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Originally published as JCO Early Release 10.1200/JCO.2008.17.5588 on October 14 2008 © 2008 American Society of Clinical Oncology.
The Physician: A Secure Base
From the Division of Psychiatry and the Palliative Care Consult Team, Sunnybrook Health Sciences Centre, and the University of Toronto, Toronto, Ontario, Canada Corresponding author: Philip Gerretsen, MD, MSW, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada; e-mail: philipgerretsen{at}sympatico.ca PATIENT HISTORY Mr. Irving, an elderly man with a recent diagnosis of metastatic duodenal adenocarcinoma, had a long-standing history of Peutz-Jeghers syndrome that required multiple surgeries to remove intestinal polyps. He presented to the emergency department with 10 days of intermittent, left-sided abdominal pain that radiated to his back. He described the pain as "sharp" and "crampy", and unresponsive to opioids administered both orally and subcutaneously. The subsequent addition of a neuropathic adjuvant drug did not provide relief. This pain resulted in four emergency department visits during a 10-day period. Imaging of the abdomen identified significant retroperitoneal lymphadenopathy, for which he had previously received palliative radiation therapy. The palliative care team had seen the patient several months prior as an out-patient and was reconsulted by the emergency department for suggestions regarding pain management. Due to the refractory nature of the pain, a subcutaneous continuous opioid infusion pump was ordered and homecare services were arranged for the patient. Shortly after the pump was initiated the patient experienced severe pain, which he rated as 8 of 10. As directed, he appropriately self-administered a breakthrough dose; however, before its onset of action he immediately telephoned the on-call service stating he feared the pain would not abate. The physician on-call contacted the patient roughly 20 minutes afterward. The patient's voice was described as tremulous, suggestive of an anxious effect. He informed the physician his pain had come on suddenly and that he was terrified the breakthrough dose would be ineffective. The patient now described the pain as a "comfortable" 3 of 10. Despite this decline in severity, the patient remained fretful. It was only after significant reassurance that he would not be left alone with his pain, and that the physician would be available to him 24 hours a day over the course of the weekend that the patient's anxiety lessened. His voice was described as calm and no longer quivering. No further calls were made by the patient that night or the remainder of the weekend. On reassessment early the following week, the patient indicated his pain was adequately controlled and responsive to self-administered breakthrough doses. INTRODUCTION During an era in our health care system when time is at a premium and is felt by many health care professionals to be the most precious resource; it is time, or at least the genuine perception of availability that can be one of the most powerful clinical interventions. Physician and health care provider availability figures prominently in consumer/patient satisfaction.1,2 The perception of practitioner inaccessibility or inattention to the patient's quality of care can result in untoward anxiety, behavioral symptoms, and patient dissatisfaction. This is of particular relevance to oncology and palliative care patients who face multiple physical and psychological challenges stemming from life-threatening diseases.3 As many as 33% of oncology outpatients experience moderate to high levels of anxiety and depression, and approximately one fifth warrant ongoing evaluation or intervention for psychological distress.4 This vignette is intended to guide the exploration of the physician-patient relationship through the lens of attachment theory, an evolutionary and ethological theory to understand interpersonal relationships.5 The deliberate pronouncement to patients of physician accessibility is of little expense to the clinician and health care system, and may have profound therapeutic benefit and result in improved quality of life for patients. ATTACHMENT THEORY Attachment theory5 was originally designed to emphasize and elucidate the importance of infant-caregiver relationships to survival and personality development. It is applicable to most close relationships including those beyond the parent-child dyad, such as spouses, romantic partners, therapist-client, and doctor-patient. Attachment theory holds that dependent relationships to primary caregivers are essential to a child's physical and psychological survival. Without an "attachment," (ie, a parent or primary caregiver), along with the failure of another responsible adult to intervene on the child's behalf (eg, other relatives, foster parents, the state), the child is abandoned and will die. A child is wholly reliant on others for the provision of food, water, shelter, and safety, without which she cannot survive. To ensure an attachment, the infant/child engages initially in predetermined (eg, crying, reaching out) and later developmentally adaptive behaviors to maintain proximity to its caregivers. The success of this goal directed behavior and subsequent attachment style that forms from the parent-child interaction, not only facilitates the infant's immediate survival, but greatly influences his/her