The self-destructive denier
All physicians encounter patients who exhibit denial of their illnesses. The defense mechanism of denial can be quite positive and adaptive in coping with illness. However, denial is pathologi- cal when it interferes with the patient’s ability to seek and accept proper medical care, as is the case of the self-destructive denier.
Unlike the adaptive deniers, patients in this group are fundamentally dependent on others, and seem to be oblivious to their own self-orches- trated destruction. From the physician’s perspec- tive, these patients seem to take great pleasure in placing roadblocks on the way to receiving optimal care. An example of such a patient is the intravenous drug abuser who keeps coming back with yet another complication related to their drug use (such as cellulitis or endocarditis), but avoids seeking treatment for their underlying substance-abuse problem.
The self-destructive denier prompts a physi- cian to feel used, abused, angry, and helpless. The physician resents the fact that this patient uses medical services that could be given to pa- tients who are seemingly more deserving. While younger physicians may try to rescue this type of patient, more experienced doctors may have fantasies of them signing out against medical ad- vice, or even dying. As a result, many physicians often will feel guilty about their hateful feelings towards the patient.
The best management of the chronically self- destructive denier is to be aware of the patient’s unrelenting self-destructive behavior, and to acknowledge his or her helplessness to change that behavior. The physician also needs to set realistic expectations for the medical staff relative to the patient’s ability or inability to follow a course of medical care that will lead to health. One way of thinking about these patients is that they are no different than those patients who have a degenerative or terminal illness for which there is no medical treatment. Our goal as physicians, then, is to provide supportive care and alleviate suffering to the best of our ability.
In summary, taking care of difficult patients can undermine a physician’s enjoyment and satisfaction in the practice of medicine. A negative physician-patient relationship can lead to a very unhappy physician and a dissatisfied patient. Developing clinical strategies to manage difficult patients can foster a better relationship, and lead to a lower risk of litigation and to improved medical care.