It's helpful to be attuned to the non-medical roles patients need us to play. Familiar roles—such as listener, problem solver, prescriber—are often sufficient, but sometimes we need to at least briefly be something else and yet remain professional. Recognizing and responding to this need facilitates clinical engagement, especially with behaviorally challenging patients.
Take Vanessa, for example. We first met when she was cowering naked on the floor in the corner of an elevator in my hospital's medical clinic, screaming that her doctor was trying to kill her. Around the open doors of the elevator stood a crescent of frozen helpers: bewildered security personnel; a few anxious aides and nurses, one holding a chemical restraint; and Vanessa's doctor, an earnest white-coated deer in Vanessa's headlights.
I happened to be the psychiatrist responding to the behavioral emergency code, and luckily had the advantage of having trained in a public psychiatric hospital where such behavior wasn't unusual. Familiarity with it allowed me to focus on the obvious fact that Vanessa was panic-stricken. In her regressed psychotic state she seemed like a terrified child. If I played the doctor role in the usual somewhat formal or “clinical” fashion I risked making her feel more alone and frightened. Instead she needed me to act in 2 very specific ways: first, to be explicitly non-terrifying; second, to appear interested without being intrusive. That sounds like standard doctor behavior, but in this case I had to, above all, emphasize creating a sense of safety.
As I approached the elevator I asked everyone to leave except for her doctor, the syringe-bearing nurse, and one security guard. Conscious of Vanessa's vulnerability, I tried through body language, tone of voice, and facial expression to radiate concerned benignity. “Vanessa, you're terrified … what's going on?” I asked. She replied instantly: “Someone told me that Dr. Smith”—her doctor—“is really the Devil. When I took off my clothes I thought he was going to kill me so I ran away.”
This was clarifying. I made a friendly collegial gesture toward the still-frozen Dr. Smith and said to Vanessa, a little light-heartedly: “That's so interesting … You know, I actually know Dr. Smith and he's usually a pretty good guy. I don't think he'd actually try to hurt you. Listen, why don't we get you a blanket? It's not good to be undressed here.” The nurse gave her a blanket and I stepped inside the elevator. Evidently she needed her doctor to be non-diabolical and I intended to play that role to the hilt. She also needed to feel less physically vulnerable—hence the blanket.
Now that Vanessa felt safer, she needed me to act as a curious but non-threatening ally if we were to move beyond the elevator. This was the moment to perform a biopsychosocial biopsy,
A benign invasive procedure: the biopsychosocial biopsy.
a term I use to describe a few simple questions that help any patient to quickly feel more known, and therefore less anxious:
As we began an increasingly friendly chat, I omitted question #2 and focused on #4, which for Vanessa was watching professional basketball on TV. This was my cue to act like a regular person, a role available to all physicians yet neglected by many. Because this happened in the early 2000s, I asked “So what do you think of Kobe Bryant?” She eyed me sheepishly and said “He's kinda cute.” My work was done. We got her easily onto a stretcher and off to the Emergency Department for further treatment.
What role had I taken on? In retrospect I see that it was my playing calming parent to Vanessa's frightened child that allowed us to begin collaborating. Rather than maintaining clinical distance, I tried instead to be benevolent, unfazed, friendly, and even a bit humorous. Briefly assuming a parental role didn't compromise being a doctor. No boundaries were threatened in the making of my connection with Vanessa.
Sometimes a more unusual role is called for. This was the case recently with George, an elderly outpatient whom I've seen once a year over 2 decades for long-remitted depression. In younger years he did hard time in state prison and ran with Whitey Bulger, the notoriously vicious Boston gangster. George, too, could be ruthless, but was always polite and even playful with me. We'd banter back and forth as he nicely asked after my health and teased me about what he imagined was my bleeding-heart liberal, Harvard ivory tower sensibility.
When we last met he made it clear that he wasn't having anything to do with “all this COVID vaccine BS.” It was all a hoax, the President was an idiot, etc. I knew that playing the sober expert helping him weigh risks and benefits was a fool's errand. Wondering what he needed from me to take things seriously, I realized the obvious: George respected toughness more than reason. The stakes were high and I knew my audience, so I pulled out the stops:
“George, can I share some of my thoughts about the vaccine with you?” I asked.
He chuckled. “Sure, Doc. Fire away.”
“Just get the flipping shot.”
I actually used the earthier version of “flipping.” George clearly wasn't expecting his supposedly effete doctor to sound more like Al Capone than Anthony Fauci. He needed me to temporarily seem as “brutal” as he was if I was to be credible. Our usual banter ceased and I had his full attention.
“You really think so?” he replied. “Yeah, I really think so,” I said emphatically. You could see that he felt my concern for him, and agreed to discuss it with his primary care practitioner. I don't yet know whether he received the shot but I had given him something to think about. Clinical use of profanity is a tricky business and is only rarely indicated, but when used thoughtfully it can sometimes help reach an otherwise inaccessible patient.
To paraphrase Jacques in As You Like It, “one doctor in his time plays many parts.” To determine which part is indicated, the doctor can wonder “Who does this particular patient need me to be in order to work together most effectively?” Vanessa and George needed me to briefly take on the respective personas of mother and mobster—but I never stopped acting like a doctor. Many less-challenging patients need us to also be a counselor, a confidant, or—most commonly—just a fellow human being. With thoughtful reflection, aspects of these other roles can be safely taken on by the doctor without violating professional boundaries or seeming inauthentic. On the contrary: the doctor may feel the gratification of providing something the patient truly needs but couldn't quite ask for. Paying attention to the particular role each patient needs us to play can enhance professionalism rather than threaten it.
A benign invasive procedure: the biopsychosocial biopsy.Am J Med. 2019; 132: 1368-1369
Published online: March 24, 2022
Conflicts of Interest: None.
Authorship: Sole author is responsible for all content.
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