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Unhappy endings

When proactive patients and harried physicians clash, breaking up is hard to do

Pearl Lischinsky (with daughter Karen), a longtime patient of Dr. David Steinberg, developed an aggressive blood cancer. Pearl Lischinsky (with daughter Karen), a longtime patient of Dr. David Steinberg, developed an aggressive blood cancer.

Pearl Lischinsky had been Dr. David Steinberg's patient for 16 years when she developed an aggressive blood cancer in May 2005. Their appointments grew more frequent, and she always brought her youngest daughter to help sift through treatment options.

It wasn't long before the visits grew tense.

Karen Lischinsky was devoted to her mother and arrived at appointments prepared with Internet research and questions about chemotherapy. But she felt Steinberg acted insensitively and rushed, bolting out the door before addressing her concerns and failing to make time to discuss important end-of-life issues.

Steinberg, a hematologist, felt he patiently tried to answer her questions, but that they were endless and hostile. Even when he said he had another patient waiting, 15-minute appointments would stretch 30 minutes beyond their scheduled time, his attorney said.

The smoldering conflict erupted during one appointment, with Karen saying she was firing Steinberg. Steinberg argued that she couldn't fire him because he was her mother's doctor, not hers.

Several weeks later, Pearl Lischinsky got a letter from Steinberg saying that he was "very fond" of her but that "The behavior exhibited towards me by your children is so negative and hostile that it affects my ability to continue providing effective care for you." Steinberg gave her 30 days to find another doctor.

Open conflict in the doctor-patient relationship can be painful and time-consuming for both sides. There is little guidance available for patients, families, and doctors about how to manage these difficult situations.

Some doctors and communication specialists say disputes are occurring more often as patients and families - encouraged to be critical consumers who take control of their medical care - research treatment options and become more opinionated about care, an approach that can cause old-school physicians to bristle. Sometimes, patients and families go too far, making excessive demands, or crossing boundaries.

At the same time, doctors are more pressed for time, making lengthy conversations inherently difficult for both sides.

"This relationship is changing right before our eyes," said Dr. Gordon Harper, a child psychiatrist who for many years taught a class on communication skills at Harvard Medical School. "There's much more opportunity for conflict."

While little data exist about how often conflicts occur or relationships are ended, neither is rare.

"Most of the time, [patients] just walk with their feet," said Dr. Leonor Fernandez, an internist at Beth Israel Deaconess Medical Center. "They don't have to explain why." Even if they need their medical records, someone else in the office other than the doctor handles getting them, she said.

Communication an issue

Studies by Dana Gelb Safran, a researcher at Tufts-New England Medical Center and vice president of Blue Cross and Blue Shield of Massachusetts, have shown that about 8 percent of Massachusetts adults change primary care doctors each year because of relationship issues, including poor communication. The relationship between doctors and patients has eroded since the late 1990s, Safran said, as doctors became more harried at the same time as patients became more engaged in their medical care.

But, Safran said, relationships now appear to be stabilizing as more physicians focus on increasing patient satisfaction.

Ending a relationship is tricky for doctors, who must guard against ethical lapses and claims of illegal abandonment. ProMutual Group, the largest medical malpractice insurer in Massachusetts, said the most common reason physicians call the company's telephone consultation service is for advice on when and how to call it quits.

Patients who won't follow medical advice, don't pay bills, verbally abuse or physically threaten staff, stalk a doctor, repeatedly miss appointments, or engage in criminal behavior, such as stealing prescription pads, are fair game for termination, ProMutual advises. But the company recommends against firing patients who are in medical crisis, need treatment for an acute problem, or who are more than 20 weeks pregnant - all of which could be considered abandonment.

The Board of Registration in Medicine, which licenses doctors in Massachusetts, has received 85 complaints of abandonment since 2004; so far the board has disciplined doctors in 11 of those cases.

Most doctors say they have at least one stressful relationship with a patient or family.

Seven years ago, Dr. Thomas Lee, an internist at Brigham and Women's Hospital, prescribed a generic diabetes medication to an elderly woman who is a longtime patient. She developed a rash and concluded she was allergic to all generics.

Lee explained that this was impossible, and refused to prescribe brand name drugs when a low-cost generic alternative was available, which her health insurer also required. They argued about it constantly. Still, she wouldn't back down, even risking her life by refusing to take a generic heart medication.

When her heart rate soared and she still wouldn't take the drug, Lee's nurse suggested she find another doctor, but the woman refused. "I want him to write the prescription," the patient said, according to an article Lee wrote in the Annals of Internal Medicine in July 2004. "If he won't and I die, it will be on his head. I've known him for so many years and he knows me really well. I don't want to start over with someone new."

To save the relationship, Lee compromised. He prescribed brand-name drugs for serious problems, and generics for the ones she could live without.

The woman is still his patient and gives him small gifts at Christmas. "We are still fighting, and she is still winning. But I am not giving up," he wrote in a recent e-mail.

Ways to work it out

When patients or family have many questions, Dr. Beth Lown, an internist at Mt. Auburn Hospital and a specialist on communication, said she tries to determine whether anxiety or fear is motivating them, and will sometimes enlist help from a social worker. Often, she suggests a contract both sides can live with to talk at a specific time each day or week.

Karen Lischinsky said she was definitely anxious about her mother's condition. She was driving back and forth between her jobs teaching sociology at several local colleges and her parents' home in Swampscott to cook meals, wash laundry, and bring her mother to the beauty salon. Her father, who has Alzheimer's, also needed special attention.

"We were a frightened family about to go down the road of watching our mother die," she said. But "we had a reasonable number of questions. We as family had a right to know some of the consequences of chemotherapy."

David Gould, Steinberg's attorney, said the physician did not call in an outside mediator because he believed he could handle the family's questions on his own. As head of the hospital's ethics committee, Steinberg knew how to manage difficult situations, he said. "He didn't feel until the very end that he wasn't able to deal with the situation." During that final appointment, the family threatened to sue, Gould said, although Karen Lischinsky said this is untrue. (Steinberg declined to be interviewed for this story.)

Another Lahey hematologist, Dr. Neil Weiner, eventually took over Lischinsky's care. The retired secretary died in December at age 77.

Her three children still hurt from Steinberg's actions, Karen Lischinsky said, and the family has filed a complaint with the Board of Registration and met with the hospital's ethics committee.

He has not attended the meetings to avoid conflict of interest, his attorney said. But the family is trying to get Steinberg, who denies he abandoned his patient, to meet with them.

"I want to ask why he sent that letter saying the children were disruptive," Karen Lischinsky said. "I want to ask why there wasn't a process (before he sent it.) We're the ones who have to live with it."

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