Patients request health care for reasons that transcend the management of medical disease. Patients seek to create an "alliance" with the physician which "compensates" for conflict or deficit in the family system. This is particularly true for "problem," "difficult," or "hateful" patients who have significant psychosocial problems. When such a compensatory alliance evolves, it may become dysfunctional, limiting the physician's ability to make necessary medical interventions. By not explicitly including other family members, the traditional dyadic model of the doctor-patient relationship predisposes towards the formation of a compensatory alliance. The nature of the dysfunctional compensatory alliance may even remain obscure because the patient presents a distorted picture of the family situation. Therefore, to manage the compensatory alliance, the physician must perform a simple family assessment, including direct communication with other family members, early in the formation of the doctor-patient relationship. The physician should be alert to the formation of a dysfunctional compensatory alliance and the need to perform a family assessment whenever a patient explicitly or implicitly makes a request that engages the doctor with another family member. Recognition that a patient is "difficult" or awareness of a sense of helplessness, and frustration in caring for a patient may also indicate formation of a dysfunctional compensatory alliance and the need for family assessment. Recognizing key aspects of the doctor-patient-family relationship will enable the clinician to manage the compensatory alliance in a productive and therapeutic fashion. When family dysfunction requiring significant change is discovered, involvement of a family therapist should be offered.