Beyond Patient Satisfaction: Physician Ambivalence, Authenticity, and the Challenges to Patient-Centered Medicine

by Levine, Kiera

Despite tremendous and increasing clinical opportunities for cure and comfort, patients often still feel dissatisfied in their relationship with their doctor. That patient dissatisfaction has endured, even in the face of increasing medical knowledge and capacity, suggests a failing not in the quality of medical treatment but in the way it is administered. Increasingly, the modern medical movement toward patient-centered medical care (and away from doctor-centered care) has attempted to address this failing, looking to patient-satisfaction as one of its primary measures of success in these efforts. However, its willingness to overlook the importance of the basis of reported satisfaction, belies its deeper, if unconscious, aim: to allow doctor and patient to avoid confronting deep-seeded ambivalence that each feels towards the other, inherent in their relationship. The opposing urges constitutive of this ambivalence threaten to reverse physicians hard-won, positive self-concept, anchored in their sense of beneficence. Faced with this threat, physicians often flee to the seemingly safer psychological territory of strict adherence to professional norms. But far from finding safety in these norms, many physicians feel failed by them and their promise of protection from the harms of deep involvement with patient turmoil. Thus unprotected, physicians often breach these norms in effort to protect themselves. This loss of standing with their sense of professional commitment, however, leaves them feeling further betrayed, now by themselves. Caught between a loss of protection and a loss of standing, doctors often feel disaffected and deeply embattled, as do the patients who bear this outcome. Unable to sustain these complex feelings, doctors often engage the problems of patient care in ways that promise to conceal these feelings. The false premise of this engagement, however, undermines physician authenticity and disables patient-centered care. How then can the doctor be restored to the feeling of authenticity he/she needs to stay with his/her patients in the midst of the tremendous and tremendously evocative ambivalence posed by serious illness? If physicians are unaware of the negative counter-transference that is activated in such evocative circumstances, they will be unaware of the danger that the treatment plans they pursue aim at least as much at self-protection as at patient care. This is the loss of patient-centeredness wrought by physician inauthenticity. Thus, this thesis contends that the deeply ambivalent feelings that commonly trouble physicians, far from requiring suppression, ought to have a role in the care of the patients they are thought to threaten, if the doctors who have them are to be restored to themselves and so, too, to the patients depending on them.