Rev. bras. ortop. vol.48 número6

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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

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therapeuticeffectofamedication,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:[email protected]