“Oh No, My Patient is a Physician!” Hurdles When Treating Physician-Patients

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CLINICAL REFLECTIONS

Control is a powerful tool and can affect every aspect of daily life. Within the medical field the term control has its own implications, especially when treating patients. There is an unspoken bond that control is relinquished by the patient and given to the physician in hopes of recovering from the illness. What happens when the physician is the one in need of treatment? What happens when the physician perceives themself as ill and weak?

Physician-patients can be very reluctant to give control of their medical health to another person. The general public is taught from a young age that “the illness belongs to the patient” and that physicians are supposed to be invulnerable.¹ When they are sick, they can be in a world of denial and feel forced to bear the torment of their illness alone. Therefore, physicians may delay seeking medical help; when they do, they may also project their own feelings onto the treating physician, or transference. On the other hand, it is very easy for the treating physicians to project their own feelings onto the physician-patient, or countertransference.

This article will discuss the characteristics of a good physician; the different dynamics and challenges that arise when treating physician-patients, especially during the era of COVID-19 when physicians feel increased moral obligations to their patients; and strategies to resolve this dilemma.

Discussion

It is important to first discuss what characteristics make a good physician and a good patient. A good physician is said to be competent, altruistic, responsible, and empathetic.² From the beginning of their medical training, physicians are taught to be “resilient, collaborative, scientifically adept.”³ Meanwhile, a good patient is seen as “someone who listens, follows directions, asks relevant questions, shows trust in his or her doctor and ‘massages’ the doctor’s ego.”⁴ Although physician-patients theoretically are supposed to encompass all traits of a good physician and a good patient, a degree of antagonism between these traits can arise.

It is easy for physician-patients to be consumed by the principles expected of good physicians and lose sight of their own health. Physician-patients are known to have higher rates of alcoholism, substance abuse, and suicide when compared with the general population, but can be reluctant to pursue health care and often minimize serious illnesses.^5-7 Furthermore, there are cases of physician-patient psychiatrists who, despite having clear symptoms of mental illness, insist on caring for their patients while psychiatrically unstable themselves. Some suffer from serious substance use disorders, leading to frequent absenteeism and poor continuity of care for their patients. The perceived shame and misinterpretation of professionalism and resiliency can make physicians feel they are letting their patients and colleagues down by taking time off, even when it is necessary.⁷ On the other hand, some physicians fear projecting the image of being vulnerable and attempt to impose their own plan of care. Others will prescribe their own medication, self-investigate, and self-refer.⁷

During the peak of the COVID-19 pandemic these challenges were highly amplified, as physicians felt a duty to be on the frontline to save lives despite the danger of exposure to COVID-19. This put them at a higher risk for fatigue, insomnia, burnout, anxiety, and depression, among other stressors. These included working long hours witnessing patients dying alone in the hospital. Some physicians also felt the need to isolate from their own families at home due to the fear of transmitting the virus. During this period, they often ignored their own mental and physical well-being. This shared belief that physicians are always expected to be “resilient” can affect how often physician-patients ask for help, and also how their treating physicians perceive them as colleagues in lieu of as patients.

This powerful dynamic between physicians and physician-patients can hinder treatment. On one hand, physicians can make wrong assumptions about the knowledge the physician-patients have on the condition they are facing.⁸ The treating physicians can also assume that physician-patients are looking after their illness in the correct way, such as self-monitoring, scheduling follow-up visits, and making the right lifestyle choices.¹ Unfortunately, this is not always the case. Furthermore, during assessments, treating physicians can avoid asking physician-patients pertinent questions on certain topics including domestic violence, high risk sexual behaviors, substance abuse, and mental health.¹

On the other hand, physicians can also feel intimidated due to thinking that their performance is being critiqued.⁷ Some physician-patients expect to be treated as colleagues rather than patients, which often blurs the boundary and makes limit setting extremely difficult.⁷ This exchange between physicians and physician-patients can generate feelings of transference and countertransference, which were heightened during the COVID-19 pandemic and are illustrated in the Table.

Table. Feelings of Transference and Countertransference With Physician-Patients

Treating physician-patients may seem complicated at first, but developing strategies beforehand can help navigate this challenge. As outlined by Domeyer-Klenske and Rosenbaum, one strategy is to try to ignore the background of physician-patients and treat them as any patient.¹ Although ignoring the medical knowledge of physician-patients can be quite difficult, treating them as any other patient seems like a reasonable solution. Instead of assuming the physician-patients are familiar with their illness, we believe it is best to provide them with the necessary information regardless of their medical training. Another possible strategy suggested by Domeyer-Klenske and Rosenbaum is to “acknowledge physician-patients’ background and negotiate care.”¹ We therefore emphasize the importance of setting boundaries early in the interaction with physician-patients. We cannot stress enough how crucial it is for the treating physician to do a proper assessment and have an open discussion about the treatment plan and recommendations so the physician-patient feels involved in their own care. Furthermore, we recommend avoiding all evaluations and treatments by friends and family members. Finally, we strongly advise our colleagues working alongside physician-patients to help them avoid self-sacrificing and seek care when needed.

Concluding Thoughts

There has been an implicit understanding that physicians are healers responsible for the treatment of patients and therefore thought to be immune to illness. The vulnerability associated with illness can be difficult to accept and the COVID-19 pandemic has undoubtedly led to the amplification of the stigma associated with physicians being sick. Powerful transference and countertransference dynamics occur when physicians treat physician-patients. Therefore, recognizing and addressing this matterearly in the assessment is as crucial as the need to develop strategies to mitigate the perceived struggle over control. It is important to avoid making assumptions about the knowledge of the physician-patient on their condition, maintain strict boundaries, and keep an open discussion about treatment plans. It is also vital to attempt to engage colleagues who appear to be struggling with their physical or mental health and may require help. Illness should not be perceived as a weakness but rather as a common trait of humanity, including that of “good physicians.”

Dr Yazeji is a third year adult psychiatry resident at Nassau University Medical Center, New York. Ms Sachdev is a fourth year medical student at American University of the Caribbean School of Medicine, St. Maarten. Dr St. Victor is the Assistant Clinical Director of Consultation-Liaison Psychiatry at Nassau University Medical Center, New York.

References

1. Domeyer-Klenske A, Rosenbaum M. When doctor becomes patient: challenges and strategies in caring for physician-patients. Fam Med. 2012;44(7):471-477.

2. Wei H, Wei T, Brown KJ, et al. Parents’ perceptions of caring characteristics of physicians and nurses. International Journal for Human Caring. 2018;22(1):49-55.

3. Discover AUC’s Caribbean Med School. AUC School of Medicine. Accessed November 14, 2022. https://www.aucmed.edu/

4. Campbell C, Scott K, Skovdal M, et al. A good patient? How notions of ‘a good patient’ affect patient-nurse relationships and ART adherence in Zimbabwe. BMC Infect Dis. 2015;15:404.

5. Allibone A, Oakes D, Shannon HS. The health and health care of doctors. J R Coll Gen Pract. 1981;31(233):728-734.

6. Aasland OG, Ekeberg O, Schweder T. Suicide rates from 1960 to 1989 in Norwegian physicians compared with other educational groups. Soc Sci Med. 2001;52(2):259-265.

7. Jaye C, Wilson H. When general practitioners become patients. Health. 2003;7(2):201-225.

8. Fox F, Harris M, Taylor G, et al. What happens when doctors are patients? Qualitative study of GPs. Br J Gen Pract. 2009;59(568):811-818.