difficult and unlikeable parents · difficult and unlikeable parents roy meadow abstract children...

Archives ofDisease in Childhood 1992; 67: 697-702

Difficult and unlikeable parents

Roy Meadow

AbstractChildren of parents who are perceived asdifficult or unlikeable are at risk of receivingless good medical care. Therefore a postalquestionnaire was sent to 100 hospital doctorsdealing with children asking which featuresmade them consider a parent to be difficult orunlikeable. Seventy eight responded.Most problems arose from parents who

displayed aggression, disparagement of theirchild, unacknowledged anxiety, or fixed ideasabout the medical condition and its manage-ment. Other unpopular parental features werepoor compliance, failure to listen, and theattendance of more than one accompanyingadult.Respondents graded 16 features in order of

their detrimental effect on the child's care. Amajor factor was ifthe child had a condition forwhich the doctor could offer no treatment;less important was the fact that the childmight have a condition not understood by thedoctor. Parents originating from the Indiansubcontinent posed additional problems, inparticular the common unavailability ofinterpreters.Doctors of ali grades understood why

parents behaved in awkward ways, but lackedstrategies for dealing with them. A similarsurvey of nurses and therapists produced a

poor response (51% returns). Only the mostsenior acknowledged that some parents weredifficult or unlikeable and that, as a conse-

quence, the child's care might be affected.Nurses acknowledged difficulty with parentswho were violent or who abused their childrenphysically.

Table I Sociodemographicfeatures

FemaleMaleMuch older than myselfMuch younger than myselfMuch wealthier than myselfMuch poorer than myselfMuch cleverer than myselfMuch less cleverOf white English originA northernerA southernerOf West Indian originOf Indian subcontinent origin

Department ofPaediatrics andChild Health,St James's UniversityHospital,Leeds LS9 7TFCorrespondence to:Professor Meadow.Accepted 15 February 1992

A pilot survey of 25 doctors who worked in a

hospital to which children were admitted showedthat all the doctors considered that a child'shealth care was likely to be worse if the parentswere perceived as 'difficult' or 'unlikeable'.House officers were likely to spend less timewith the parents and to see less of the childwhen such parents were present. Registrars andconsultants were likely to spend less time withthe family at outpatient clinics and were lesslikely to make follow up appointments for thechild. Most doctors believed that the healthservice for children, and the help for theindividual child, would be less effective and thatcompliance would be poorer (in the same waythat studies have shown that compliance ispoorer when the patient perceives the doctor as

difficult or unlikeable).Therefore a survey was undertaken of 200

medical and nursing staff to identify the factorswhich caused them to regard the parents of achild patient as difficult or unlikeable.

MethodA questionnaire was sent, together with anexplanatory letter, to 100 doctors working in thefour different hospitals in Leeds to whichchildren were referred as both outpatients andinpatients. The questionnaire sought initialdetails of the grade of the doctor, sex, length ofexperience after qualification, and the proportionof the doctor's patients who were aged under 16years of age. The doctors were allowed toremain anonymous if they wished (which fewdid). In addition the doctor was asked to specifyif he or she had specific paediatric qualificationssuch as the Diploma in Child Health or theMRCP (Paediatrics).The key question on the form was: 'Which

features cause you to feel that a parent, of achild, is difficult or unlikeable (in the context ofyour consultation or work)'? The second sectionof the questionnaire asked the respondent tosignify whether certain 'general features' of aparent tended to make him/her regard thatparent as difficult or unlikeable. The respondentcould choose between 'No effect', 'Slightly', or'Definitely'; 13 sociodemographic features werelisted (see table 1).Two additional questions related to the child's

illness: the respondent being asked if the parentseemed more difficult or unlikeable firstly 'Ifthe child has a condition I do not understand'and secondly 'If the child has a condition forwhich I can offer no definite treatment'.A similar questionnaire was sent to 100

nurses and therapists in the same hospitals asthe doctors.

ResultsForms that were fully completed and returnedcame from 78 doctors, of whom 32 wereconsultants. Table 2 shows that over half of the

Table 2 The medical grade of the 78 responding doctors andthe proportion of their patients who were children

Proportion of patients Doctor's grade<16 vears of age (0/A)

Consultant Registrar Seniorhouseofficer

>90 17 15 1240-90 0 0 0<40 15 10 9

Total 32 25 21

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respondents worked all, or nearly all, of theirtime with children-they were mainly paediatri-cians but included a small number of childpsychiatrists and paediatric surgeons. Those forwhom children comprised a minority of theirpatients included dermatologists, ear, nose, andthroat and orthopaedic surgeons, and accidentand emergency doctors.

