Introduction

Mr Taylor entered the consulting room almost stealthily and took his seat. The doctor's greeting was received silently with a somewhat jeering smile. Mr Taylor had a shifty appearance, accentuated by the wandering of his gaze, which was hardly ever allowed to engage the doctor's. He began to detail his minor complaints, which were numerous. The doctor, looking at his own notes, saw uncomfortably that Mr Taylor was regularly prescribed five different medications, three of which might potentially interact in a harmful way. As he listened, endeavouring to make contact with Mr Taylor's wandering gaze, the doctor's shoulders drooped as if in resignation. From long experience he sensed nothing would change as a result of this clinical encounter. Mr Taylor left with a prescription to continue all five drugs, a prescription written guiltily and received with an almost sadistic smile, the only steady eye contact of the consultation.

The above clinical vignette based on an actual doctor–patient interaction (videotaped and discussed by trainer and trainee) represents a consultation with which most doctors are familiar. Mr Taylor is a so-called ‘problem patient’. He does not appear to experience great suffering and certainly does not have a life-threatening disease. In spite of repeated consultations little progress is made in alleviating his multiple complaints.