Recent debates regarding clinical transactions oppose a macro-level approach which emphasizes political, economic and institutional forces, and those analysts who consider patient perceptions regarding illness to be major influences on the outcome of clinical encounters. This paper utilizes both approaches to illuminate the interactions between medical personnel and 'problem patients'. The macro-level approach draws attention to the way power is negotiated and expressed in clinical interactions, and to medicalization that gives priority to medical values and condemns patients who do not act in accord with these values. The patient belief approach explores one of the major weapons in the struggle for control, the disease model of illness. Use of both approaches permits a better understanding of clinical medicine in these problematic interactions.