WHICH FEATURES CAUSE YOU TO FEEL THAT APARENT, OF A CHILD, IS DIFFICULT ORUNLIKEABLE (IN THE CONTEXT OF YOURCONSULTATION OR WORK)?Most respondents mentioned at least three or

four features, often giving specific examples.Nearly all of the features mentioned can befitted into one of the nine headings listed below.Explanation of these headings, together withexamples, are given.

(1) AggressionIt was rare for doctors to feel threatenedphysically by parents, but the majority resentedparents who were combative or blaming in theirapproach to the doctor. An example given was

when the doctor welcomes the patient saying'Hello, what's the matter, how can I help you?'and the parent responds 'You're the doctor-you tell us'. Doctors complained about 'Parentswho make it clear that they regard doctors as

people who are more likely to do harm thangood' and about 'Parents who give you theimpression that it is your fault that the child isunwell' and keep stating 'Something must bedone'.

(2) Disparagement ofthe childMany doctors were influenced adversely byparents who spoke disparagingly of the child inthe child's presence. This ranged from parents,of children who wet their beds, who referred totheir children as being 'lazy and smelly', tothose who spoke of their child as being 'evil andjust like his father'.

(3) Pressure for priorityExamples of this unwelcome behaviour byparents came mainly from surgeons. Typical isthe comment of one, 'One of our major prob-lems is the parent who wishes the child to havethe operation in such a way that no time is lostfrom school, and that plans for holidays, birth-day parties, school trips or the Tuesday eveningBrownie meeting should not be upset. This typeof parent is never off the phone, changesappointments at very short notice, cancelsadmission dates and yet still expects prioritytreatment; an impossible situation of impassearises resulting in deferment of treatment to thechild's detriment'. Respondents were sympa-thetic to parents who had a child with a seriouscondition who pleaded for priority treatment,but were adversely affected by parents whopleaded for priority when, from the doctor'sviewpoint, no case for priority existed.

(4) Non-listeninglpoor complianceMost doctors seemed to feel that, when they hadspent time listening carefully to the parent'sstory of the child's problems and had beenasked a lot of questions, the parent ought to bewilling to listen to what the doctor had to say: 'Ican't stand those mothers who continued to aska lot of questions, one after the other, and yetnever wait for a single answer'. Another doctorresented 'Parents who demand regular prolongedconsultations, but persistently fail to act on theadvice given'. A surgeon cited 'Parents who donot follow the advice offered at a previousconsultation, and are unhappy with the resultsof the treatment, which was not followed'. Poorcompliance with treatment was a feature thatwas frequently mentioned as causing a doctor toview a parent as difficult or unlikeable.

(5) Fixed ideas'When parents' expectations are for a particulartest or a particular treatment, and what I haveon offer is a little better understanding andsome management strategies which may or maynot help'. Another paediatrician found parentsdifficult 'Who come to clinic certain that theyknow the cause of the problem, and refuse toconsider other suggestions even after whatseems to be a reasonable discussion and ex-planation'. Several doctors mentioned thescientific gulf between medical knowledge aboutdisease and the cultural and neighbourhoodbeliefs for the cause of illness, leading toirrational and unproved treatments, and theinability of many parents to realise that treat-ments based on controlled trials or lengthyexperience had increased validity.

(6) Unacknowledged anxietyThis linked with many of the other featuresmentioned. Doctors seemed to be more sym-pathetic to parents who expressed their feelingsand worries than those who disguised them.One doctor recounted a consultation in which anephrectomy was advised for a 6 year old girl.She had come to the clinic dressed in nurse'suniform, clutching a toy medical set, and wasabsolutely delighted by the ambience of thehospital and was hoping to have a chance to stayin the hospital. During the discussion aboutfuture surgery, the mother went into a detailedexplanation about it not being possible because'Jennifer would be so worried about being inhospital'. Doctors often had problems dealingwith families where 'It is apparent that much ofthe problem is due to abnormal parental anxiety,but I am not able to communicate this success-fully to the parents'.

(7) Accompanying friends and relativesDoctors found it easiest to like a parent whocame alone with the child, rather than one whocame with a spouse, a grandmother, or a friend(termed as 'hangers on', by one paediatrician).Grandmothers were cited as being particularlyirritating when they did not allow the mother togive the history or answer questions and if they

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were torever interrupting or trying to takepossession of the child. Most of the paediatri-cians were more comfortable talking with oneparent than trying to conduct a session with afamily. It was not clear whether they feltthreatened by the family or whether they wereconfused and unsure whom to address.

