"Difficult Patient": What is your definition and ARE YOU ONE?
Graphic: "Difficult Patient" retrieved from Google Images.
posted by Maurice Bernstein, M.D. @ 3:59:00 PM
16 comments
Bioethics Discussion Blog
What have you been reading, hearing or TV viewing that has provoked some feelings of comfort or concern about what is happening in the world of medicine, medical care, treatment or science? Ethics is all about doing the right thing. Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior? Write about them here.. and I will too! ..Maurice (DoktorMo@aol.com)
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Wednesday, June 06, 2012
Graphic: "Difficult Patient" retrieved from Google Images.
About Me
- Name: Maurice Bernstein, M.D.
- Location: Los Angeles, California, United States
Previous Posts
- Do You Want to be Autopsied?
- Patient Modesty: Volume 49
- A Change of the Medical System to Patient-Centered...
- If You Were A Medical Student: How Would You Respond?
- Overcoming the Inevitable in Medicine: Doctors Sim...
- IVF Ethics: Should an Embryo be Rejected Because I...
- Does End-of-Life, Hospice, Comfort Care Represent ...
- Spending A Lot of Money on Your Sick Dog or Cat: I...
- How Much Truth Should the Doctor Tell the Patient ...
- Dying and Donating Your Organs but by Whose Criter...
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16 Comments:
To start off the discussion of what is a "Difficult Patient", I would like to copy my commentary of how I described "The Ideal Patient" on my blog thread of August 3 2004. ..Maurice.
In my posting on July 30th mention was made of an "ideal patient". What do you think is the physician-view of such an ideal patient? Well, as physicians, though we would like to think of caring for an ideal patient, we have to face the reality that this would rarely happen. You see, the ideal patient would be one who, first of all, bears many of the views and goals of the physician. As physicians, we really can't believe that we will be so lucky. Then, physicians generally yearn for illnesses which they can easily diagnose and readily treat to an outcome which is optimal for the patient. That usually means that the patient has real physical symptoms, one acute disease-- not confusing multiple new diseases at the same time and, finally, clear cut physical findings and lab tests. The illness, hopefully, would have standard treatment which is virtually universally satisfactory and the risks of treatment being minimal, if at all. The patient should be alert, in good spirits (not too sick), have confidence in the physician, readily competent to make decisions, thoroughly interested in learning about the illness and its treatment and willing to take time to listen carefully to the explanation by the physician and the options of further diagnostic tests and treatment. And when it comes to treatment, the ideal patient will make the effort to follow the physican's prescription directions and remain fully complient. The patient will also carefully monitor their reaction to the medication and promptly report to the physician any side-effects or complications. The ideal patient will also have the ideal family. Such a family will support the patient but also show confidence in the physician and support the physician.
As I mentioned at the outset of this posting, this all may be just wishful thinking on the part of the physician. It is unlikely that all these features would appear in the one patient. However, if the doctor had repeatedly such ideal patients, caring for them might be a boring experience. The wonderful "goose-bump" experience of a physician suddenly finding that he/she has made an emotional/spiritual connection with a patient would no longer occur. The wonderful challenge of the difficult diagnosis and the emotional uplifting for the physician who has made the diagnosis that was missed by others, even specialists, would be missing. The splendid realization of a cure, finally occuring after a course of many ups and downs, would be a rarity if all cures occurred easily and on schedule. Finally, if the physician had all ideal patients, the challenge of the difficult patient, the difficult family and the challenge of managing the patient and family if the cure doesn't come will be absent.
It is the job of a physician to make the diagnosis when the illness is not easily identified, to make the patient's treatment satisfactory when that isn't easy or simple and finally to meet the criteria and be that ideal doctor to every patient who turns out not to be the ideal patient imagined by the physician. ..Maurice.
Without a doubt the combination drug seeker with
munchausen syndrome clearly is the winner here in
this category. With their obnoxious,persnickety attitude
all the while wasting everyone's precious time.
PT
PT, a very understandable and realistic combination. But does your negative description of that drug seeking/Munchausen patient remove the physician or other caregiver from any responsibility for creating or maintaining a "difficult patient" relationship? Would you say that the professional caregiver is the "victim" of such a relationship and I could breathe a little easier? ..Maurice.
These kinds of patients represent a burden to the health
care system. To answer your questions respectively,no
and as far as these patients go, everyone is a victim
including the patients who have real legitimate health
concerns.
