What’s up, doc?
Does your doctor think you’re a jerk? It may affect your health
WAS that a grin-and-bear-it expression your doctor flashed when greeting you?
In what may be a well-kept professional secret, physicians dread encounters with about 15% of their patients.
In 1978, the New England Journal of Medicine published what has become a classic on the subject: “Taking Care of the Hateful Patient”.
“Admitted or not,” wrote the author, psychiatrist James Groves, “the fact remains that a few patients kindle aversion, fear, despair or even downright malice in their doctors.”
For physicians, these suck-thelife-out-of-you patients are needy, demanding and forever unhappy with their care.
“When one of their symptoms is relieved, another mysteriously appears in its place,” Groves writes about one variation of what British physicians call “heartsink patients”.
“Low-level torture (death by a million little cuts),” write the authors of “Managing Difficult Interactions with Patients in Neurology Practices”.
They may order the doctor to perform diagnostic tests, prescribe medications, or make referrals, none of which are medically necessary, they say. The attitude: “I bought you. It is my right.”
Take it down a notch to everyday thoughtlessness. One internist asking for confidentiality described a patient who called her office emergency line at 2.52am. She returned the call immediately, only to find he needed routine prescriptions. The kicker? His pharmacy didn’t open until 9am.
Doctors may pay the price for a disgruntled patient whether it is deserved or not. A patient can destroy a doctor’s reputation with bad reviews of the practice across the web. Another physician regretfully declined an interview for this article on the advice of lawyers; one of his patients is suing him now.
“It takes extra effort,” says Jeffrey Jackson, an internist and professor of medicine at the Medical College of Wisconsin, to deal with difficult patients. “I sit at my desk and gather my thoughts before I call them in.”
His research, however, shows that physicians practising longer found fewer patients difficult because they had developed better interpersonal skills. But that still leaves patients with personality or somatic (feeling extreme anxiety about physical symptoms) disorders who defy any behavioural strategy, he says.
Engaged patients typically have the best outcomes but not when the doctor has to take slow, deep breaths before seeing them.
Doctors try to put personal feelings aside but it’s hard to do when they feel overwhelmed or victimised, says Isabel Schuermeyer, a psychiatrist at Cleveland Clinic.
“As the physician’s exhaustion increases with each request, the care and well-being of the patient may no longer be the primary focus,” she writes.
Two companion studies in BMJ Quality and Safety came to the same conclusion. Disruptive patient behaviour led to errors when residents and medical trainees in the Netherlands were asked to diagnose symptoms after reading vignettes.
Half of the vignettes contained neutral symptom descriptions and the rest included the same symptoms plus details about the patient behaving badly – yelling about the waiting time, for instance, or questioning the doctor’s competence.
The doctors misdiagnosed the difficult patient from 6% more for simple symptoms to 42% more in complex cases.
Authors of the second study attributed the errors to “resource depletion”. Instead of devoting full attention to analysing symptoms, their mental energy was diverted by the challenging behaviour.
The doctors were more likely to recall patients’ poor conduct than the clinical particulars when asked about the cases later. The effect of disruptive behaviour would be much greater during an actual exam, the researchers say.
So how much can you challenge a physician without risking substandard care or becoming the hateful patient of medical journals?
“Patients should err on the side of being assertive. They are not there to please the physician,” says Joy Lee, assistant professor at Indiana University School of Medicine and researcher at Regenstrief Institute.
But Lee, who has studied what makes some patients “favourites”, notes that being respectful and understanding a doctor’s limits will get your calls returned quicker.
The meek do not win in health care, echoes San Francisco clinical psychologist Tamara McClintock Greenberg. At the same time, “it can be hard to know how much to push back when we don’t feel like we’re getting the care we need”, she writes in her book, When Someone You Love Has a Chronic Illness.
This tends to matter most in the primary care setting where doctors are in shorter supply and can terminate difficult patients or refer them to another physician.
Greenberg tells patients to “adapt to the culture of medicine”. That means treating your appointment like a business meeting where the physician is the authority.
“Bring a list of no more than three items,” she recommends. “Tell the doctor: ‘We have only 15 minutes but if we can cover this, it would mean a lot to me’.”
The trick is to be a squeaky wheel but not require too much grease.
If you bring in information from a Google search to discuss, don’t make the physician feel devalued or second-guessed, Schuermeyer says.
“Ask the physician, ‘What do you think about this source?’”
Insisting on tests against the doctor’s judgement can backfire, too, she adds. Incidental findings from unnecessary procedures can lead to a cascade of potentially injurious and costly tests. |