The Physician–Patient Relationship in Specific Populations of Patients
Addressing cross-cultural issues such as race, ethnicity, religion and gender is vital to the establishment and maintenance of an effective physician–patient relationship. Failure to clarify cultural assumptions, whether stemming from differences or similarities in background, may impede the es-tablishment of a trusting therapeutic alliance, making effective treatment unlikely (Cheng and Lo, 1991).
Establishing an effective physician–patient relationship with children, adolescents and families is one of the most challenging and rewarding tasks in the practice of psychiatry. Rather than being treated as “little adults”, children and adolescents must be approached with an appreciation for their age-appropriatedevelopmental tasks and needs. When physicians treat this popu-lation, they must establish a trusting relationship with both the patient and the parents. Preadolescent children face the psycho-social developmental tasks of establishing trust, autonomy, ini-tiative and achievement. By understanding the facets of normal childhood development, physicians may help parents understand the nature of their child’s disturbance and work within the family system to establish effective mechanisms for coping and recov-ery (Angold, 2000; Erikson, 1950).
Adolescent patients, facing the task of establishing an indi-vidual identity, pose particular challenges to the physician–patient relationship. Adolescents are particularly sensitive to any signals from the physician that their powers of decision, their intelli-gence, or their perceptions are being ignored. The critical time for engagement with the adolescent is often in the first session, sometimes even in the first few minutes (Katz, 1990). Defiance, detachment and aggression may be anticipated and defused with a steady therapeutic presence grounded in consistent boundaries and open acknowledgment of the adolescent patient’s distress (Colson et al., 1991).
In working with families, physicians in general and psychi-atrists in particular must clearly address questions and concerns regarding all aspects of treatment and convey respectful compas-sion for all members. The therapeutic alliance, or “joining” with the family and patient, requires developing enough of a family consensus that treatment is worth the struggle involved. Taking sides and engaging with individual and family power struggles can be particularly destructive to the physician–patient relation-ship in families. Rather, it is the physician’s ability to relate to the family as a multifaceted organism, massively interconnected, transcending the sum of its parts, that often allows treatment to progress and, in the best scenarios, allows for growth and under-standing to occur (Fleck, 1985; Ziegler, 1999).
Terminally ill patients share concerns related to the end of the life-cycle. Elderly patients at all levels of health face the develop-mental task of integrating the various threads of their life into a figurative tapestry that reflects their lifelong feelings, thoughts, values, goals, beliefs, experiences and relationships, and places them into a meaningful perspective. Patients newly diagnosed with a terminal illness such as metastatic cancer or acquired immunodeficiency syndrome may be particularly overwhelmed and initially unable to deal with the demands of their illness, es-pecially if the patient is a younger adult or child. Psychiatrists may enhance the terminally ill patient’s ability to cope by ad-dressing issues related to medical treatment, pharmacotherapy, psychotherapy, involvement of significant others, legal matters and institutional care (Lederberg and Holland, 2000). Patients struggling with spiritual or religious concerns may benefit from a religious consultation, a resource that is frequently unused.
Countertransference feelings ranging from fear to help-lessness to rage to despair can assist the therapist greatly in maintaining the physician–patient relationship and ensuring ap-propriate care. Physicians working with patients with acquired immunodeficiency syndrome must frequently confront their own feelings and attitudes toward homosexuality (McKusick, 1988). Issues commonly encountered with disabled patients include inaccurate assumptions about their ability to function fully in all areas of human activity, including sex and vocation. Terminally ill patients may evoke reactions of unwarranted pessimism, thwarting the physician’s ability to help the patientmaximize hope for the quality of whatever time may remain. Patients and their family members often look to their physician for guidance.