PT
PT, how would you suggest that this potentially "difficult" patient (drug seeking/Munchausen) be handled by the the doctor who is faced with this patient? What is available in the physician's armamentarium to handle this clinical situation beyond simply a "hands off" approach and leading the patient out the front door? A call to social service, church or the police department, would that be helpful? Or to varying degrees of "hands on" starting with sitting down and talking with the patient? Do you think we don't always do that is because of the limitation of time and/or because we already suspect that any resolution of the problem is hopeless? ..Maurice.
For drug seeking behavior: firm boundaries, a pain contract stipulating few (ideally one) prescriber(s), and hopefully a database that allows docs and pharmacies to track rxn's. For the munchausen's, a psych consult (following an appropriate medical work up for the cc, of course).
This post is nearly direct copy of one I posted on an earlier post. Apologies for repeating, but it’s more relevant here:
I’m a patient from Australia, with complex chronic conditions from high doses of radiation for bone cancer as a child. I learned very early to not blindly follow the advice given by the ‘best’ doctors if it did not fit in my paradigm of quality of life. This saved me from hindquarter amputation.
I come across the attitudes voiced by PT all the time. I am not stupid. But I am routinely criticised for my intelligence; my capacity to understand and use medical terminology (or find out), my ability to read peer reviewed articles, my capacity to think critically with depth and breadth. The only way I am given ‘permission’ to have and use these abilities is when I tell them I have an animal science degree. Then I’m ‘allowed’ to be intelligent and use correct terminology. But even the basic stuff that any person can manage is ignored. After 30+ years, I know my veins are hopeless and beg doctors to use pediatric needles to have success. I am ignored. I beg for IV’s to be slowed so the vein will not blow, and I am ignored – again and again and again. And always I am the one that pays, with pain and distress and more invasive procedures.
I am labeled ‘difficult’ and ‘non-compliant’ if I do not blindly follow advice, even though I have MANY instances when being non-compliant has proven to be in my best interests. It is completely illogical for me to NOT question the relevance of treatment and weigh up the outcomes based on my empirical observations. Yet most doctors refuse to accept this basic logic. THAT is illogical. ‘patients rights’ is a lip-service term
I’ve made friends with people in the medical system – surgeons, nurses and other para-medicals. And I have found one core thing: they don’t trust each other, even at peer level. I see that many people within the medical system are, as stated in a prior post ‘control freaks’, and have extremely limited ability to self-reflect and alter their behaviours, even ones that are patently causing problems. They employ the insanity principle – doing the same thing over and over and expecting different results. This behaviour is directly against what a competent scientist should employ.
If I disagree with a healthcare choice I am ‘difficult’. If a protocol chosen by doctors is incorrect I’m told ‘mistakes happen’. This is patently unfair. If I am part of the decision my healthcare management, then if something goes wrong, or doesn’t work, then I must take equal responsibility and we move on, as a team, to something new. If you come from a hierarchical angle, ‘doctor knows best’, then when mistakes happen the patients trust is betrayed and it immediately sets up the potential for retribution, via litigation and further, amplified non-compliance from the patient that has been ‘failed’.
That earlier thread to which MC refers was in the context of changing medical care to "patient-centered care" and can be reviewed with this link. ..Maurice.
MC
I see stupid people all the time,just yesterday
here in my state it was 115 degrees. Some guy wore
a full sleeve jacket to in this heat to the post office,where
he proceeded to box a full array of household goods
in the line. Obstructing everyone with his oddities every
where on the floor.
PT
PT
I see them too. They're often the one's who answer my question: "Why do you think that everyone who is intelligent enough to become a doctor WANTS to become a doctor?" with "Err....*blink blink blink*.."
I'm not fluent in stupid,but consider the voices you think
you keep hearing,might actually
be your own.
PT
I don't hear voices. I do keep reading your comments all over this site and failing to see the point (or sense) in them. I note from other peoples posts that I am not the only one who has this problem with what you write.
'East is East and West is West, and never the twain shall meet'. I'll stick to replying to people who have productive, on-topic, posts.
Hello! Let's have everyone writing to this thread to orient their commentary to "the difficult patient" and NOT the "difficult commentator".
In the discussion of the "difficult patient" can we theorize that it really is a "difficult doctor" which contributes to the development of a "difficult patient"? Or beyond the doctor can we say that a "difficult patient" is really the consequence, looking at the whole picture, of the medical system itself and that the fact that ER doctors have to deal with those "difficult" drug seekers is really due to a "difficult" system. And patient behavior designated as "non-compliant" may be related to defects in the medical system to encourage and maintain compliance. What I am getting at is whether society and medicine puts too much of the responsibility for cooperation on the sick patient. What do you think? ..Maurice.
