'Sick people' and 'trolls': a contribution to the understanding of the dynamics of physician explanatory models.

This paper describes and interprets a case in which the mutual influences of countertransference and physician explanatory model (EM) are identified, as are their roles in negotiating the clinical relationship and in clinical decision-making (assessment, diagnosis, treatment, expectations of outcome). The author argues that physicians' EMs do not derive exclusively from the official and professionally ideal biomedical model, but are shaped by situational, historical, and subjective influences. Patient-typing (e.g., the widespread distinction between "sick people" and "trolls"), together with its associated emotions (e.g., empathy and disdain, respectively), pervades medical education and practice, and often supersedes the biomedical model. Physicians' subjective responses to patients can affect biomedical diagnosis. Failed empathy can lead to missed diagnosis. Finally, the case study illustrates the validity and vitality of the ethnographic approach in clinical teaching and supervision, both in eliciting physicians' own complex EMs, and in facilitating the process of reinterpretation as well.