Cases and Stories

The narratives in medicine

Politics in the Exam Room

What to do when the subject of politics comes up with patients?

I had always liked my patient Gertrude. A woman in her 60s who had been widowed young, she ran her own business and traveled the world. She seemed to me a model of how to age well: independent, engaged, active, feisty. We always enjoyed good conversation-about books, art, and life--when she visited my office.

Then, one day in the fall of 2008 during a routine physical, I asked her casually if she was following the presidential campaign with interest. Was she ever! She embarked on a several minute tirade about the candidates and the issues holding, as it happened, opinions exactly the opposite of my own on every point. "And what do you think about all this, doctor?" she asked.

A friend of mine who is a psychiatrist often jokes with me that I am lucky. As an internist I can chat with my patients about various topics and compliment a new hairstyle or outfit as would not be appropriate for my friend, a psychotherapist, to do. Transference, countertransference, and boundaries are crucial parts of the psychotherapeutic relationship. But it would be naïve to think that these elements are absent or unimportant in other clinician-patient relationships. Internists and other caregivers need always to be mindful that patients project onto us characteristics we can't foresee and that their trust in us-most importantly their trust that we have their best interests in mind and are not judging them negatively-is as important a part of the therapeutic relationship as it is in mental health settings.

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So what did I answer? I answered, "You're terrific, Gert" which is true about her-what was true about me at that moment didn't matter.



Suzanne Koven practices at Massachusetts General Hospital and teaches at Harvard Medical School.


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