A role for the sick role
Online posting: Oct. 16, 1997
Published in print: November 15, 1997 (CMAJ 1997;157:1349)
Re: "A role for the sick role: patient preferences
regarding information and participation in clinical decision-making", by Anne M. Stiggelbout and Gwendoline M. Kiebert, CMAJ 1997;157(4):383-9 [full text / résumé] and
"Should physicians discourage patients from playing the sick
role?", by Christine Laine, CMAJ
1997;157(4):393-4 [full text / résumé]
See response from: A.M. Stiggelbout & G.M. Kiebert
In "A role for the sick role" we learn that "the mere fact of
being a patient leads to a shift in preference away from
participation." This leads to some interesting speculation about
patients' preferences compared with those of physicians and
administrators in medical decision-making.
Drs. Stiggelbout and Kiebert suggest that cultural expectation
might account for this. In her accompanying editorial, Dr. Laine
suggests that physicians may have no choice in the matter but
they might be prudent to warn patients that playing the sick role
may prevent them from obtaining optimal health.
I suggest that the nature of the physician-patient relationship
is at the heart of this issue. When ill, patients tend to regress
emotionally. Part of the physician's role is to assess the amount
of regression and demoralization and to instil hope and improve
morale by providing information and explanations. It may be
bordering on insult to suggest the sick role as a chosen role for
the majority of patients.
Some patients play a different sick role. They often mistrust
physicians and when they do seek help are unable to take advice
because of their rigid ideas. Some patients resist taking and
sometimes refuse to take antidepressant drugs for fear of
"poisoning themselves." In such cases the patient often wants to
take charge of decisions involving treatment. Most physicians
will be uncomfortable if they have to treat someone
inappropriately, at the patient's insistence.
It takes a lot of effort and understanding to work with these
patients and to establish a therapeutic alliance whereby the
patient has enough trust to follow the physician's advice. By
requiring patients to collaborate and make their own decisions we
might sometimes be failing to take responsibility for our own
role within the physician-patient relationship.
Perhaps we need to assess each patient for the impact of the
illness in terms of demoralization and capacity to make choices,
as well as the capacity to collaborate and trust. It would then
be part of treatment planning to encourage the patient's
increased self-care.
Roy Salole, MD
Ottawa, Ont.
roys@magmacom.com
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