Helping Patients Avoid Doctor Dependency

Doctor dependency is a recognised concept, although it has not been clearly defined. As a working definition, doctor dependency is likely when a patient persistently consults more frequently than is appropriate for their situation, or where the pattern of requesting help suggests reliance on doctor or the medical consultation, to an extent which is unhelpful.

Balint recognised that 'the doctor is a drug', that 'no guidance whatever is contained in any textbook as to the dosage in which the doctor should prescribe himself', and that there may be 'hazards' and 'undesirable side effects' of this type of medication. Recognition of doctor dependency is important.¹ It can be useful to look at the doctor-patient relations as 'transactions' involving both patient and doctor factors.²

The doctor dependent patient may also belong to the group known as 'heartsink patients' (see separate article on this topic).

Frequent consulters are a heterogeneous group. Few are likely to conform to the heartsink stereotype. They have high rates of physical disease, complex problems, chronic illness, psychiatric illness and social difficulties.³ In one study, 12 out of 28 'heartsink' patients had, or developed, serious medical problems.⁴

Patient and doctor factors

• Dependency may be part of the patient's style of relating to others. This may relate to the patient's previous experience of relationships, especially in childhood. Difficulties with past or parental relationships may be re-enacted in the consultation. For example, Norton and Smith describe a frequently attending patient who behaved in a way that made his doctors feel increasingly angry and unsympathetic towards him. It transpired that as a child, his parents had been very unsympathetic towards illness. Unconsciously, this patient and his doctors were re-enacting his parent's role.²
• Doctors may like power or need to be needed. As with patients, the doctor's past experiences and psychodynamic factors play a part.²
• Dislike of change or confrontation: allowing dependency may seem easier than trying to help the patient be more assertive.
• The doctor and patient may be emotionally attached or involved with one another.
• Loneliness may increase the consultation frequency.⁵

Dynamics of the doctor-patient relationship

The dynamics of interpersonal relationships were explored by Eric Berne over 40 years ago in his book Games People Play.⁶ He classified relationships into 3 types:

• Parent - taking control and making decisions
• Child - submissive and letting others make decisions
• Adult - being autonomous

The doctor may need to promote an adult/adult relationship, rather than (for example) a parent/child relationship which the patient has tried to foster. It helps to understand the benefits gained by the patient in assuming the child role, and also the benefits to the doctor that allowed it to develop. Either or both parties may have been unaware that this relationship was developing.

Social and cultural factors

• Medicalisation: doctors encourage dependency if they 'medicalise' self limiting or psychosocial problems. Issuing unnecessary prescriptions, eg. for antibiotics or tranquillisers, may encourage patients to re-attend or to view their problem as requiring a doctor. Research suggests that many patients don't want a prescription anyway.^7,8
• Family patterns: illness behaviour is learned within families, and most GPs recognise that some families are frequent consulters.
• Cultural influences: these affect the presentation of illness and the role of the doctor and patient. They may play a part in doctor-dependency, especially if cultural issues promote misunderstandings. For example, in some cultures, psychological illness or other problems such as epilepsy or rape, are considered shameful and will tend to be hidden. This may lead to somatisation or hidden agendas, both of which contribute to doctor dependency.

Medical and diagnostic factors

Undiagnosed, unacknowledged or under-treated problems can make patients appear as doctor-dependent when they are, in fact, appropriately seeking help.

• Both physical and psychological problems may go unrecognised: for example, hypothyroidism and depression can present with subtle, insidious symptoms; anxiety or depression may present with somatisation.
• Some patients find it very difficult to openly request help with psychological problems. Often it is because they come from a family or culture where this type of problem is not seen as a legitimate reason to ask for help.
• As examples: Danzig describes the 'patient journey' of a man who had undiagnosed acromegaly for 10 years, despite seeing several doctors. He was a frequent attender and 'challenging patient' whose GP had a 'drawer full of his notes' Later, after the diagnosis, the doctor-patient relationship developed into a true partnership.⁹ Davis describes a patient whose many physical symptoms were dismissed, but who most likely needed help with anxiety.¹⁰

'Symptoms' for concern are:

• Frequent consultations for minor problems.
• Regular consultations with little content or same content .
• The patient won't see another doctor/nurse, or has no faith in external advice eg. a specialist.
• Strong feelings on the doctor's part (negative or positive), on seeing that the patient is on their appointment list.
• Refusal to terminate treatment or the consultation.
• Gifts or excessive positive feedback.
• Persistent symptoms without any identifiable pathology or aetiology, despite extensive examination and investigations.

Possible strategies include:

Gaining insight

According to an RCGP workshop, there is a triad of factors involved in every difficult patient's case: the doctor, the patient and the interaction between the two. Insight into the situation is facilitated by regular review and discussion with others outside the relationship.¹¹ Norton and Smith agree, and propose a framework for evaluating the doctor-patient transactions, using their 'transactional window'.²

Teamwork and management plans²

A case discussion with colleagues or other members of the team can help in various ways: it can provide insight (as above); the group can plan a management strategy, and the team can support one another in implementing it. A study in one practice involved regular meetings to discuss 'heartsink' patients, many of whom were frequent attenders. This was followed by a reduction in the consultation rate, and other improvements.⁴

Promoting patients' self-care and coping skills

This includes:

• Education, for example, reducing antibiotic prescribing, educating patients about minor illness, using deferred prescriptions, offering information leaflets or discussion instead of a prescription.
• Improving life skills, e.g. through counselling or cognitive behavioural therapy.

Information management

Summarizing the patient's notes is often suggested, and may be helpful in understanding the patient. However, one study found that this in itself did not affect the frequency of attendance.¹²

The history of frequent consulting behaviour seems to persist in many cases.³However, both anecdotally and in one study, discussions of difficult patients with colleagues did reduce consultation rates or improve the doctor-patient relationship.^2,4