Am Fam Physician. 1999;59(9):2639-2640
A well-dressed, intelligent 30-year-old woman presented to my office with pelvic pain that she described as occurring “on and off.” She was convinced that the pain was related to Gardnerella infection and requested intravenous antibiotic treatment for it. She had recently been seen by several physicians before this visit. During the first visit, I took a great deal of time to explain to her that continually seeking treatment for pelvic inflammatory disease was not the solution; instead, she needed to develop a trusting relationship with her physician.
She came back several times and seemed to be developing a relationship with me. Although wet mounts showed no indication of Gardnerella, I could not convince her that her pain wasn't associated with infection. On the third visit, she reported significant abdominal tenderness and cervical motion tenderness, so I admitted her to the hospital to receive intravenous antibiotics.
The results of all laboratory studies and cultures performed in the hospital were negative. While my patient was hospitalized, I asked a psychiatrist to consult with her, and my patient reluctantly agreed. The psychiatrist's initial assessment suggested that some sexual abuse may have occurred early in my patient's life and that she seemed childlike.
When my patient came to see me for follow-up, her demeanor was distant. She seemed to think that I had tried to trick her into getting psychiatric care. Even though she told me that she would continue to see a psychiatrist, I knew she would not, and that soon she would be shopping for another physician.
How did things go wrong in this physician-patient relationship? The patient ended up angry and distrustful of the physician. At what point did this lack of trust develop? One obvious trouble spot occurred when the patient only reluctantly agreed to see the psychiatrist. A referral to a mental health professional is often interpreted by a patient as “He doesn't believe me. He thinks it's all in my head.” There is much that a physician can do to discover underlying meanings and emotions before referring a patient to a mental health professional.
As physicians, we often do not understand why patients are convinced of something that we believe is irrational. Patients always have explanations for their symptoms—ones that make sense, based on their background and experiences—whether they express them or not. And they probably won't follow our advice if it conflicts with their explanation. So what we, as physicians, need to do is to discover the meaning behind the patient's symptoms. In the process, we may discover a better approach to working with that patient.
Perhaps the referral to the psychiatrist would not have broken the patient's trust if a strong empathic connection had been established beforehand. It is interesting to note that the physician states that the patient “seemed to be developing a relationship with me,” not that the two of them were developing a relationship together. The first priority with any patient—and particularly with a patient who may have a somatization disorder—is to listen and truly try to understand not only the symptoms, but also what the patient is thinking and feeling. The patient needs to feel both heard and understood. Not only does this let the patient know that the physician really cares, but it also produces better information on which to base an accurate diagnosis. It can dramatically increase the likelihood of adherence to a treatment plan.
So how do you let patients know they have been heard and understood? First, allow patients the opportunity to tell their stories without interruption. This will probably take no longer than two to three minutes. Then, begin asking open-ended questions rather than a rapid succession of specific questions. A question such as “Does this pain wake you up at night?” might be replaced with a question such as “Tell me more about your pain.”
When we encounter a patient or situation that we feel is “difficult,” we often react or draw conclusions too quickly. Instead, pause to ask yourself what's going on. Use reflective listening and allow the patient to correct you if he or she feels you have misunderstood. For example, you might ask: “It sounds to me like . . . Do I have it right?” Finally, validate and normalize the patient's experiences or feelings: “Given what you've been through, I can see why you'd feel that way.” Or, “I think that most people would . . .” or “Many of my patients . . .”
Sometimes, when patients with somatization disorders feel that they have been heard and understood, their symptoms diminish. It can also be helpful to elicit the patient's full agenda. Try asking: “What were you hoping we'd accomplish today?” The patient may only be seeking reassurance that her pelvic pain is not like the pelvic pain that her mother, who died of endometrial cancer, had experienced.
Finally, when you and your patient disagree about the etiology of the illness or the treatment plan, it can be helpful to discuss the disagreement. The physician might say something like this: “I'm having some difficulty here. You seem convinced that your pain is being caused by an infection, even though all the test results have been negative. I'm curious about why you believe that so strongly” or “We seem to have a significant difference of opinion about what's causing your pain. How can we work together to help you feel better?” This won't always solve the problem, but it will at least allow for the possibility of a mutually satisfactory solution.
While it is true that “doctor-shopping” is not the solution for the patient described here, I doubt that telling her that she needs to “develop a trusting relationship with her physician” is as effective as simply being the kind of physician that she can learn to trust.