* * Anonymous Doc

Saturday, February 12, 2011

"I have a sinus infection."

"How do you know it's a sinus infection?"

"I feel it from my head and all the way out when I urinate."

"What? What do you feel?"

"The sinuses. They're coming out when I urinate."

"That's really not how a sinus infection works. You want me to take a minute to explain what a sinus infection is?"

"No. I just want a decongester."

"A decongestant?"


"I'm going to need to examine you first."

"Sure. I brought a urine sample from home."


I saw the string of comments on my post from earlier in the week about the patient who wanted a second opinion-- and wouldn't even tell me what was wrong with him-- and I actually felt like commenter WarmSocks got a pretty rough ride in there, maybe more than he or she deserved. I think WarmSocks is absolutely right that I didn't help the patient very much-- and at the end of the day, that's a failure on my part, absolutely. I don't know that sitting down and trying to explain what a second opinion entails would have made a difference-- I suspect it wouldn't have made any difference at all, and he still would have refused to help me figure out his problem and I wouldn't have gotten any further than I did-- but I'm pretty sure I didn't try hard enough to see if there was any hope of getting anything from the guy.

Fact is, it's really easy to lose patience when someone doesn't seem like they want to be helped. Especially at the end of a long day, but even at the beginning of a long day. There's only so much we can do. I'd say at least 50% of the patients I see admit, on any sort of questioning, that they're either not taking their prescribed medication, or they're not taking it correctly. Some of it is surely the fault of whoever prescribed the medication in the first place, by either not explaining the instructions or not making sure the patient has a plan to even get the prescription. But some of it has to fall on the patient. And if someone isn't going to help themselves, it's hard to get all that motivated to spend an hour-- delaying everyone else-- while you try to see if there's anything beneath what seems like craziness on the surface.

Part of the problem with the clinics we have in residency-- and this isn't the fault of the residency program, or anyone's fault, it's just a fact of the schedule-- is so many of our patients are one-offs. They see a different doctor each time they show up, we all have to start from the beginning, get their whole story, they're telling the same story every time they go to the doctor and there's no continuity of care, no one who knows them, no one who knows how they express themselves, what's really going on, etc.

They try for continuity when they can-- we encourage our patients to ask for us when they make an appointment and try to arrange their schedules to see us, if they can. But we're in clinic one, maybe two half-days a week-- some months more than that, and some months never in clinic at all-- so unless the patient happens to have a flexible schedule, non-urgent needs, and actually cares to see the same doctor again (many of them don't bother to try, either because they don't think it makes a difference, or didn't particularly care for the first doctor they saw), it doesn't happen. Maybe one in six patients I see are repeats. And the repeats, without a doubt, end up with better care. There's a difference between reading the notes in the chart and actually remembering that I saw this person, I talked to him, I know what his baseline is, and so I know if this new problem is actually a new problem, or it's not a problem at all.

"I buy my mother sugar-free everything," says the daughter of my 95-year-old patient, proudly.

"She needs the calories," I tell her. "The sugar-free stuff isn't necessary-- and is actually bad for her. The more calories the better. She should be drinking milkshakes."

"But I don't want her to get diabetes."

"She's 95. Diabetes isn't a problem we're worried about. Getting the calories is far more important."

"But I have diabetes, so I think it runs in the family."

"Your mother doesn't have diabetes. She needs the calories to keep up her strength.

"But I don't want her to get fat."

"She's 82 pounds. Please feed her more calories. That is priority number one."

"Except nothing too fattening, right?"

"Everything fattening."

"For me too?"

"No. For your mother."

"But why should she get to eat all the good stuff that I can't?"

"Because she's 95 and weighs nothing."

"How about sugar-free pudding?"

"Okay, let me start again..."


It's really hard to have these conversations with every patient. So I do lose patience. I try not to, but I do. We have residents who yell at patients. There are residents who've told patients specifically to request a different doctor next time. It's frustrating. It's hard. It's our job, and we get better at it over time, but it's still hard. Because it's not about the medicine-- in a lot of ways the medicine is easy. It's about communicating on their level, in ways they will understand. And that's not something they teach us.


  1. Hell, if they tried to teach you how to communicate, they'd probably just tack on an extra few useless months to med school where a socially inept professor explains it all theoretically by powerpoint. And you'd be right back where you started.

    Some things are better learned in the real world :)

  2. They try to teach it in some clinical medicine courses, but it ends up being condescending. Realizing how uneducated many people are about medications, their bodies, and the medical system is something one must experience, and then empathize with if there's any hope of taking the time to educate them.

    Patients may not be taking meds for a whole slew of reasons - cost, inability to get to the drug store, lack of understanding about their asymptomatic disease, more worried about feeding their kids than taking pills, etc etc. The system we're set up in that doesn't encourage continuity and real, long term doctor-patient relationships hurts people's health.

    I'm still holding onto some hope about the power of preventative medicine that you've seemed to lose in the past year and a half, AnonDoc. But then, I shouldn't be as jaded as you... not just yet.

  3. Med school could just make students read the top ten patient dialogues on this blog, including the lady who doesn't have diabetes video. That would be instructive.

    If WarmSocks hangs around the blog, he should see that you have really good communication skills at times too... hard to keep from offering advice anyway.

    You get so much chance to practice a different approach with each patient, it seems like you should automatically get very good at it. Maybe a few directed practice tools like goal statements and focusing on specific parts of the interaction could help too.

  4. But Noumenon, Didn't you know? Blogs are the epitome of unprofessionalism. And we can't be encouraging that, right?

  5. I think we have to start requiring a higher level of health education in school and it should be all 4 years of High School. Because people just do not know how their sh*t works.

    These conversations make waterboarding look like fun. I've had similar dynamics in my area of expertise. It's annoying. Hopeless. Waste of time. No one ever learns.

    But as a patient, I seem to experience a lot of role reversal where I'm trying to get the doctors up to speed and they are fighting me tooth and nail. It's very weird.

    No one wins.