I believe it is a complex and multi-faceted problem, and perhaps the common denominator is responsibility. I see many patients who won’t take responsibility for their health problems, yet expect doctors to magically fix the problem and make it go away. In the same way, I see doctors who won’t take responsibility for inflexible thinking and arrogant demeanor, and the negative effect that has on patients. There are patients who are rude, aggressive and belligerent, just as there are doctors.
Here in Oz we have sadly developed a culture of entitlement, and this permeates both sides of the doctor-patient equation. Lack of respect for another’s point of view is what follows, and positive communication stalls. And the system, as it is set up, fails both sides. Doctors are overworked, exhausted and frustrated, and patients are frustrated, powerless and are treated as disease entities to be cured, rather than people as a whole. This is goes back to the unacceptable workload that doctors must endure, but removing power from patients does not help to gain respect, or compliance long-term.
I have no idea what the solution is. Questioning that is what led me here. But I think one thing that could change is word choice. Compliance/non-compliance are terms that are unhelpful, and simply serve to reinforce the ‘us against them’ mentality from both sides.
Why isn't tee any talk about "difficult doctors"? There must be plenty of them about.
Beside Im convinced there are patients that are labeled "difficult" for not accepting experimental or controversial treatments, taking large doses or several medications at once, or refusing hospitalizations or surgery in environments that they find unethical or that afford zero privacy or cleanliness.
To read about the patients' views of "difficult doctors" you should go to the thread "I Hate Doctors: Chapter 3". Anonymous posted to that thread today a commentary that would be more appropriate on this "difficult patient" discussion. The following is what was posted. ..Maurice.
I quit reading all of these comments after a while. I actually ended up here because I googled "I hate working for physician's"....and some of the time, that is true. Some of them are so high up on themselves that in their 10 years of education, they didn't even grasp the basics of common courtesy or respect.
Regardless, I work in an office with about 15 doctors. I would say of the 15, probably 12 of them leave me alone to do my job. The other 3 make me want to quit.
I am overworked, underpaid, and no human on this planet can possibly keep up with the amount of work we have to do. After reading these comments though and thinking about a typical day at work, I realize it is the patients I hate the most.
If I am working in the walk-in clinic, I check in at least 10 patients in an 8 hour period that want to see the doctor because "their throat is sore". Nevermind that there are 20 other people in the waiting room with actual problems, yet Mr. Sore Throat is going to be the one coming up to me every 5 minutes asking me how much longer he has to wait, complaining how unfair the healthcare system is, blah blah blah. You still have to wait over an hour, just like you did five minutes ago. Yes, I agree it is rediculous to wait 2 hours to see a doctor for a sore throat, I also think it's rediculous to even go to your doctors because you have a sore throat. You don't need antibiotics, even if you have strep. You need to gurgle some aspirin for a few days until it goes away. If you're going to wait for 2 hours to see the doctor, I think you need a life, and yes I am rude to you because I have piles and piles of work to do, and you keep interrupting me with your complaints! I used to think the doctor couldn't possibly be as stressed as I am, because I have so much work to do and all he does is get his little clipboard and talk to the patient for 5 minutes, but I figure he probably is pretty close to as stressed as I am, because his JOB is to listen to people COMPLAIN. Complain about their illness, complain about their injury, complain about their healthcare system. I am allowed to tell the patient to save it for the doctor, and by the time the patient gets in to see him/her, they have that much more to complain about - I was rude to them, they had to wait too long, wah wah wah.
Nevermind that I live in ONTARIO, where healthcare is paid for out of our taxes. Now patients complain incessantly how the government plans to cut billions of dollars out of our healthcare. Well I don't blame them. I bill OHIP after every patient visit, and every time you come to the clinic for your "sore throat" it costs the government at least $50.00 for your 5 minute visit. If an 8 hour period, if I check in 10 people with sore throats, you just cost the government $500.00 PER DAY.
Worst of all is answering the phones and listening to you bitch about how you called three times before someone picked up. That's because I'm busy listening to the person in front of me bitching about how they have been waiting for 2 hours and their throat hurts and no one cares wah wah wah. Then to complain about how we are rude to you or incompetent. Doctors are not miracle workers, they are people with a very expensive education. And just like any education, some of them probably barely made it through, and some of them probably worked really hard. Regardless, they are JUST people. Patients need to acknowledge that, and so do some of the doctors. I could careless about their credentials, and I would trust Google just as much as I would trust any regular old GP.
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