Attending to a Problematic Alliance

To establish a good working alliance based on trust, acceptance, and confidence, the family physician should begin each patient encounter by listening, asking open-ended questions, and continually striving for empathy. The alliance is also fostered by the physician's own self-awareness, ability to acknowledge mistakes, and efforts to adapt to the patient's wishes or needs that will foster improved health. Problems often occur in developing an alliance with a patient who has a personality or somatoform disorder. If tension develops in the alliance, the physician should first ask what the patient thinks of the current problem. If the patient expresses the problem clearly, the physician should join with the patient in solving the problem to deliver effective medical care. If the problem is the physician-patient relationship, nondefensive reflective listening, clarifications, admitting mistakes, and expressing new efforts to improve the situation are often helpful. If the physician believes that there is a different problem affecting the alliance, the physician may say, "I believe that there is a different problem [identify the problem, e.g., psychosocial distress, problem drinking] that is affecting my ability to help you get well and offer you the best medical care available. We need to think about this problem and come up with some solutions."

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