Some years ago, in my role as a workplace coach, Sam, a female GP, came to see me because she was struggling at work. At our first session, she told me she’d had a number of difficult appointments with a male patient that were challenging. She said she found him intimidating, as he frequently questioned her clinical judgment and decisions, and demanded investigations she felt were unnecessary.
‘There was something about his manner,’ she said, ‘I felt paralysed.’ As a result, she conceded to his demands but felt she had lost her authority. She began to dread seeing his name on the computer. It was starting to affect her professional judgment at work, not just with this patient, but with others.
Most of all, she felt a sense of shame. ‘I’m the doctor,’ she said, ‘I’m supposed to be in control of my consultations. I feel small and weak, being pushed around by my patients.’
As an experienced GP, she began to doubt whether she wanted to continue in a clinical role,and was considering a move into teaching.
Understanding the problem
My role as a workplace coach is to understand a client’s problem, and see it in the context of the rest of their lives, their role, the dynamics at work, as well as looking back into the past.
It soon transpired that Sam grew up with a domineering father, who she described as a bully. He wasn’t physically abusive, but was overbearing and controlling. After further discussion, she was able to trace back the ‘sense of paralysis’ to memories she’d had as a young child when he was quick to become angry about a minor issue. She also recalled her mother’s response; passive and silent, and ‘wringing her hands in the background’.
It was the first time Sam had spoken about this as an adult, and the first time she had been able to see a link between past experiences and this present dilemma. ‘It hadn’t occurred to me that this was triggered by something so far back,’ she said.
In our work together, she recalled feeling ‘small and stupid’ as a child, and we explored the feeling of powerlessness in the face of male anger, and the link between past and present. The focus of the work was on separating out these events: her experience as a child, and her experience now, as an experienced and competent GP.
After exploring her feelings associated with her child-self, we were then able to think about how she might take up her authority differently, and with confidence, in these challenging sessions with this patient, but also with other male patients with whom she often felt railroaded.
She hadn’t told anyone at work about this, and we discussed her sharing this with other colleagues. To her surprise, other female GPs told of similar experiences with different patients. As a result, Sam felt less alone with it, and the group became a forum of support to share experiences and strategies, as well as leading to useful discussions on boundaries and what constituted ‘unacceptable’ behaviour by patients in the consulting room.
Why women may feel intimidated
While Sam’s difficulty had a particular resonance for her in her past, the issue she brought was not an unfamiliar one. I had seen similar scenarios it in my workplace consultancy practice over the years with a number of different female clients - a female lawyer and her male client, a teacher and a father of a child in her class - and I began to wonder about how male clients or patients might use their physical presence or intimidating manner to manipulate situations in a professional context.
It made me think about the setting of the interactions, and while the privacy of a 1:1 conversation allows for confidentiality and the sharing of personal information, it is also a place that, on the flip side, might not always feel safe for women. A closed room, with an angry man who is likely to be physically stronger, can feel intimidating and risky.
Years ago, when I worked in primary care as a clinical psychologist, a regular client of mine unexpectedly came in to her session with her adult son. He was forceful in his demands for a housing letter in support of his mother.
I recall the thumping in my chest as I explained that a letter had already been sent. He was tense and agitated and, given we were tucked away in a quiet back corridor, I was suddenly very aware of my vulnerability. I agreed to the letter and he left, and I continued the session with my client.
At the time, I was in a junior role, and I did mention it to my supervisor, but I wonder how many women like Sam, once they have reached senior positions, feel ashamed that they aren’t handling these situations better, and so choose to keep quiet.
Sometimes difficulties with patient interactions might be triggered by a childhood experience, or a current relationship issue, or some consultations will simply be harder to manage when they land at a time when life and work is overwhelming. And once a communication pattern has been established in the consulting room, it can be hard to reel back from.
The doctor-patient relationship
While much has been written about the nuances of the doctor-patient relationship, and how best to manage tricky patients, it’s important to remember the individualised nature of the interactions, and that a doctor, like everyone else, has a past they carry into the consulting room and therefore, certain patients, certain illnesses and certain demands, may bring up personal associations that are difficult.
In the case of my client, the memory was ‘paralysing,’ and led to an excellent clinician questioning her career choice.
There has been considerable focus on bullying and intimidation in the workplace but largely on the hierarchy and dynamics between senior and junior staff. In addition, we hear that in the current climate of the NHS, verbal abuse of primary care staff by patients is on the increase. But my work with Sam (and other female professionals) left me wondering about the type of intimidation in the consulting room, which is more subtle and nuanced, and can lead to a subjective experience that can evoke confusion and shame.
It's a theme I chose to explore in my novel The Family Retreat. Here, my GP protagonist is intimidated into making a referral that’s unnecessary, and in this case, it’s the patient’s physical presence, and his obvious, but controlled rage that leads her to comply. In short, she does what he wants because she is frightened.
In the aftermath, a well-intentioned male GP wants to support her and asks what happened. 'Did he threaten you?' he wants to know. She is floored by her colleague’s question. The reality was there was nothing to identify in behavioural terms that he had crossed a line, and yet she was left feeling shaken and nervous when he had gone. 'Did he threaten me? Or did I find him threatening?' These seemed very different questions. She realises she doesn’t know how to answer the question: ‘How can I explain that there is a cavernous divide between feeling afraid and a tangible act of intimidation?’
Many women grapple with these situations regularly in their daily lives, but my work with Sam and others suggests that a proportion of highly competent senior leaders and clinicians often feel ashamed of these fearful and intimidating situations and remain silent.
While Sam found the individual sessions to explore her past very helpful, she also found it liberating to discuss these issues with colleagues. It’s impossible to work with a patient if you are feeling unsafe or insecure. It takes effort to foster a workplace culture where these issues can be discussed and shared, so that clinicians not only develop strategies to manage situations better but, more importantly, feel less alone, isolated and ashamed.
Bev Thomas worked for many years as a clinical psychologist in primary care in east London. Her work now focuses on supporting teams and organisations in the NHS. Her second novel, The Family Retreat is published by Faber.
This case study is an amalgam of several real cases to protect confidentiality.
