Letters How patients make us feel

Negotiating the power gradient

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4063 (Published 05 October 2009) Cite this as: BMJ 2009;339:b4063
  1. Anna Sobel, ST3 psychiatry1,
  2. Farhana Mann, ST3 psychiatry2
  1. 1St Ann’s Hospital, London N15 3TH
  2. 2Margarete Centre, London NW1 2LS
  1. a_sobel{at}hotmail.com

    Although we have something to learn from the death of Michael Jackson,1 such extreme examples seem far from everyday practice.

    Medical education includes occasional vignettes or objective structured clinical examinations (OSCEs) featuring difficult patients, but as doctors we are left to negotiate the power gradient and appropriate boundaries on our own. Feelings elicited by powerful and difficult patients are waived aside to maintain professionalism. Doctors fear attention to feelings may negatively affect practice. But is it helpful to deny that patients make us feel certain ways?

    For psychiatrists, feelings elicited from patient interactions yield invaluable material, offering crucial insight into the patient’s presentation. This facilitates understanding of why the doctor feels a certain way and of the transference and countertransference—basic processes in communication.

    Part of the doctor-patient relationship can be reframed as a reflection of the patient’s past relationships. If patients seem dominating or difficult they may have treated others similarly before. Doctors’ responses are also coloured by their experiences. Psychiatrists regularly process what may be experienced by the patient unconsciously, contextualising their own feelings. The dangers from not doing so include hostile confrontation, hasty decisions, or identifying with accusations and seeing yourself as a failure.

    This is not solely psychiatric fare, or only an issue when treating celebrities, but an integral part of every doctor-patient interaction. Training in understanding our emotional reactions to patients would benefit all specialties both personally and professionally.


    Cite this as: BMJ 2009;339:b4063


    • Competing interests: None declared.


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