Reader's Response and Author's Reply to “A Survey of Neurologists on Bothersome Patient Behaviors”

Readers' Response

The data accumulated by the Evans on bothersome patient behaviors, and reported in their article,[1] are indeed valuable.

As a therapist with patients who experience relational issues with their physicians (and with me), I endorse the need for gathering these kinds of data. I offer one caution, however.

It is too easy to see the behaviors that are bothersome as a problem that may simply be mediated by a practice policy discussion. Undoubtedly that can help in some situations, but the issue is far too complex for that to be sufficient.

Concerns I have:

• In the context of a neurology practice, to what extent are these bothersome behaviors related to the patients' presenting issues?

• If patients have traumatic brain injuries (TBIs), one might well expect to see such behaviors. I believe that the psychiatric sequelae of TBIs have been well documented, including the rapid shifts in mood, the propensity for anger, substance abuse, and lack of compliance with treatment.

• The preferred patient behaviors fall well within a middle-class paradigm for socially acceptable conduct (eg, if you make an appointment you keep it, arriving punctually, or advise of inability to attend). I work with many people from the inner city who, for reasons of social upbringing, culture, or mental health issues, are often unlikely to adhere to this paradigm. I have clients whose relationships with physicians have broken down around an apparent inability to meet the expectations for preferred patient behaviors. How do we, whether we are physicians or psychotherapists, develop ways to accommodate these patients?

The Evans have opened a significant area for professional reflection and discussion, one that not only impinges on our comfort levels as caregivers, but also, in some cases, on life and death issues for our patients.