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Shifting from the Difficult Patient to the DifficultRelationship: Can Ethics Consultants Really Help?Kayhan Parsi aa Loyola University ChicagoPublished online: 01 May 2012.

To cite this article: Kayhan Parsi (2012) Shifting from the Difficult Patient to the Difficult Relationship: Can Ethics ConsultantsReally Help?, The American Journal of Bioethics, 12:5, 1-1, DOI: 10.1080/15265161.2012.677321

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The American Journal of Bioethics, 12(5): 1, 2012Copyright c© Taylor & Francis Group, LLCISSN: 1526-5161 print / 1536-0075 onlineDOI: 10.1080/15265161.2012.677321

Editorial

Shifting from the Difficult Patient tothe Difficult Relationship: Can Ethics

Consultants Really Help?Kayhan Parsi, Loyola University Chicago

I co-facilitate with a neurosurgeon a small group of first yearmedical students for our clinical skills course. The course iscalled Patient-Centered Medicine (PCM), and in this course,students learn the basics of interviewing patients, taking ahistory, and writing a chart note. In our introduction to thecourse, we state that “PCM is a 3 year course designed forLoyola medical students to develop the skills needed tobecome balanced, competent, patient-centered physicianswith life-long career satisfaction.” Our students also de-velop knowledge and skills about various aspects of patientcare. One of the sessions we cover is called Difficult Pa-tient/Physician Relationships. We teach our students thatour thinking has shifted from a punitive approach of blam-ing the patient (e.g., the patient is “hateful,” “difficult” orthe “problem”) to one where we acknowledge that the rela-tionship is what can be challenging or difficult.

In her target article, Autumn Fiester finds fault withour traditional concept of the “difficult patient” and arguesthat such encounters necessitate the involvement of ethicsconsultants. She recounts case scenarios where patients areperceived to be difficult—the first case involves a youngpatient who is quadriplegic and has become verbally abu-sive. Because of his behavior, the care team refuses to workwith him. In another case, a patient is made to wait for anexcessively long time, whereupon she is greeted by an un-friendly receptionist and a brusque treating physician. Thepatient then yells at the clinician. As we teach our own med-ical students, these cases exemplify difficult relationshipsbut not necessarily difficult patients. Interestingly, Fiesterargues that it is part of the ethics consultants’ professionalobligation “to recognize this obligation as being part of theirself-identified mandate.”

Commentators such as Zackary Berger are concernedabout such a move, citing concerns related to over-

Address correspondence to Kayhan Parsi, JD, PhD, Neiswanger Institute for Bioethics and Health Policy, Loyola University ChicagoStritch School of Medicine, Bldg. 120, Room 280, 2160 S. First Ave., Maywood, IL 60153, USA E-mail: kparsi@lumc.edu

specialization and continuity of care. Presumably, the onusis on the clinician to cultivate the skills needed to address thedifficult patient/physician relationship and not simply toturf this to an ethics consultant when the going gets rough.Recognizing that addressing difficult patient/physician re-lationships is part of the clinician’s job, Blackall and Greenprovide a framework to address such difficult relationships.The clinician has to 1) focus on the patient’s competencies,2) identify psychological distress, 3) realize control is amyth, and 4) acknowledge blind spots. Blackall and Greenecho Berger’s view, aiming “to help doctors strengthen theirrelationships on their own.” Others here (Davis et al.) findfault with the mediation model employed by ethics consul-tants as an appropriate model for all patients or their fami-lies. Still others (Landy et al.) call for other patient supportservices to help address difficult situations.

My students during their third year rotations will reportto me instances where they feel some of their patients aregaming the system in order to obtain some perceived ben-efit. The students I talk to feel that the social contract getsfurther frayed when such abuses occur. The challenge is torecognize that both patients and physicians are merely hu-man. Physicians, nurses and other health care professionalswill get frustrated with patients. Patients will become angryif they believe their concerns are neglected. By re-framingthe “difficult patient” to a difficult encounter or difficult re-lationship, we depersonalize the situation (in a healthy way)and re-focus our efforts on strengthening a relationship thathas become weakened. Although the onus is ultimately onthe clinician and his or her patient, other professionals suchas ethics consultants, patient support representatives, andothers may play a vital role in those (hopefully) rare occa-sions where communication truly has broken down and theinput of a third party is necessary.

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