Introduction

Ms King suffered from diabetes mellitus that was hard to stabilise, partly on account of her poor compliance with medication and partly due to her failure to curb her craving for chocolate. She would begin a consultation in a rather timid and self-deprecating manner. However, with little or no warning she would move from this childlike posture into a verbally abusive tirade against the doctor whenever he, no matter how tactfully, tried to indicate that she had a part to play in the suboptimal management of her condition. The doctor believed that he was experienced as somebody who was entirely uncaring. Since his view of himself was very different from this, he found himself rising to the bait of her provocation and reacting with annoyance. He thus tended, at least from time to time, to enter into active confrontation and direct criticism of the patient. In effect, he was turned into somebody who indeed appeared uncaring. The result was a kind of instability within the doctor-patient relationship that was inadequate to support the successful pursuit of the clinical goal of stabilising the diabetes.

Clinical transactions may become complicated for a variety of reasons and evidence for the complication may surface, to be recognised as such, within either public or personal (if not both) levels of the doctor-patient interaction. Evidence for departure from the straightforward clinical transaction, within the public domain, is often obvious, since it may involve gross, behavioural departure, for example poor compliance with treatment as with Ms King. Consequently, it may be discovered before other departures, which may be more subtle, although no less significant in terms of their complicating effect.