Error of Accommodation in the Care of the Difficult Patient in the 1990s

Consumerism, patient rights legislation, and malpractice litigation have created a greater power symmetry between patient and physician. Patients read, question, and insist upon greater participation in decision-making involving treatment. The ideal patient is knowledgeable and an active negotiator in the physician/patient relationship. However, there are some patients who feel so empowered that they are determined to direct and control their treatment. They may request or refuse laboratory tests and attempt to dictate the terms under which diagnosis and treatment should be accomplished. There are as well some physicians who, as a result of conciliatory personal styles, are willing to accommodate to the demands of these patients. In this article, four cases are presented in which physicians have accepted those terms against their better judgment. In two cases malpractice suits followed, ultimately won by the defendant physician. In the last instance a physician patient committed suicide and a malpractice action was settled by mediation. These four case examples establish the principle that physicians, for whatever reason, cannot accommodate the demands of empowered patients that contradict clinical judgment and violate the scientific practice of medicine. Such accommodation may have disastrous results for both patient and physician. Physicians should listen compassionately to patients’ needs and desires, but they may have to refer a patient elsewhere when a negotiated consensus cannot be reached.