(8) Doctors' familiesThese were mentioned less than some mighthave expected. A few doctors mentioned theparticular complexity of dealing with colleagues'children, but the additional difficulties ofdealingwith such families were balanced by the doctorfeeling flattered at being selected by a colleagueto help with their child.

(9) Specific terms ofspeechMany doctors were irritated by specific phrasesor expressions that parents used about theirchildren. The expressions that irritated weremainly ones that involved over indulgence and asort of 'kiddie' speak involving over use of 'tiny'and 'little' as well as pretty euphemisms for thegenitalia. (I was reminded of Richard Asherquoting a mother: 'He draws up his little legs,doctor, and his little face is all screwed up whenhe passes his little motion'. I )

ANALYSIS OF GENERAL FEATURESThe responses were analysed in relation to thegrade, sex, experience, and qualification of theresponding doctor. The numbers did not allowsignificant differences to emerge according tothe sex or qualification of the doctor or to theproportion of the doctor's patients who werechildren. There were some differences accordingto the grade and experience of the doctor andfor the purpose of presentation the senior houseofficers and registrars are grouped together as'juniors' to compare their responses with thoseof the consultants. Less than 20% of eitherconsultants or junior doctors were influencedsignificantly by the following parental features:sex, origin from the north of England (whereLeeds is situated) or from the south, or whetherthe parent was much older or younger than thedoctor. The fact that the parent was muchpoorer than the doctor did not make that parentmore difficult or unlikeable for most doctors.Hardly any doctor admitted to any of thefeatures making a parent 'definitely more diffi-cult', but nearly all indicated one or morefactors that made a parent seem 'slightly moredifficult and unlikeable' (table 3). Indian referredto parents originating from the Indian sub-continent who, in Leeds, come mainly fromPakistan, though there are substantial numbersof Indian and Bangladeshi families also. Mostdoctors made clear that the reason why theyfound such parents difficult or unlikeable wasbecause of communication problems primarilyresulting from lack of interpreters. The differentcultural beliefs and lifestyle posed lesserproblems. The West Indian community, whohave been living in Leeds for many years,mainly originated from St Kitts. The West

Table 3 Proportion (%) of senior doctors (consultants) andjunior doctors (registrars and senior house officers) who founda particular parental characteristic difficult or unlikeable

Consultants 7uniors(n=32) (n=46)

Indian 67 46Much less clever 47 46Much more clever 43 60West Indian 40 28Much wealthier 37 49Older:youngerNorth:south Less than 20Male:femalePoorer J

Table 4 Percentage of doctors who found a parent moredifficult or unlikeable 'if the child has a condition I do notunderstand' and 'if the child has a condition for which I canoffer no definite treatment'

Nature of child's condition Consultant 3uniors(n=32) (n=46)

Not understood 63 83No definite treatment 77 44

Indian parents posed no problem with regardsto language but several doctors indicated thedifficulty they had in coping with the 'laid backattitude' of some parents and what seemed tothe doctor as erratic and casual keeping ofappointments. It is relevant that over 90% of thedoctors were white and that none were black.

THE CHILD'S CONDITIONDoctors of all grades found the parent moredifficult or unlikeable if the child had a conditionwhich the doctor did not understand (table 4).Juniors found this significantly more upsettingthan consultants (p<005). Whereas 'If thechild has a condition for which I can offer notreatment' significantly more consultants wereupset than junior doctors (p<005).

ADDITIONAL RESPONSESSeveral doctors took the opportunity to writeexplaining their responses, and several suggestedother inquiries that ought to be made in relationto the quality of doctor-family consultations.One junior doctor wrote 'It is usually thecircumstances that surround a particular con-sultation that make it difficult for me to dealoptimally with parents. Particularly [if I am]feeling ill, [with] headaches and colds, lack ofsleep, or hungry'. Another paediatric registrarsummed up the feeling that several expressed'Finally I try to remember that while I am notgoing to like every parent that I meet, not all ofthem are going to like me'.

