An article by Paula Rapp appeared in medmontly  on June 4, 2012 regarding a case study on doctor-patient relationships.
The patient presented to the emergency room with chest pain. Read on:

A young friend of mine recently experienced minor chest pain. Not the kind that made her want to call 911 immediately, but worrisome enough to land her before a triage nurse at the local emergency room reviewing her symptoms. The patient, a nurse herself, was promptly seen by the ER physician and after completing the requisite battery of chest pain examinations and blood work was discharged. The tests ruled out a heart attack and she was told to follow-up with her primary physician to determine other possible causes of the discomfort.

Patient Bullying

Of course as the pain persisted, she did what any well-informed health care consumer would do, she Googled the symptoms to find out what was ailing her. Within several clicks, she found the elusive diagnosis of which the ER doctor failed to provide: costochondritis, inflammation of the cartilage in the chest wall that can cause pain during breathing.  Dutifully, she followed-up with her primary doctor and proclaimed the diagnosis within minutes of their interaction. Silently she scoffed at the need for further testing that included x-rays, echocardiograms and blood work, and (although she politely listened to the recommendations) she left with what she had gone to receive: a prescription in hand for pain relief. When the symptoms eventually faded, she felt reassured that her diagnosis had been correct and was relieved not to have been subject to a further battery of tests.

If either party (doctor or patient) distrusts the other’s judgment, decreased compliance with the treatment will often occur. Decreased compliance leads to frustration, aggravation and further erosion of the relationship.

 _There is another phenomenon however, emerging in the doctor-patient relationship: patient bullying.  This is not to suggest a physical or name-calling type of bullying but rather a more passive, subliminal form. In light of the Internet era, it has become easier to instantly review symptoms and self diagnose, thereby making the doctor seem more of a “middleman,” rather than the voice of diagnosis determination. The situation is often exacerbated by the fact that that the doctor has limited time with each patient and will often comply with a patient’s strong request.The doctor’s knowledge and experience has been demystified by the age of modern technology.  Patients present to their doctor’s office with the expectation of the antibiotic prescription or the desired test or the clinical trial referral and often won’t relent until their “demands” are upheld. If these requests are ignored, patients feel as if they are being slighted or their symptoms minimized – all before the stethoscope has heard its first heartbeat.Patient bullying behavior is seldom aggressive in nature; in fact it is often so subtle that it may seem more like the patient is just taking an active role in their own health care. After all, patients are indeed savvier when it comes to their health and want to showcase to their doctor that they also have some medical insight. However, this type of rapport can become toxic when the patient’s strong arm requests outweigh the physician’s judgment.

A population of educated and interactive patients would certainly be ideal, but some of these behaviors may lead to over-demanding patients. The goal of patient education is to make knowledgeable health care decisions that are evidence-based and – more importantly – considered within a positive, reciprocal patient-doctor partnership.


As we transition into a patient-centric model of healthcare, it is no longer viable to take a paternal approach to treating patients. They must be allowed to know the differential diagnoses, risks, workups and treatments of each so that they can participate in further evaluation and treatment options. When thinking seriously about this, it seems obvious. It is the patient that is suffering, the patient that knows the symptoms best and the patient that will bear the brunt of any consequences.

While it would have been a good idea to make the patient aware that costochondritis was a possibility, it is also foolhardy not to completely evaluate the patient to rule out any more serious cardiovascular event.
It is fortunate for the patient that she was suffering from a more benign condition but not to rule out a problem that could lead to a fatality is exposing the patient to unjustifiable and unacceptable risks.

The patient-centric model of treatment is well illustrated here as the patient did the research and then consulted with a physician whereupon a professional evaluation was done. The patient was an integral part of the discussion and treatment decision and everyone was satisfied with the ensuing result.