personality structure by providing an internal working model or psychic template (explained below) for all future self-other interactions. For example, when either hungry or in need of being held, an infant feels anxiety (a danger signal of either an unmet need or a threatening stimuli6,7) and screams to alert his caregivers; to bring them closer to intervene definitively. If the caregiver is responsive and the child's needs are met, the child's anxiety resolves. In turn, the child develops a secure attachment characterized by a cognitive-emotional model of the self as good and lovable and of the other as responsive, available, and loving. As a secure base, parents’ availability gives the child enough psychological freedom to explore his/her environment, grow and learn. Conversely, if the caregiver neglects the child's needs or punishes the child, the infant's anxiety persists and he/she, with repeated insults, develops a model of the self as unworthy of love or worthless and of the other as unavailable or threatening. There is no sanctuary to which the child can return, impeding exploratory behavior, growth and the healthy formation of later attachment relationships. In this scenario the child develops an insecure attachment style. It should be noted that the child presented here is not having a tantrum or testing the limits of his caregivers, but in fact has an unmet need. As many parents know, it is often very difficult to distinguish between these two scenarios, leaving caregivers with much uncertainty. Adult insecure attachment styles are categorized as anxious-preoccupied, dismissive-avoidant, or fearful-avoidant.8,9 Anxious-preoccupied persons are ambivalent about the commitment and availability of others. They are described as clingy, seeking high levels of intimacy, approval, and responsiveness from their close relationships; often becoming dependent. Dismissive-avoidant individuals tend to think highly of themselves, but are distrustful of others, preferring to be independent and self-reliant. They do not seek out intimacy and typically suppress their emotions. And lastly, people with a fearful-avoidant style desire close relationships, but are afraid of being hurt by others. As a result of their conflicted feelings they are uncomfortable with emotional closeness and tend to present a chaotic mix of avoidance and seeking behavior. APPLICABILITY OF ATTACHMENT THEORY TO PRACTITIONER-PATIENT RELATIONSHIPS As noted earlier, the attachment theory is applicable to most close, nurturing relationships. In the case of the vignette patient with advanced metastatic cancer, the issues of threatened survival and uncertain prognosis are amplified with each acute pain exacerbation. These repeated assaults activate attachment behaviors that aim to elicit an intervention from his caregiver, in this case his physician. By assuring the patient that he was not alone and by making the patient aware of the physician's availability as a caregiver, a secure base is provided and allows for great psychological comfort. The perception of availability is a powerful anxiolytic. It is well known that anxiety is a significant contributor to the subjective experience of pain and distress, and greatly diminishes one's quality of life.10 Not only does attachment theory guide our understanding of this case, its principals are germane to other practitioner-patient interactions, such as the patient that presents to the emergency room with chest pain; or in delivering a diagnosis of a chronic, potentially life-threatening or altering condition; or being on-call to the floor of a patient with an acute exacerbation of chronic obstructive pulmonary disease. In these instances, the clinician can deliver a powerful, comforting intervention, by informing the patient they are not alone and that the health care worker (as caregiver) is present and accessible as needed during the acute crisis, whether during daily duties or on-call. Paralleling the infant-caregiver dynamics, the patient develops a model of the practitioner-patient relationship in which the self is viewed as valuable and worthy of care and the health care provider is regarded as available and compassionate. The perception of availability instills a profound sense of security, thus potentially alleviating anxiety and establishing a secure doctor-patient relationship. The caveat to the above are the inconsolable, persistently anxious patients that may have either continued unmet needs (eg, intractable pain, delirium) or pathological anxiety that may require further behavioral or pharmacologic interventions, or a referral to a specialist. Adequate pain management played a critical role in allaying the vignette patient's anxiety. If his pain remained uncontrolled this would represent a continued unmet need, resulting in persistent distress requiring appropriate management. In this case, patient comfort was not solely derived from the accessibility of an on-call physician. Rather, it was the patient's awareness and resultant internalized perception of physician availability that provided him with the security that comes with feeling one is not alone. To intervene in this way, with our oncology patients or with patients in any other branch of medicine, can be of great service to them at little to no cost to the health care provider—the professional that struggles to meet not only the many needs of his or her patients, but also those