The Clinician in the Difficult Encounter

The Clinician in the Difficult Encounter

Most of us who care for patients can remember seeing a name on the schedule and feeling our heart sink. What makes some clinical relationships so difficult? Is it something about the patient—or something about the interaction itself? Dr Jeffrey Jackson has spent more than two decades studying this question. His research has shown that difficult encounters are associated not only with patient characteristics but also with physician factors, including the clinician's approach to psychosocial issues. In this conversation, we explore what his work can teach us about why encounters become difficult, how trust can gradually emerge, and why some of the patients that physicians initially dread eventually become among the most meaningful to care for. Along the way, we discuss chronic pain, personality disorders, longitudinal relationships in primary care, the role of physician self-awareness, and the difference between caring for patients and trying to control them. This episode asks what it means to remain present with patients whose suffering—and whose behavior—challenge us the most.

Contextualizing Care: From Competency to Curriculum (BONUS Episode)

Over the past several years, contextualizing care has surfaced repeatedly on On Becoming a Healer. In 2025, contextualizing care was incorporated into new Foundational Competencies for Undergraduate Medical Education [https://engage.aamc.org/UME-Competencies-AAMC-ACGME-AACOM]. Around the same time, co-host Saul Weiner worked with the Institute for Healthcare Improvement (IHI) to develop an online course designed to teach these skills, called Contextualizing Care for the Clinician (IHI Open School). [https://www.ihi.org/learn/courses/open-school/catalog/cc-101?utm_source=chatgpt.com] Now that the course has been added to IHI's subscription-based Open School curriculum, making it available to learners at hundreds of subscribing institutions, we thought it would be a good time to revisit several conversations from past episodes that illustrate what contextualizing care is, why it matters, and how we can teach it.

Do Mental Illness Diagnoses Obscure More Than They Reveal?

What if many of the core assumptions of modern psychiatry are wrong? In this episode, we speak with internist and author Dr. Khameer Kidia about his provocative new book, Empire of Madness: Reimagining Western Mental Health Care for Everyone. Kidia argues that mental illnesses are often understood too narrowly through a biomedical lens and that psychiatric diagnoses may function less as explanations for suffering than as labels we apply to it. As he puts it, "generalized anxiety disorder doesn't cause anxiety; rather, anxiety causes generalized anxiety disorder." Drawing on experiences in both Zimbabwe and the United States, Kidia challenges us to reconsider how culture, inequality, migration, social isolation, debt, and political structures shape psychological distress. He discusses evidence that conditions such as schizophrenia present very differently across cultures and explores why outcomes in some lower-income countries may surpass those in wealthier nations despite far less reliance on psychiatric medications. Throughout the conversation, we return to a practical question: How should clinicians care for patients when the roots of suffering often lie beyond the reach of medicine itself? We explore how a deeper understanding of the social and political dimensions of mental health might change the questions physicians ask, the assumptions they bring to clinical encounters, and the ways they connect with patients.

"Dire Consequences": When students do not receive appropriate accommodations on the USMLE examinations

In last month's episode we learned that there is no evidence that time limits that impose any sort of pressure on even a small percentage of students improves test validity and that, in fact, there is ample research showing that they make tests less valid and less equitable. In this episode we discuss how, despite the data, the NBME denies accommodations on the USMLE exams to over half of medical students who have a documented learning disability and are approved for accommodations at their medical school (e.g., extra time). We talk with a leading medical educator who is co-author (along with last month's guest and co-host Saul Weiner), of a paper published last month in the journal Medical Education, titled The myth that slow test-takers are worse students: Implications for time-limited testing [https://urldefense.com/v3/__http:/doi.org/10.1111/medu.70215__;!!NoSwA-eRAg!FH7S4cIGt6W4vn2iiP5DIwYRGZLaz2KDD6-XBgi74GR0dRWPzVrzzOPeUhDCYnBIKhwjq43e_5sze-mSyA$]. The publication is Open Access, so fully accessible to everyone. In this episode, originally aired in 2023, our guest discusses a published national survey she and her colleagues conducted to assess the scope and harmful impact on medical schools and their students of current NBME policy on accommodations. We conclude with a discussion about how the NBME could make the test fair and valid for everyone by functionally eliminating time limits.

Why it's time to remove time limits on tests, like the USMLE exam

There is a widely held misperception that being able to complete a test quickly is an indication of mastery when compared with those who need more time. As a result, it is often difficult to obtain accommodations on high stakes examinations, including the MCAT and USMLE exams. Many students who request extra time because of a disability are denied accommodations and many other students who need it aren't eligible (e.g., English is a second language) or are inhibited from applying (e.g., Veterans, students from certain cultural backgrounds). In this month's issue of the journal Medical Education, titled The myth that slow test-takers are worse students: Implications for time-limited testing [https://urldefense.com/v3/__http:/doi.org/10.1111/medu.70215__;!!NoSwA-eRAg!FH7S4cIGt6W4vn2iiP5DIwYRGZLaz2KDD6-XBgi74GR0dRWPzVrzzOPeUhDCYnBIKhwjq43e_5sze-mSyA$] (open access), the authors review the evidence that time pressuring even a small proportion of students taking an exam makes it less valid and less equitable, and that a simple solution would be to give everyone the time they need. In this episode, originally aired in 2023, we hear from one of the authors about why it's past time to do away with time limited tests for everyone.