r e v b r a s o r t o p . 2013;48(6):469–470
w w w . r b o . o r g . b r
Editorial
The
difficult
doctor–patient
relationship
A
difícil
relac¸ão
médico-paciente
Our relationship withpatients is close, technical and pro-fessional.Close,becausewedealwithpersonalproblemsin theirlives;technical,inordertogivethecorrectdimensions totheircomplaintsandtheconsequences;andprofessional, sothatwecanguidepatientsregardingthebesttherapeutic choice.Wearealwaysinasituationofsuperiority,sincewe havebeensoughttosolveproblemsthatonlywecansolve.No otherserviceprovisionrelationshipisanythinglikethis.This isperhapsthereasonwhythisrelationshipissocomplex.
Fortunately,this relationshipusuallyhas apositive
bal-anceandweexperienceit throughamixtureoffriendship
andadmiration,whichislife-long.Thebestsourceofpatients isreferralsfromotherpatients.
Asmallbuthighlydangerousproportionofthepatients thatweattendmaycreatesituationsoffantasyandgenerate seriousproblems forourprofessional activity.These situa-tions maybe created duetopsychiatricproblems thatwe, becauseofourobjectivetraining,prefertoignore.
Thelinebetweenpsychiatricdisordersandcharacter fail-uresistenuousandsometimesthesestatesoverlap.
AstudypublishedinRBO48(4),onfactitioushandinjuries, reportedtheworstmanifestationofthispathological relation-shipbetweenadoctorandhispatient,inaveryinteresting manner.Inthis,thepatientcausesinjuriestohisorherown bodyandmaintainsthem,whichaddsgreatdifficultytothe diagnosisandtreatment.
Therearemanydescriptionsofpatientswhocause symp-tomssuchasulcerativelesions,edemaduetoatourniquet, bleedingduetowoundsmadebysharpinstruments, introduc-tionofneedlesintosubcutaneoustissues,andsoon.There is an intermediate situation that is less serious,in which
anenormousrange ofpatientssimulate symptoms, refuse
therapeuticactionsandholdthe doctorresponsible forthe worseningoftheirsymptoms.Thesesituationsaredescribed inpsychiatryastheSHAFTsyndrome(sad,hostile,anxious,
frus-tratingand tenacious),inwhichpatientsdescribesymptoms
thatdonotexistorplaceabsurdlyhighvalueonsymptoms
that they present.In some cases, based on other people’s
symptoms, theymay describe a set of symptomsthat are
totally nonexistent.Suchpatients generallyseek out many doctorsandundergoavarietyofprocedures.
AnothersyndromeisMünchausen,whichhasbeenknown
formanyyears.Thisdescriptionisgiventopatientswholie abouttheirsymptomsanddeceivetheirdoctors.Itwasfirst describedin1950byAsher,whogaveitthisnamein“homage”
toBaronMünchausen,anoblemanwhowaswellknownfor
histallstories.Therearealsodescriptionsof“Münchausenby proxy”,inwhicharelativeorcaregiverofthepatient
simu-latessymptoms,forexamplebyheatingupthethermometer
tosimulateafeverishstate.
Itisalwaysofinteresttorecallthesedisorders,whicheither duetopsychiatricdisordersorduetocharacterfailuresmay occurinpatientswhoseekourassistance.Thesepatients sig-nifymuchmorethandiagnosticvariation:theymaygiverise toasevererisktoourprofessionalactivity,sincetheymayhold usresponsibleforcomplaintsthatlaypeoplehavedifficultyin recognizingasnonexistent.
Alayperson,evenifheisajudgeoflaw,willnever con-testacomplaintbyapatientwhosaysthatsheissuffering
fromlumbarpainthathasbeenstoppingherfromgoingto
thebathroomforweeks(whichwasdescribedrecentlyinone ofthosetelevisionmagazines),likesomanyothersymptoms thatwegrowtiredofhearingaboutbutareunabletoobserve:
- Mykneeswelleduplikeapumpkinandnowitisnotswollen;
- MyhandwentnumbandIcannotmovemyarm;
- Ispentthenighthowlingwithpaininmyback; - Itookthismedicineanditwaslikewater;
- Isufferedalotwithaninfectionthathasnowgottenbetter allonitsown.
In the eyes oflay people, patients with complaintsare alwaysrightandarealwaysvictimsofdoctorswithlittle ded-ication.
We are the only ones who are able to and know how
470
r e v b r a s o r t o p . 2 0 1 3;48(6):469–470therapeuticeffectofamedication,andotherabsurd manifes-tationsthataredescribed.Onlyouracceptancemakesthese situationsrealandcapableofharmingthecolleaguewho pre-cededus. When a colleague speaks badly ofanother to a patient,everyoneloses:thepatient,becauseheorshedoes notknowwhotobelieve;thedoctorwhoisspokenofbadly, forobviousreasons;andtheonewhospeaksbadlyofothers, becausethisgeneratesinsecurityinpatients.
Patientswhoarenotmadeawarethattheirsymptomsare absurdwillpersistinendlessperegrinations,whichmayend upindisastrousprocedures.InRBO22(10),in1987,Ipublished acaseseriesofyoungfemalepatientswithuncharacteristic andsometimesabsurdpain intheirkneeswho underwent countlesssurgicalprocedures.Oneofthem hadmorethan tenoperations!
Weknowthat,unfortunately,theformulaofpatientwith fantasies plus unscrupulous doctor leads to serious harm forthepatient,forcorrectcolleaguesand,byextension,for medicine.
Wedonotknowwhetherthereisasolutionforperverse orpsychologicallyillpatients,butweknowwhatisrealand whatisalieinthedoctor–patientrelationship.Theonlyway forustoprotectourselvesandprotectourpatientsistokeep ourrelationshipclose,technicalandprofessional,todebunk com-plaintsbasedonfantasyandnottoacceptuntruecomments fromcolleagueswhoprecedeusinattendingpatients.
Acceptanceofdefamationfromacolleagueistoenrollon thelistasthenextpersontobespokenofbadly.
GilbertoLuisCamanho RevistaBrasileiradeOrtopediaSãoPaulo,SP,Brazil
E-mail:gilbertocamanho@uol.com.br
2255-4971/$–seefrontmatter ©2013SociedadeBrasileiradeOrtopediaeTraumatologia. PublishedbyElsevierEditoraLtda.Allrightsreserved.