LAUSR

We slipped into our office but even before the nurse practitioner began to present I could tell things were not good. ‘‘Ms. K is at it again. She was yelling that her pain medications are not working and will only talk to you.then she screamed at me to leave the room since I was not a doctor.’’ Ms. K was a 60-year-old, single Caucasian female with stage 4 nonsmall cell lung cancer with metastasis to her lower spine. She had been admitted two weeks earlier to a hospitalist service with a female attending, but was quickly switched to the oncology service as ‘‘those doctors are just generalists when I need specialists.’’ After reporting poor pain management and ‘‘firing’’ two nurses, the palliative care team was consulted. Ms. K had received steroids, zoledronic acid, and different opiates for her pain. Staff noted that she had a low frustration tolerance when interacting with them. She had a tendency to make multiple requests that could never be adequately fulfilled and was seemingly never satisfied. Nurses began to avoid her room. Before even meeting with Ms. K, a nurse shared that ‘‘.seeing her is like visiting my mother-inlaw.I can’t stand it.’’ Upon our first meeting, Ms. K shared that she was never married. She had worked as an accountant and enjoyed the male comradery, as she was the only female employee in the office. Ms. K noted that her father was also an accountant whom she admired, while her mother ‘‘cleaned the house and never knew much.’’ Her father protected her from her mother who reportedly always ‘‘picked’’ on her. At the end of the first visit, a fentanyl patch was started and an oxycodone was made available for breakthrough pain. The following day, I followed the nurse practitioner into her room and as I entered, Ms. K exclaimed, ‘‘Oh it’s the young doctor who helped my pain so much.’’ The female nurse who had joined us looked shocked as before our arrival she only heard contradictory statements. I reviewed the treatment plan with Ms. K who responded ‘‘..it just makes me feel better knowing that you are caring for me unlike these nurses.’’ The staff was stunned by this encounter and asked to meet to discuss what had transpired. I believe to understand this interaction, one must look to Sigmund Freud’s 1895 book, Studies on Hysteria. In that brilliant work, Dr. Freud initiated an awareness that patients often had unconscious, intense feelings toward him. He termed it transference, an unconscious tendency of a person to assign to others in the present environment feelings and attitudes associated with a significant person in one’s earlier life, which could be affectionate (positive), hostile (negative), or ambivalent. It has become a pillar of psychoanalytic theory as analysts have utilized transference as a tool to view the problems in past relationships that, through their contemporary misassignment, are impeding functioning in the present. Furthermore, no one has immunity as providers can have their own unconscious feelings misassigned to patients, which is termed Countertransference. The training in psychoanalysis is to know when and how to interpret transference/countertransference, which if mistimed could lead to heightened resistance and psychological regression. Using this framework, it was clear that Ms. K had a positive paternal transference toward me based on her earlier positive relationship with her father. Her history revealed that she had felt closer to him as a child, which led her to follow his career path into a male-dominated field. On the other hand, Ms. K was demonstrating a hostile transference to female staff. Her constant criticisms and comments to their ineptitude were connected to her negative view of her mother. Hence in this case, Ms. K’s transferences were captured by her words, ‘‘.it just makes me feel better knowing that you [male-father] are caring for me unlike these nurses [female-mother].’’ Countertransference was also demonstrated by the treatment team, as reflected by one nurse’s comment that Ms. K was like her mother-in-law. As I provided these formulations, the palliative care team and nursing staff identified their own examples of this process and by doing so were less reactive and more sympathetic. Nurses began to feel less personally targeted by Ms. K. It also began a conversation among staff when they recognized their own countertransferences and took steps to avoid these feelings interfering with care. Over the next few days, Ms. K noticed and explicated her changing observations regarding staff’s increasing patience, empathy, and support. This facilitated a reduction in her resistance to consider hospice on discharge. I did not share these insights with Ms. K due to the above-noted concerns with the timing of such interpretations and her clear progress around goals of care. Hence, transference/countertransference is another tool that can be utilized by palliative care teams to understand their patients’ difficulties with treatment.