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Am Fam Physician. 2001;63(3):575-579

Case Scenario

For all of my professional life, I have been seeing overweight, diabetic, hypertensive patients with severe osteoarthritis in their knees and hips. I admit thinking to myself, “Don't they know how much better they would feel if they would only lose some weight? Don't they know how much better their diabetes and high blood pressure would be if only they would lose some weight?” My opinion of some of these patients has been that they are lazy, lack willpower and like being sick. At times I felt that they wanted me to give them a magic pill to cure their problem, when they were the ones who actually needed to do the work.

One day an elderly, extremely obese woman was rolled into my clinic in a wheelchair. She had high blood pressure, diabetes (she was taking more than 100 units of insulin a day), severe osteoarthritis and some of the most swollen legs I have ever seen as a result of post-phlebitic syndrome. She had recently been seen at another health facility, and a resident there had just called me about her laboratory results. He pejoratively referred to her as “the whale.”

I asked the patient why she was changing doctors. The clinic where she had previously been seen had a good reputation. Perhaps I asked the question because I was feeling a little sorry for myself and thinking, “Another obese, diabetic, hypertensive patient who is noncompliant.” As if reading my mind, the patient answered, “My doctor was tired of taking care of a fat old lady, and you'll probably get tired of me, too.” I was really taken aback by her answer. I thought I had hidden my feelings pretty well.

Since that day, I have had a different attitude toward the care of such patients, and I find that I have become more successful in helping them get their diseases under control. Could the change in my attitude have made a difference?


The title of this case scenario is emphatically appropriate because it describes the intense feelings that obese patients and those with difficult, chronic lifestyle issues evoke in their physicians. The author aptly describes feelings and reactions such as frustration, cynicism about the patient's motivations and hopelessness about the ability to cure a problem that he or she perceives as belonging more to the patient than to the physician.

These reactions can occur not only to obese patients but also to those with conditions such as chronic obstructive pulmonary disease who say they cannot quit smoking, or patients with asthma or diabetes who cannot seem to remember to take their medications correctly or who cannot follow a healthy diet.

The resident physician's disrespectful labeling of the patient as “the whale” somewhat mordantly summarizes the resident's assessment and frustration. This labeling sets up a potential adversarial interaction between the physician and the patient. Labeling patients in this way is likely to evoke a bit of humorous laughter among the health care staff. This humor will most likely appear to be uncaring, but it is important to realize that the use of such an epithet expresses on a deep level the frustration and cynicism that the “humor” is designed to reduce or disguise, and allows the physician to set boundaries as a way of handling personal discomfort.

The patient's woeful statement that the other physician just got tired of her may have been intended to evoke sympathy. However, the statement also assumes some of the characteristics of a challenge by implying these questions: “Will you also get tired of me?” “Will you be up to the challenge of taking care of me?”

What does all of this have to do with attitude? Isn't knowing how to handle patients with chronic problems in a scientific, organized and disease-management fashion the answer? Balint1 addressed these issues in a book, The Doctor, His Patient, and the Illness, that was published in 1957. Balint was an English psychiatrist who had previously been a general practitioner. Consequently, he understood the loneliness and frustration of the general practitioner with regard to the patients seen in everyday practice.

Since the book's publication, physicians in England and family practice residency programs in the United States have formed Balint groups. These groups focus on recognizing, articulating and dealing with the frustration and other feelings patients can evoke in physicians. This activity helps reduce the likelihood that physicians will develop an adversarial relationship with those patients—the kind of relationship that is not likely to help either party and is almost certain to interfere with management of the medical problem. In short, physicians must have the courage to address the discomfort they feel as a result of their patients' behavior.

Siegler2 describes three clinical moments in the patient-physician encounter. The third clinical moment is the “physician-patient accommodation,” in which Siegler says, “The patient wonders whether his symptoms are serious or trivial, and whether this physician can help him. Simultaneously, the physician is deciding whether the patient has a disease or just a ‘problem of living,’ and whether the problem is one that the physician can help with.” He concludes that any understanding of clinical medicine must be based on an analysis of the way physicians and patients interact rather than solely on a theoretic analysis of the nature of health and disease.

Finally, to address the physician's question in this case, Baughan and associates3 reported that an educational process with family practice residents could result in a shift in focus from the problem patient to the problem patient–physician relationship. When this shift occurred, it resulted in improved strategies that made a difference in physician satisfaction and in the outcomes of care. The answer, then, to the author's question “Could a change in attitude make a difference?” is, emphatically, yes.

Changing one's attitude from a position of frustration to one of understanding a patient's needs, expectations and feelings is more likely to result in interpersonal and medical success. This change in attitude permits a contract for honesty to be made between the physician and the patient. This contract consists of an informal, verbalized agreement to behave in a certain manner or do something differently. The agreement may be written as a physician's note in the patient's chart so that it can be referred to later.

Physicians who have an honest relationship with their patients should be able to share their frustrations about diagnosis, lack of compliance or other issues in a way that is therapeutically positive. Statements reflecting this honesty might include: “Nothing I've tried to help you has worked, and it is very frustrating to me”; or “We agreed that you would exercise three times a week, but you haven't done so, by your own admission, and I don't know what else to recommend that will help you as much”; or “I don't know why you're having these headaches, and we're both frustrated. We may need to get another opinion.”

Mutual understanding and a contract for care will make it less likely that the patient or the physician will reject the other's opinions or needs. Better understanding is a two-way street. The patient needs to understand and feel able to question why a physician wants to do something, or how the physician has come to a particular conclusion. The patient has to understand that his or her role in the interaction with the physician includes an obligation to be honest in asking questions, sharing attitudes and negotiating straightforward plans of action to address problems. This attitude can help move the patient-physician interaction from contract to partnership.

Realignment of goals is appropriate for the physician who better understands the abilities and desires of the patient. It may be that the patient cannot see himself or herself reaching the ideal body weight but can imagine losing 20 to 30 lb. A patient with chronic obstructive pulmonary disease who still smokes may not be able to imagine living without cigarettes. Understanding these attitudes and life situations will enable the physician to realign goals and make an appropriate physician-patient contract to allow for a more successful interaction. This positive interaction will greatly enhance the likelihood that the patient will do his or her best to meet mutually and respectfully determined goals for the relationship and the disease management.

Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at

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