparted wise advice based on training and experience.
Not only are these the characteristics that most physicians expect in a good patient, but they also use these qualities to describe themselves. Thus, good patients are actually people who reflect what the physicians and nurses view in themselves as desirable characteristics. Many of the traits that physicians judge as most desirable include shared language and cultural values. Treatment of these “good” patients leads to congenial, effective, and mutually rewarding interactions.
The Virtual Instruction Guide
In effect, physicians have adopted, over the years of training and practice, a basic how-to guide or instruction book for how they believe that their patients should behave. In reality, the patient instruction guide has never been published; however, the people who would follow the guidelines would be our fantasy patients.
When a middle-aged man presents during the month of Ramadan fasting, hunched over in pain, holding his hand on his right flank, we can clearly see that he has read and followed the instruction guide on how to present with a kidney stone. When an elderly man presents with diffuse abdominal pain and refuses both pain medicines and imaging, he is not following the good patient guide. Because he chooses not to follow the physician’s advice or comply with the nurses’ plan of treatment, we develop negative feelings about him. We might think, “he doesn’t respect me!” or “doesn’t he know my shift is almost over?” Clinicians immediately ask: “Why did he even come to see me if he will not follow my plan or my advice?” Patients who don’t follow the instruction books are labeled as “difficult” patients.
Four Core Ethical Principles of the Clinician–Patient Relationship
The ethics of the doctor–patient relationship don’t go into the trash bin just because the patient refuses medicine, speaks a different language, or prefers an alternate approach. Four core ethical principles form the base of the healthcare provider–patient relationship(1):
Autonomy: Autonomy is the ethical principle widely considered most central to healthcare decision-making. In medical practice, autonomy is usually expressed as the right of competent adults to make informed decisions about their own medical care. Adult and emancipated patients with decision-making capacity have the right to accept or decline offered healthcare, and physicians have a duty to respect the decisions of those patients, even if they disagree.
Beneficence: Beneficence means promoting the patient’s best interest by treating or preventing disease or injury and by informing patients about their conditions. We also must protect our patients’ right to confidentiality.
Nonmaleficence: Do no harm. We are expected to avoid actions or treatments likely to cause the patient harm. Our patients trust us; they have faith in us that we will not harm them.
Justice: We are expected to allocate the benefits and burdens related to healthcare delivery fairly. We must act impartially with regard to patients’ gender, race, age, or ability to pay. Hardest of all, when we consider someone difficult or noncompliant, we are expected to treat them with justice and impartiality regardless of their demeanor or their behavior. We are expected to act with justice, regardless of our own beliefs.
The nursing code of ethics is called the “Nightingale Pledge” in honor of Florence Nightingale, the founder of modern nursing. As a modification of the Hippocratic Oath taken by medical doctors, the Nightingale Pledge has been recited by nursing students at graduations with little change since inception in 1893. The four principles of ethics for nurses’ echo those listed earlier: autonomy, beneficence, nonmaleficence, and justice.
The formal code of ethics for nurses was developed in the 1950s by the American Nurses Association (ANA) and underwent the last major modification in 2015. The nurse’s code of ethics includes nine main provisions, with, notably: “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.”(2)
The Four Models of Physician–Patient Relationships
The complex physician–patient relationship can be illustrated through four models. The classic article detailing the evolutions of the models was written by Drs. Ezekiel and Linda Emanuel and published in the April 1992 issue of Journal of the American Medical Association.(3) The authors identify these models as follows:
Paternalistic model: The physician acts as the patient’s guardian, using his or her skill to diagnose the patient’s medical condition and determine the tests or treatments likely to restore health. The physician presents the patient with selected information that will encourage the patient to consent to the treatment that the physician considers best.
Informative model: The physician informs the patient of his or her disease state, the nature and probability of risks and benefits associated with the treatment, and any uncertainties. The patient selects the medical treatment or interventions based on his or her values.
Interpretive model: The aim is for the physician to determine what the patient’s values are. The physician still provides the information and options for treatment; however, the physician does not dictate to the patient but helps the patient determine care according to their values.
Deliberative model: The physician takes on the role of teacher or friend, encouraging the patient regarding what course of action would be best. Autonomy empowers the patient to not only explore their unexamined preferences or examined values, but to consider alternative healthcare based on their own values and the implications of treatment.
In my experience, most physicians adopt the physician–patient model that I like to call the “maternalistic model with beneficent coercion.” Most of us adopt an approach in which we advise the testing and treatment that we would want for our children or family members. Then we gently sell our patients on the most likely diagnosis, the best course of treatment, and discharge or admission that is based on our values, our best medical knowledge, and our own experience. We downplay or fail to mention the side effects of medications, adverse effects of procedures, or the potential benefits of alternative treatment options. In other words, we offer a plan based on our best educated guess.
We should respect our patients’ autonomy and unique preferences, but, in reality, we want them to accept, with little resistance, our chosen plan. We are concerned that some “difficult” patients are under controlling influences of obstructive family members or have personal limitations that prevent meaningful choice (such as inadequate understanding or faulty reasoning).
Like us, our patients operate within the motivational triad to seek pleasure, avoid pain, and conserve energy. Some patients want relief from pain and will exaggerate their symptoms, plead, and threaten you to try to get opioid pain relievers. Physicians do not want to begin or perpetuate their patients’ dependence on opioids. The clinician wants to do a thorough work-up to find the cause of the pain and provide analgesia. The patients’ and physicians’ motivations occasionally conflict.
Consider this issue we face daily: A patient who has classic symptoms of a viral upper respiratory infection will only be happy with an antibiotic prescription. He does not understand that the treatment he so desperately wants may actually harm him. Many of us try to please the patients and give them what they want. This seemingly small ethical dilemma has probably generated alarming amounts of antibiotic resistance, serum sickness, and C. difficile colitis in our population. Making the “correct” decision in the face of a persistent or threatening patient will be a constant source of angst unless you can adjust your own thinking about demanding patients.
Excerpted from Changing How We Think About Difficult Patients, by Joan Naidorf, DO (American Association for Physician Leadership, 2022).
References
Post LF, Blustein J. Handbook for Health Care Ethics Committees. Baltimore, MD: Johns Hopkins University Press; 2015.
Gaines K. What is the Nursing Code of Ethics? https://nurse.org/education/nursing-code-of-ethics/ .
Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992;267:2221-2226.