THE NURSES' AND THERAPISTS' QUESTIONNAIRETheir questionnaire was identical to that of thedoctors apart from having an additional initialquestion: 'If the parents are difficult or unlike-able the health care received by the child islikely to be (1) unaffected, (2) slightly less good,(3) considerably less good'.The response rate was poor-51 completed

questionnaires out of 100. It became apparentthat part of this poor response was because, in

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some departments, the senior nurse consideredthe questionnaire improper and encouraged thestaff to disregard it. The length and quality ofthe responses were also disappointing in thatvery few of the nurses took the opportunity towrite lengthy comments in the way that hadbeen hoped (and as the doctors had). Eventhough the nurses were encouraged to remainanonymous, many gave the impression that theywere trying to give an acceptable answer ratherthan express their personal feelings. Thus, of 36responding nurses, only six thought that thecare received by the child was likely to beaffected by a parent being difficult or unlikeable.That response was countered by a seniorchildren's trained nurse with over 20 yearsexperience who wrote 'If a parent is aggressiveor over-critical, no matter what the reason, itputs the nurse on the defensive and thusreluctant to involve him/herself with the family.It is something one learns to cope with and I donot find it a big problem now, due to mylengthy experience, so I hope that it makes mycare of the child only slightly less good. Morejunior nursing staff, however, do not cope wellunder that sort of pressure and avoid the child ifthe parents are around'. Few of the nursesindicated that any of the general features madethem consider the parents difficult or unlikeable.When asked specifically what features made aparent difficult orunlikeable, several did respondmentioning the following factors:

(1) Aggressive and violent. Several nursesfelt physically threatened by abusive, aggressiveand, sometimes, drunk parents particularlywhen on duty alone at night.

(2) Child abusers.(3) Parents who demanded preference and

who were inconsiderate of other children on theward.

Responses came from 15 therapists (dietitians,physiotherapists, occupational therapists). Allexcept three considered that the child's care wasless good if the parents seemed difficult orunlikeable. Their list of specific problemscausing them to regard a parent as difficult orunlikeable was similar to that of the doctors,though they were rather more irritated byparents who failed to keep appointments or whofailed to comply with treatment.

DiscussionThere have been many investigations of patientsatisfaction with health services and withencounters with doctors.2-7 Several havedemonstrated the need of patients for bothtechnical excellence and doctors whose per-sonalities are sympathetic and helpful."7 In thelast 20 years there has been a trend for patientsto seek a sympathetic listening doctor and to beless satisfied by doctors with a more didacticapproach.8 ' The surveys are a reminder thatthe practice of medicine is an art as well as atechnical exercise. Recent investigations confirmthat the patient's satisfaction is closely related tothe patient's perception of the outcome of themedical encounter and the degree to which thatoutcome matches up to their initial expectationsof the consultation. '0 A common reason for

anger in the doctor-patient relationship isdisappointment of expectation. "There have been far fewer surveys of the

doctor's perception of the clinical encounterdespite most doctors acknowledging that theyare influenced by the character of the patientand the patient's family. Those dealing withchildren are aware that they are influenced bythe child's parents and acknowledge that thecare is likely to be less good if the parents seemto them difficult, unlikeable, or irritating. 1

In this survey nearly 80% ofdoctors respondedto a postal questionnaire, and did so at length.That is heartening because, though most doctorstreating children try hard, on behalf of thechild, to provide optimal treatment regardlessof interfering factors, they are far more likely toachieve that even handed approach if theyacknowledge that certain parents do make itdifficult for them to provide optimal treatment.Moreover, acknowledging that difficulties doarise for doctors, as well as patients, in con-sultations can be a starting point for post-graduate education, problem solving, and bettertraining.

It is worrying that the response rate fromnurses was poor and that so few acknowledgedthat parents could be difficult or unlikeable andthat those qualities might make a child's medicalcare less good. The limited response fromnurses may have resulted from several factors.A minority of senior nurses adopted a dis-couraging attitude to the questionnaire, whichled to poor response and apparent lack ofcandour from their staff. Other nurses wereencouraged to complete the questionnaire bytheir seniors, but it may be that being less usedto research questionnaires, tending to beyounger and more junior than the doctors, somefind that the only way to cope with difficultfamilies is to pretend that none are difficult orunlikeable. Those concerned with training aremore likely to feel that the starting point forbetter relationships is to acknowledge problemsand work out ways of coping with them.

The features which caused the hospital doctorsto feel that a parent was difficult or unlikeablewill be familiar to most doctors. Several of thecharacteristics were similar to those that havebeen said to cause adult patients to seem'hateful'.'4 Aggressive combative parents wereunpopular, but few doctors felt physicallythreatened by them. In contrast the nurses wereworried by the prospect of physical violenceand, bearing in mind the lonely responsibilitiesof many young nurses late at night in hospital, itis an understandable fear.