in the other aspects of his or her life. The importance of practitioner availability to cancer patient care is evident in the medical literature. An evaluation of an outpatient oncology orientation program that provided, among other things, access to a support care practitioner for follow-up contact revealed that the program led to patients feeling more relaxed and comforted, and less anxious and fearful.11 An encouraging finding was that 89.3% of participants reported they would feel comfortable contacting a designated supportive care practitioner. In a retrospective cohort study comparing hospice (n = 2,095) and nonhospice (n = 2,260) patient survival among patients who died within a 3-year window, the mean survival after regression analysis was 29 days longer for hospice patients.12 The authors concluded that for people who are on the edge of survival, attention to patient well-being and physical health may increase a desire to continue living. This outcome suggests that a health care environment that fosters favorable caregiver-patient attachments may indeed confer a survival advantage, at least for some patients. A recent study examined the contribution of attachment security and social support to depressive symptoms in outpatients (n = 326) with metastatic cancer.13 They found that attachment security buffered the effect of symptoms of depression associated with disease burden, and that this relationship was mediated through the degree of perceived social support. By directing interventions toward patients’ perception of support availability, there is the possibility of alleviating symptoms of depression. Physician and health-care provider availability figures prominently in patient satisfaction.1,2,14 More empirical research is required to explore the effectiveness of the intervention described in this article toward alleviating symptoms of anxiety and depression, improving quality of life, and increasing survival. The possible benefits of other interventions derived from the basic principles of attachment theory also warrant investigation in the health care setting. We speculate the deliberate pronouncement to patients of physician accessibility costs the clinician at most 30 seconds of his or her time, but is often withheld because of a number of contributing factors, including the clinician's lack of awareness of many patients’ perception of physician inaccessibility; disbelief that it is of any therapeutic value; or the fear that it may result in subsequent "unnecessary," nonurgent patient contact detracting from essential medical encounters with other patients. In addition to improved patient satisfaction, we believe that the internalized perception of physician availability will result in reduced anxiety, depression, and somatic complaints leading, paradoxically, to fewer calls to resident and staff physicians. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. ACKNOWLEDGMENTS We thank Susan Brandes. NOTES published online ahead of print at www.jco.org on October 13, 2008. Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article. REFERENCES
1. Shiozaki M, Morita T, Hirai K, et al: Why are bereaved family members dissatisfied with specialised inpatient palliative care service? A nationwide qualitative study. Palliat Med 19:319-327, 2005 2. Coulter A: What do patients and the public want from primary care. BMJ 331:199-201, 2005 3. Scheier MF, Carver CS: Adapting to cancer: The importance of hope and purpose, in Baum A, Andersen BL (eds): Psychosocial Interventions for Cancer. Washington, DC, American Psychological Association, 2001, pp 15-36 4. Stefanke ME, Derogatis LP, Shaw A: Psychological distress among oncology outpatients: Prevalence and severity measured with the Brief Symptom Inventory. Psychosomatics 28:530-539, 1987 5. Bowlby J: A Secure Base: Clinical Applications of Attachment Theory. London, United Kingdom, Routledge, 1988 6. Basch MF: Understanding Psychotherapy: The Science Behind the Art. New York, NY, Basic Books, 1988 7. Freud S: On Psychopathology: Inhibitions, Symptoms and Anxiety: And Other Works. Harmondsworth, United Kingdom, Penguin Books, 1993 8. Cassidy J, Shaver P (eds): Handbook of Attachment: Theory, Research, and Clinical Applications. New York, NY, Guilford Press, 1999 9. Bartholomew K, Horowitz LM: Attachment styles among young adults: A test of a four-category model. J Pers Soc Psychol 61:226-244, 1991[CrossRef][Medline] 10. Yalom ID: Existential Psychotherapy. New York, NY, Basic Books, 1980 11. Gallant MD, Coutts LM: Evaluation of an oncology outpatient orientation program: Patient satisfaction and outcomes. Support Care Cancer 11:800-805, 2003[CrossRef][Medline] 12. Connor SR, Pyenson B, Fitch K, Spence C, et al: Comparing hospice and nonhospice patient survival among patients who die within a three-year window. J Pain Symptom Manage 33:233-246, 2007[CrossRef][Medline] 13. Rodin G, Walsh A, Zimmerman C, et al: The contribution of attachment security and social support to depressive symptoms in patients with metastatic cancer. Psychooncology 16:1080-1091, 2007[CrossRef][Medline] 14. Vohra JU, Brazil K, Szala-Meneok K: The last word: Family members’ descriptions of end-of-life care in long term care facilities. J Palliat Care 22:33-39, 2006[Medline] Submitted April 6, 2008; accepted September 8, 2008.
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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