When the patient not only has a pain, but is a pain Posted on September 4th
My patient and her older sister greeted me with profuse gratitude when I brought them into the examining room at the Wills Eye emergency room at Thomas Jefferson University. “We need your help,” the sister said. “We’re so worried.”
The patient was a teenager who had lost vision in one eye. She had been seen at another eye center and diagnosed with optic neuritis, an inflammation of the optic nerve that can be associated with multiple sclerosis. They wanted a second opinion.
Second opinions are often challenging because they involve complicated cases, or the patients themselves can be inherently difficult.
This patient’s story had already raised eyebrows. The two had just gotten off a plane from the other center, had no records with them and no name of their prior doctor, and were going to California the next day.
Once I started taking a look, her sister asked me for my opinion. “Will she see again? Do we need another MRI?”
I told her I needed to finish the exam and would then be able to assess the need for more tests.
A few minutes later, another flurry of questions came, and I tried to answer. Then more. At that point, I tried to tune out her questions and finish the exam quickly.
“You’re not listening to me,” she said.
“I’m sorry,” I said. “I can’t tell what’s wrong with your sister until I finish my exam. Please give me a moment here.”
That much set her off. “You are a terrible doctor. You don’t even care. You’re ignoring me and you haven’t answered any of my questions.”
“Ma’am, I’m sorry. . . . ” I began to escalate. “Your sister has a serious problem and. . . . ”
“You’re the worst. I want another doctor right now.”
“But . . .”
At that point, the director of our emergency room, Michael DellaVecchia, came in. One of our nurses, Sheila Starr, had summoned him from his office in the back and told him of the ensuing melee.
Eventually our white-haired director calmed them down.
I walked out and felt like crying. Sheila followed me into the back break room and comforted me. But then she gave me the bottom line, which she had come to realize after 36 years in the trenches.
“You stand up for yourself and don’t let them walk all over you. When a patient is being unreasonable, you let them know.”
And right then, my world turned upside down. Just as in business, where the customer is always right, I had always thought that in medicine, the patient can do no wrong. But what happens when the patient is being too difficult? When the patient is so disrespectful it impedes your ability to help him?
Some people need tough love. “You lay down the ground rules and tell them, ‘You can accept them or go,’ ” DellaVecchia tells me. In other cases, he’ll try a softer approach: “I’ll take the first step in extending the olive branch and say something like ‘I understand you are frustrated. . . . ‘ ”
But ultimately, he says, there is no cookbook method: It boils down to how you were raised to interact with people and the life experiences you’ve had since.
As director of our emergency room, he sees patients criticizing female doctors more often than males. Perhaps insulting women is easier and less physically intimidating than starting up with men.
Patients who insult doctors are not an uncommon occurrence during residency, when we are in training and look younger than our salt-and-pepper-haired counterparts.
One night in our emergency room I was taking care of a patient who had gotten a severe eye injury from an animal that kicked her to the ground.
She asked to see the surgeon but I needed to see her first. No, she told me, I want to see him now. I apologized but told her that this was protocol - the surgeon gets notified once the problem is deemed surgical by me.
“A horse would get better treatment than this,” she said.
Right then, Sheila’s voice echoed in my head: “Stand up for yourself!” I told the patient that I could see how she might be frustrated but that I needed to examine her first.
I firmly told her: “I want to help you but if you cannot treat me with respect, I will not be able to help you.”
She became quiet and then let me examine her. I ended up calling in the surgeon after all. After the treatment plan fell into place, she apologized and thanked me. I told her not to worry. I was glad we could take care of her.
Contact Rachel K. Sobel at rachelkimsobel@gmail.com.