MEDICINE : GOOD HEALTH MAGAZINE : THE GOOD PATIENT : ‘THE DAYS OF THE PASSIVE PATIENT JUST SEEKING TO FOLLOW THE ORDERS OF THE PHYSICIAN ARE OVER. THIS IS A WELCOME CHANGE.’

What sorts of patients do physicians prefer? The answer is not supposed to matter, because doctors should offer the same standard of care to all, irrespective of their personal feelings. A patient is, after all, “simply a fellow human being in need of help,” in the words of Cecil’s standard “Textbook of Medicine.”

But in the real world, doctors’ preferences can make a difference. “For a patient to be regarded by his physician as ‘undesirable’ can be catastrophic . . . despite the Oath of Hippocrates and the high aspirations of the profession,” wrote Dr. Solomon Papper of the University of Miami School of Medicine in a classic editorial on the subject nearly 20 years ago. “Not only may such a patient sense his situation with uneasiness, but in general he is likely to receive less than the best total care, including emotional, physical and social aspects.”

Conversely, physicians may be more likely to do more than the bare minimum for patients they like or patients they become personally involved with. They may spend more time answering the questions of the patient and family members and talking to specialists or nurses.

Often it is a patient’s very inquisitiveness that appeals to doctors. “I really enjoy somebody who asks a lot of questions and is very much involved,” says Dr. Alexandra Levine, an oncologist and AIDS specialist at the USC School of Medicine. “I adore a positive attitude. I like people who can roll up their sleeves and say: ‘This is the problem; what are we going to do about it?’ ”

Dr. Frank Apgar, an internist at UCLA Medical Center, says he likes patients “who take an active interest in their health.” Apgar adds: “Whether they have any significant medical problems is not that germane. I don’t like to be placed on a pedestal. I like to serve as an adviser to patients and to help them manage their medical problems.”

“The days of the passive patient just seeking to follow the orders of the physician are over,” says Dr. Steven Freedman, chief of family practice at Kaiser-Permanente Medical Clinic in Fairfield in Northern California. “This is a welcome change. Patients know a lot more about their health. Doctors have also made much more of an effort to educate patients about all aspects of their diseases.”

Even before they consult physicians, many patients with high blood pressure, for example, are familiar with non-drug methods of treatment such as weight loss, low-salt diets, stress reduction and exercise. Some have even started such treatments on their own. Other patients have taken similar steps to learn their cholesterol values and, if the values are high, have modified their diets.

Engaging physicians on a personal level may be particularly important for patients who see doctors in busy outpatient settings, when only five to 10 minutes may be allotted for a visit. Otherwise, patients may feel that the doctor is paying more attention to staying on schedule than to their individual problems.

Some physicians, however, feel that some patients want to know too much. That may be interpreted--rightly or wrongly--as showing a lack of faith in the medical profession. Such patients may consult medical textbooks or do their own library research. On the other hand, most physicians have anecdotes of patients who correctly diagnosed their own ailments, only to have their opinions ignored by doctor after doctor.

Many physicians, like many of their patients, wish there were no complications either in life or in the practice of medicine. Doctors typically appreciate patients with “straightforward” diseases with “effective and easily given treatments,” says Dr. Robert C. Smith, an internist at Michigan State University who has studied physicians’ emotional reactions to patients. “They also like the patient to come back cured and say, ‘Thank you.’ ”

Short of that, doctors want their patients to heed their advice. Patients who continue smoking despite serious lung or heart problems are particularly likely to arouse medical ire. So are those who are advised to take steps to control drug, alcohol or weight problems but fail to do so. One thing the patient should not do is to provide misleading information about the use of medicines. Physicians want patients to accurately report how frequently they take non-prescription as well as prescription drugs and whether they believe they are experiencing side effects. Concealing such information may interfere with a doctor’s ability to gauge the patient’s response to treatment, adjust the dose of a medicine, or try a different medication.

“I appreciate patients who have thought about barriers to compliance,” Freedman says. He cites the difficulty a husband may have quitting smoking when his wife also smokes or the difficulty of remembering to take three or four medicines several times a day. “When they tell me what problems they are having, then I can work with them on that.”

