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Good Patients, Difficult Patients - Reconsidered

Posted By Karen Kinman, Tuesday, January 7, 2014

This is a response to Dr. Aronson’s article in the New England Journal of Medicine entitled, ""Good” patients and "difficult” patients – rethinking our definitions" (Aronson, 2013). This article will address these definitions, as well as her comments regarding the collaborative process of care, the unspoken rules of medical etiquette and traits of medical culture. I am writing from the systemic perspective of a medical family therapist. 

We know that families have a significant impact on health equal to medical risk factors (Campbell, 2003).  Families are present throughout the development of disease from diagnosis and treatment, to caregiving; each family member affects the biological, emotional, mental and social health and well- being of the others. As Dr. Aronson points out, it is part of the medical culture to see families as something to "deal with” rather than as a significant resource.  She notes that "truly good care” is a collaborative process. However, this collaborative process also means giving back control to patients and families in the management of their disease. 

Control of a patient’s treatment and management of disease, by healthcare providers, in- hospital or outpatient, is a daunting and elusive task. The real paradox is that as healthcare staff relinquishes control to the patient and his/her family, both enjoy a more satisfying and collaborative relationship. Experiencing the other side of medicine, as the daughter of a patient, Dr. Aronson points out how the culture needs to shift to one which welcomes, and perhaps expects patients and families to actively engage in their health care.

The culture needs to shift to one which expects patients and families to actively engage in their health careThis is more needed today than ever before, as healthcare has become more compartmentalized. Looking at healthcare as a system, there are multiple layers which affect the culture of medicine and its challenges which present today. Some of these layers include: a) the role of physicians in their knowledge and expertise regarding treatment and management of disease, b) the development of hospitalists, who are physicians who work solely in the hospital and have no history or relationship with the patient prior to admission, and c) regulations from insurance which come between physician and patient, affecting treatment protocols and time management. Nurses are trained in treating the patient and family holistically, but their time is limited in how much they can do, as well as their limited expertise with mental health issues. When organizing priorities, medication administration, treatments for wound care, and post- operative care come before attending to the psychosocial concerns of a patient.  

Having worked as a nurse for over 30 years, and now as a medical family therapist, I am increasingly convinced that standard care should integrate physicians’ focus on health and disease with the biopsychosocial focus which mental healthcare providers and medical family therapists provide.Medical family therapy is a biopsychosocial approach within a family systems framework, with individuals and families who have medical problems (McDaniel, Hepworth, & Doherty, 1992). Medical family therapists, like other mental healthcare providers, are there for staff as well as patients and families, and can address difficult issues such as noncompliance, denial, and inadequate pain management. They see themselves and the staff joining the family system, and therefore, assess interactional patterns between staff, and between staff and patient/family. This can result in improved staff-patient and staff-staff relationships and broadens the scope of solutions to issues in which traditional intervention may be ineffective. 

I have been in hospital environments which were not nurturing or empowering to patients and families, and environments which very much respected their choices in how they were going to deal with their disease, (whether or not the staff was in agreement with those choices). I am currently  working in an ALS clinic as part of a collaborative team with physician, nurse, social worker, dietician, speech therapist, physical therapist, and a resource person for medical equipment. One salient characteristic of this environment is that we not only have good patient-healthcare provider relationships, but relationships between the staff are more respectful, empowering, collaborative, friendly, and efficient. A medical family therapy perspective facilitates this culture of collaboration and respect.
Medical family therapists, like other mental health care providers, are there for staff as well as patients and families

As Dr. Aronson points out, a "difficult” patient is described by the healthcare team as one who either has mental issues or is not "acquiescing” to staff. Medical family therapists may see what is defined as "difficult”, for example, may be related to: a) unspoken rules or beliefs regarding a disease and its treatment of which the staff is not aware, b) unresolved family problems which emerge in the midst of acute or chronic illness and is deflected on staff, and/or c) staff’s perception which is influenced by their own experiences and meanings of health and illness.

Change in culture happens very slowly. Healthcare providers do recognize the significance of patient/family-centered care, but, such care is a huge shift from traditional practice. It requires support from the top levels of management, structural changes, and a redistribution of power within the system, rather than simply a change in language or more contact with staff. Utilizing and empowering patients and their families gives them responsibility and accountability in managing their health and illness. However, on a deeper level, this hopefully will increase healthcare providers’ awareness of the wisdom and expertise of their patients and families. Perhaps, in this case, if Louise was not a physician, her father may not have made it home.  In Dr. Aronson’s case, "difficult” translated into knowledgeable and competent.


Campbell, T. L. (2003). The effectiveness of family interventions for physical disorders. Journal of Marital and Family Therapy, 2, 263-281.

McDaniel, S., Hepworth, J., & Doherty, W. (1992). Medical family therapy: A biopsychosocial approach to families with health problems. New York: Basic Books. 

Karen Kinman, PhD, RN, LMFT-A, is currently working at UT Southwestern Medical Center Family Studies Center where she sees individuals, couples and families. She is a medical family therapist in an ALS clinic, and leads support groups for the Muscular Dystrophy Association. She is currently working on her certification in hypnotherapy, and is a therapeutic touch practitioner. She is adjunct professor at TXWesleyan University in the family therapy department. The majority of her 33 years of experience as a nurse has been in maternal-child health and neonatal ICU. 

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