Parents who harmed their child were men-tioned by both doctors and nurses. To thedoctors it was usually verbal, emotional crueltythat they resented; none mentioned parents whohad physically or sexually abused their children.In contrast many nurses did find parents whohad physically abused their children unlikeable.The doctors were conscious also that the parent'snegative attitude to their child sabotaged anysuggested management regimen.The fact that so many doctors complained

about persons other than a parent accompanyingthe child to a consultation is worrying. In the

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last 20 years there has been a steady increase inthe number of people accompanying a child to,for instance, an outpatient clinic. Formerly itwas nearly always the mother with the child.Now it is commonly both parents and, quiteoften, a grandparent as well. On other occasionsa parent comes with a friend or relative forsupport. They do so because they are concernedfor the child, or because a single parent isapprehensive ofthe hospital and the consultationand needs a relative or friend for support. Yetmost doctors do not find dealing with more thanone parent easy. (Even Illingworth, with hisconsiderable wisdom and clinical experience,found grandmothers irritating.'5) A cynicmight argue that the doctor prefers to be in a

powerful position and does not like being out-numbered; more likely is simply the problem ofknowing with whom to talk when there are twoor three people representing the child. Whoseeyes does one look at, to whom does one ask thequestions?

Child psychiatrists and some other therapistsare skilled at group communication and familytherapy, but most other doctors dealing withchildren do not cope well with more than one

relative at a time. Clearly those with the skills todeal with groups need to pass on those skills tothose of us without them.

Junior doctors were more upset if the childhad a condition they did not understand thanwere the senior doctors. (Perhaps consultantsare more accustomed to failing to arrive at a

diagnosis.) But three quarters of the consultantsperceived the parent as more difficult or unlike-able 'If the child has a condition for which I canoffer no definite treatment'. This illustrates one

of the ways in which doctors work, particularlyat outpatient clinics. The doctor is most com-

fortable if he or she can perform a particularinvestigation or prescribe a particular treatment.It is a way of concluding a consultation and a

way of making themselves, and hopefully thepatient, feel that something definite is beingdone. That so many doctors, when they cannotprovide a diagnosis for the child or offer a

specific management regimen, see the parent as

difficult or unlikeable is partly explained by thatgroup of parents also tending to be combativeand blaming (perhaps because of past dis-appointments with other consultations). It isunfortunate that many adult patients, andparents of child patients, who have chronicproblems or unsolvable symptoms spend muchtime blaming others, particularly doctors, fortheir unpleasant symptoms. Doctors, for theirpart, respond poorly to blame and the patienttends to receive worse treatment. However, itmust be acknowledged that some doctors, whenthey cannot diagnose what is the matter with thechild nor suggest a management regimen, trans-fer the child's problem onto the parent andperceive the parent as being partly respons-ible-and slightly irritating and unlikeable.Several of the doctors had mentioned, in thefirst part of the questionnaire, their difficulty indealing with parents when all they had to offerwas sympathy and explanation (because therewas no further useful investigation to do and no

quick effective treatment). It highlights the

need for doctors of all grades to have bettereducation in helping people with chronicdisorders and unsolvable problems.The respondents picked out several factors

from 13 general features that tended to makethem regard a parent as difficult or unlikeable.The result lent some support to the assumptionthat families whose race, culture, and socio-economic status is different from that of thedoctor's may be more vulnerable to bias andpoor care. 16 However, it should be stressed thatfew doctors signified any factor as making theparent 'definitely' more difficult or unlikeable.Nearly all the responses were 'slightly'. It is sadthat parents from the Indian subcontinentshould be mentioned by two thirds of theconsultants and nearly half of the juniors. It iseven sadder that the reason given by the doctorsfor that opinion was mainly concerned withcommunication problems, many of which couldbe solved by satisfactory translation services.When, in so many of our health districts, a highproportion of child patients are Asian andhave parents with limited English, it is scan-dalous that translator services are so limited. Indeveloped countries such as ours a diagnosis of achild's illness is primarily from the historyrather than the examination; young childrencannot provide their own history and it isessential for the doctor dealing with them to beable to communicate with a parent. Many of theparents cannot speak English nor organisethemselves to arrive at hospital with someonewho can translate for them. Too many hospitalshave skeleton, voluntary translator serviceswhich may not be available even at peakoutpatient clinic times, and which are absentwhen children are admitted as emergencies,usually in the evenings.