Physicians may also be upset by patients who make demands that run counter to their doctors’ values. Such patients might ask for narcotic pain relievers before they have tried adequate doses of common over-the-counter remedies. Or they might ask to be certified as disabled although their physician does not believe that they are.

Doctors may feel torn in such situations. On the one hand, they may not want to impose their personal tolerance of discomfort or their personal work ethic on their patients. On the other, they may be mindful of their professional responsibilities not to prescribe narcotics or to certify disability inappropriately.

Patients who habitually don’t keep appointments or who frequently arrive late may also be annoying to doctors. In addition to being a source of lost revenue, such patients may disrupt the office schedule and deprive others of the ability to be seen.

When physicians hold their patients to such a standard, they have a particular obligation to maintain a similar standard of timeliness. This is a particular sore point for many patients, who may be reluctant to show displeasure when the doctor is frequently late, for fear of losing their doctor’s approval.

Like anyone else, doctors do not take kindly to patients who are disrespectful, critical or demeaning or otherwise threaten their self-esteem. Most physicians take pride in the years they have invested in their training and do not appreciate the perfunctory dismissal of their expertise. In a survey of 59 internists in the St. Louis area, Michigan State’s Smith found that even “experienced” doctors “harbor strong emotional reactions (to such patients) that may affect their physician-patient interactions.”

Another internist says: “To the extent that we view the doctor-patient relationship as a partnership, doctors feel very uncomfortable when patients take over and say ‘This is want I want you to do.’ ”

“Doctor shopping” also sets off alarm bells. Instead of settling on a primary physician, patients see one doctor after another, often for the same or related complaints. They sharply criticize previous doctors and treatments, despite what appears to be appropriate medical care.

This pattern of behavior goes beyond seeking a second opinion from a specialist on an occasional basis. Seeking second opinions rarely upsets physicians and, indeed, some doctors encourage their patients to do so.

Patients who doctor shop may do themselves a disservice. The fragmentation of care often subjects them to repetitive tests, unnecessary procedures such as coronary arteriograms, gastrointestinal endoscopies or even surgeries. Their medical bills pile up quickly. In such cases, a patient’s desire “to find out what is wrong” and the physician’s desire “not to miss anything” may not be a healthy combination.

In extreme situations, physicians may agree to take turns caring for trying patients or refuse to see patients they find particularly objectionable. “Doctors have complete discretion over who to accept as their patients in private practice,” says Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota. But once patients have been accepted, Caplan says, they generally can not be refused care unless an “adequate alternative” is assured.”

But in his 1970 editorial in the Journal of Chronic Diseases, the University of Miami’s Papper called upon his fellow physicians not to focus on the undesirability of certain patients. Instead, doctors may find it more productive to try to do a better job of communicating with patients. Without knowing what is on a patient’s mind, such as a deep fear of AIDS or cancer or a life stress such as the loss of a job or the death of a spouse, the physician may not be able to adequately address the patient’s concerns.

When a physician sees a patient who has consulted multiple doctors for the same problem, it may be more worthwhile to explore what is on the patient’s mind than to simply order more tests and procedures. Patients who doctor-shop may have particular reasons for doing so, such as life crises, extreme social isolation or psychological problems. The physician who takes a careful history may discover these factors and, as a result, be in a better position to help the patient than a doctor who simply focuses on the patient’s actual complaint and orders additional tests.

Physicians also may need to develop a greater tolerance for individuals who do not have clear-cut diseases, such as diabetes or tuberculosis. Many patients who see physicians outside of a hospital appear to have problems that are more psychosocial than medical. For other patients with chronic problems such as arthritis, emphysema or some cancers, the medical options may be limited.

One goal of contemporary medical education is to sensitize medical students and physicians-in-training to the importance of improving their communication skills and attending to their patients’ psychological and social needs. In addition, more medical educators are convinced that doctors should receive specific training on coping with emotional reactions to patients.

One doctor, however, has a different perspective. “I like all my patients by and large,” says the physician, a prominent San Francisco internist. “I have difficult patients who are always trying, but I am here for them. That is my job.”

The internist says it boils down to whether “physicians enjoyed the practice of medicine.” He explains: “If you don’t enjoy practicing medicine, you probably don’t enjoy your patients. But if you like practicing medicine, you probably like most of your patients.”