A pair of recent studies looked at different modalities for following patients on weight loss programs. One study compared patients who received in person follow up from primary care providers versus those who received telephone and web based follow up to those who got nothing at all. Patients in either follow up group experienced twice as much weight loss after one year than those who had no follow up at all (there was no difference between either follow up intervention). The other study looked at the effectiveness of in-person “life coaching” on weight loss results and also found it to be significant.
While the impact of this in terms of weight loss indeed could be huge I also believe this study raises an interesting question about doctor patient relationships and boundaries that is worth exploring.
The overall message of the studies was that patients in both groups who had any kind of follow up with their primary care providers (be it in person, on the phone or web based) experienced better results in losing and maintaining weight than those who did not. With 2/3’s of Americans overweight or obese, any intervention that can help patients maintain weight loss has the ability to improve millions of lives and should therefore be utilized. The authors hailed the study as a breakthrough in helping patients battle obesity.
“It could be considered something of a breakthrough in weight loss,” said Dr. Frank Sacks, a professor of Cardiovascular Epidemiology at the Harvard School of Public Health who participated in the second study.
While this intervention may be effective in the laboratory the question remains about how this impacts doctor patient relationships in the clinic and if this impact is ethical or fair? If adult patients are reporting their weight loss to physicians does this not place the physician in a paternalistic or parental role to the patient and if so is it appropriate for doctors to take advantage of this role in clinical practice?
The hidden dynamic among all human relationships, and especially those between doctors and patients, is a phenomenon called transference. Transference is the process whereby one individuals unconscious emotional perceptions influences their participation and behavior in a relationship. The perceptions are usually very powerfully influenced by early childhood influences.
For example a person who had a poor relationship with little verbal communication with a male caretaker early in life may have a difficult time communicating with other male authority figures later in adulthood.
Transference is classically thought of as a part of psychiatry and psychotherapy, but all doctor patient relationships (and all human relationships) are deeply influenced by the unconscious subjective perceptions of the participants.
In my coursework with the New England Society of Clinical Hypnosis I will never forget the words of the brilliant hypnotist and former NESCH president Dr. Max Shapiro who surprised me in a seminar many years ago when he said: “If a patient comes to you with a deific or mystical transference about hypnosis don’t be afraid to use that in your work with them.”
Shapiro felt that using the patients unconscious feelings of awe or mysticism around hypnosis (which is often held in such mystical esteem) to their advantage could be a useful intervention towards reducing symptoms and improving their lives. Could the same be argued in this situation regarding a patients parental transference to the physician?
The doctor patient relationship already intrinsically has a parent child tinge to it by it’s inherent nature. Consider the things that physicians typically provide to patients. Empathy. Nurturing. Moral, emotional and physical guidance. The very essence of the relationship evokes a parent-child dynamic between the doctor and provider that is unavoidable.
When patients report their progress in weight loss to the doctors does this not place the physician even more in a parental role with the patient? The physician becomes the source of praise and approval or of disappointment and disapproval like a parent around a critical issue in the patient’s life. This takes advantage of the parental transference-countertransference between the doctor and the patient and may produce results but is it appropriate?. Consider that patients with serious behavioral health problems often lack psychological maturity in some way.
There are no right or wrong answers to this question but it is worth thinking about: Should physicians be placing themselves in a position where they can take advantage of the parental transference countertransference dynamic that exists between them and their patients? It could produce results but is it ethical and fair to adult patients who ultimately would be best served by empowering themselves to ensure their own wellness without reliance on a professional’s praise or approval? Could taking on a parental role with a patient eventually provoke feelings of rebellion and disobedience (often a part of parent-child relationships) that may undermine the purpose of the intervention eventually? Should doctors dare to take advantage of this mechanism in patients who lack psychological maturity?
It is likely that right or wrong these interventions will become more widely used because of the results they showed in these studies but I believe these are important questions to ask.
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