Nearly half of all doctors signified 'much lessclever' as an unlikeable parental characteristic,usually linking it with the ensuing communica-tion difficulties. The 'much more clever' parentswho were difficult, were deemed so usuallybecause of pressing for priority treatment andfor more than their share of health service time.Few doctors were adversely influenced byparents who were considerably older or youngerthemselves. The myth that male paediatriciansprovide the best service for children who haveattractive mothers was not supported (nor was itin the survey of primary care paediatricians inthe USA, where a great many maternal charac-teristics, including safety consciousness, camewell ahead of the mother's appearance ornature'2).Most doctors, unlike nurses, were prepared

to write at length about the features that madeparents seem difficult or unlikeable. Severalexpressed their misgivings, and sometimes guilt,about their prejudices. However, it was goodthat the doctors acknowledged them, and perhapswe should ask ourselves whether it is realistic toexpect to feel that we have to like all ourpatients and their families. We do need strategiesfor coping with our own emotions and feelingsand, in particular, with those parents who seemto be difficult and unlikeable not only to us butto their spouse, their neighbours, and the rest ofsociety. Most of us feel inadequate when con-

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702 Meadow

fronted by such a belligerent mother of aviolent disruptive child. Perhaps we need toacknowledge that she probably knows thateveryone, including the neighbours and doctors,dislike her. There may be ways forward bysaying 'I suppose you must feel persecuted as aresult of Thomas's behaviour' and by finding ifthere is anything in life which is not too awful;'Can you think of any good thing Tom does', orin the parents' relationship 'Is there anythingthat you are able to talk about or do together'?Those of us who feel inadequate with bellige-rent unlikeable parents perhaps should feelgrateful for what they do give us, and what theyare showing by taking the time and the troubleto bring their child to us for a consultation, evenif they are complaining and obstructive andnon-complying: they have brought their childand themselves to the clinic. Nevertheless mostof us will continue to have difficulty findingways of dealing with our feelings about someparents of child patients. We wish to do the bestfor the child and know that our feelings, attimes, interfere with that. It is likely that childpsychiatrists, family therapists, and othercolleagues can contribute, during in-servicetraining, to enable all grades of medical staff toachieve better understanding and betterapproaches to difficult and unlikeable people.The subject should be discussed and notavoided.

I am grateful to all those who cooperated with the questionnaireand, particularly, to the majority who sent back long andthoughtful replies. I am grateful to Wendy Pearson and MandyJones for their assistance.

1 Asher R. Talking sense. London: Pitman, 1972:116.2 Deisher RW, Engel W, Spielholz R, et al. Mother's opinions

of their pediatric care. Pediatrics 1965;35:82-90.3 Francis V, Korsch B, Morris M. Gaps in doctor-patient

communication. N EnglJ Med 1%9;280:535-40.4 Ware JE Jr, Davies-Avery A, Stewart AL. The measurement

and meaning of patient statisfaction. Health and MedicalCare Services Reviezw 1978;1: 1-5.

5 Korsch B, Gozzi E, Francis V. Gaps in doctor-patientcommunication: Doctor-patient interaction and patientsatisfaction. Pediatrics 1968;42:855-71.

6 Hulka BS, Zyzanski SJ, Cassel JC, Thompson SJ. Scale forthe measurement of attitudes toward physicians andprimary medical care. Med Care 1970;8:429-32.

7 Hulka BS, Kupper LL, Cassel JC. Practice characteristicsand quality of primary medical care: The doctor-patientrelationship. Med Care 1975;13:808-20.

8 Freidson E. Dilemmas in the doctor/patient relationship. In:Cox C, Mead A, eds. A sociology of medical practice.London: Collier-Macmillan, 1975:285-98.

9 Schwenk TL. Patient desires and expectations of the familyphysician. (Response to letter.)J7 Fam Pract 1984;19:432.

10 Like R, Zyzanski SJ. Patient satisfaction with the clinicalencounter: social psychological determinants. Soc Sci Med1987;24:35 1-7.

11 Herman J. Anger in the consultation. Br J Gen Pract 1990;40:176-7.

12 Tellerman K, Medio F. Pediatricians' opinions of mothers.Pediatrics 1988;81:186-9.

13 Corney RH, Strathdee G, Higgs R, et al. Managing thedifficult patient. Practical suggestions from a study day._7 R Coll Gen Pract 1988;38:349-52.

14 Groves JE. Care of the hateful patient. N EnglJ3 Med 1978;298:883-7.

15 Illingworth RS. Why irritated? Arch Dis Child 1988;63:567-8.

16 Kitchen L. Taking care of the hateful patient. N EnglJ7 Med1978;299:366-7.


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