It takes two to tango

Journal of Psychosomatic Obstetrics & Gynecology

ISSN: 0167-482X (Print) 1743-8942 (Online) Journal homepage: http://www.tandfonline.com/loi/ipob20

It takes two to tango W. C. M. Weijmar Schultz & H. B. M. Van De Wiel To cite this article: W. C. M. Weijmar Schultz & H. B. M. Van De Wiel (2000) It takes two to tango, Journal of Psychosomatic Obstetrics & Gynecology, 21:4, 185-187, DOI: 10.3109/01674820009085586 To link to this article: http://dx.doi.org/10.3109/01674820009085586

Published online: 07 Jul 2009.

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Date: 18 September 2017, At: 05:07

J Psychosom Obstet Gynecol2000;27:785-787

December 2000

Editorial

It takes two to tango W C. M. Weijmar Schultz and H. B. M. van de WieV

Downloaded by [168.151.127.80] at 05:07 18 September 2017

Department of Obstetrics and Gynecology; and 'Department of Medical Psychology, Groningen University Hospital, The Netherlands

In answer to the question of what makes their profession so fascinating, gynecologists generally answer with phrases like 'contact with patients' or more generally with 'dealing with people'. In answer to the question of what sometimes makes it so hard, one remarkably enough often hears the same answer. Apparently being able to conduct their profession pleasurably stands and falls with the quality of contact with others. Very justifiably, many gynecologists spend a great deal of time and energy in maintaining good relations. Thus it is all the more harrowing when, despite all the good intentions and effort, many problems arise in this of all fields. These problems are chiefly encountered in the area of obstetrics and gynecology that can be summarized under the common denominator 'psychosomatics'. Under this common denominator we find ailments such as the premenstrual syndrome, postpartum depression, peripartum pelvic instability, chronic inexplicable abdominal complaints, therapy-resistant fluor vaginalis, focal vulvitis, abdominal wall pain, etc. These syndromes are characterized by a general lack of 'hardware' and a limited chance of recovery. Apparently, it costs considerable effort to deal with this. The classification of these syndromes as 'psychosomatic' easily gives the impression that 'psychosomatic' is reserved for certain categories of patients and care providers. Nothing is less true. In fact, every patient who presents with a complaint deserves a psychosomatic approach. 'Psychosomatic' does not point to the cause of the complaint or syndrome, but to the way in which a complaint, or rather the person who presents with the complaint, should be approached. Even when there is an obvious somatic substrate, many complaints and/or questions

for which a patient consults a gynecologist have a strong cognitive aspect. The lack of somatic substrate for these complaints is not without consequence for the doctor-patient relationship. The reverse is also true: patients with this type of complaint are particularly likely to have ambivalent feelings towards the gynecologist. On the one hand, the patient depends on the gynecologist for help, but on the other hand, the patient has problems with the gynecologist's view of the complaints and the subsequent management plan. In order for care providers to be able to steer patient contact in an adequate manner and, in particular, to find pleasure in their work, they must not only know the view of the other party, but also understand it. The contact between patients and medical specialists is particularly prone to resentfulness. This means that patients apparently have different expectations from those of the doctors. In itself, this is not surprising, because each party views the complaints in his or her own way. Patients not only want a proficient doctor, but also a warm-hearted and interested one. Patients particularly want to be quickly rid of their complaints. On the other hand, the doctor expects his or her patient to cooperate with the treatment and be prepared to honor any agreements made. In addition, the doctor wants to be meticulous in his or her choice of available treatment. Therefore, for pleasurable and efficient contact it is necessary for the doctor and patient to work together; to achieve this they will both have to hold the same view regarding the course of affairs. As can be expected, the chance that a such common view (an essential prior condition for good contact) will be lacking will become larger as the cognitive impact of the complaint increases. It is therefore important to give a

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Weijmar Schultz and van de Wiel

moment's thought to the cooperation process and the risk that it will be disrupted. What we generally refer to as 'treatment' for the sake of convenience actually comprises the solving of six different but closely associated parts of the same problem. To be able to solve a problem, there has to be agreement about each of the following:


The complaint It is not unusual for the patient and the doctor to have different views about the nature and seriousness of the complaint If a patient has several simultaneous complaints, then it is also possible for disagreement to arise about which of the complaints should be treated first. The cause of the complaint The system of medical treatment is based on cause and effect. Differences of opinion about the cause of a certain complaint can form a real problem during (further) contact between the doctor and patient. For instance, on the basis of something that she has heard or experienced recently, a patient can think that her abdominal pain indicates that she has cancer. A gynecologist who knows this patient as a nervous woman who panics easily, will first ascribe this to anxiety. If no special preventive measures are taken, then such a difference of opinion will quickly lead to problems with cooperation. The aim of the treatment If the patient and gynecologist have different views about the problem, then this will generally lead to differences in opinion about what 'getting better' entails. For instance, surgery for a patient with a prolapse will mean 'complaintfree functioning'. However, for the gynecologist it remains to be seen whether the prolapse surgery will cure the patient's back trouble. Treatment method If there is no agreement about what the problem actually is (e.g. cancer or fear of cancer) and therefore no agreement about the aim of the treatment (further tests or attempts to reduce anxiety), then discussions will arise about which treatment method should be used (surgery for cancer or psychological help for hypochondria). The conditions of treatment Once agreement has been reached about the treatment method, problems might arise regarding actual details, such as which

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takes two to tango

hospital, the time interval until treatment takes place and which specialist (familiar and local or well-known by the referring doctor). The doctor-patient relationship Interaction between the two parties can also be a source of discord, with serious consequences for the course and outcome of treatment. For instance, the doctor and patient may agree on what the complaints entail 0.e. what is going to happen), but have difficulties with the way the issues are discussed. An important potential source of problems in the area of relationships is the intimacy that arises between the patient and gynecologist and how this is to be dealt with. In the eyes of a patient, the person who saves their life or that of their baby soon becomes a first-class hero, to whom people attribute 'magical' qualities and powers. However, for the gynecologist in question, the patient is one of many. Moreover, he or she is just doing his or her job, and is only a human being after all. If the contact continues for whatever reason or is resumed after a certain period, then a moment must come when the gynecologist fails and topples from his or her throne in the eyes of the patient. Feelings of disappointment, anger, etc. are then just as unavoidable as the initial relief and euphoria. Summarizing, we can say that in order to treat complaints (or have complaints treated), there must be agreement between the patient and doctor about the complaint, the cause, the aim of treatment, the treatment method, the conditions under which the treatment must take place and the doctorpatient relationship. We have seen that there is a sort of chain of dependency. If there are disruptions somewhere in the basic elements, then this will have consequences for the rest of the process. In view of the diagnostic problems with psychosomatic complaints, the outcome in terms of cooperation, or rather in terms of a lack of cooperation, is highly predictable. In order to tackle (psychosomatic) problems adequately, it is important for every gynecologist to have thorough command of the following skills: 1 gathering information;

2 giving information and advice;

3 discussing various treatment options (doing nothing is also an option!) and their consequences; and

It takes two to tango

4 being able to repair the contact if it becomes

disrupted by one or more of the abovementioned elements.

patient societies will become incorporated into subsidy committees and have a say in the content of congresses. Here too it is important for health professionals not to see the patients as opponents but as team-mates, actively listening and then helping patients to sort out what they have collected because a great deal of the information will not have any bearing on the individual situation, or will be unreliable.


The very near future will bring a relatively new power factor into health care: the patient. Patients receive more and more information through the Internet and are combining forces through patient societies. By training a number of members to a high level of expertise and by actively collecting money,

Weijrnar Schultz and van de Wiel

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