"I Am Right" -- Dealing With Difficult Patients

I AM RIGHT:

DEALING WITH DIFFICULT PATIENTS
*          *          *

A LECTURE FOR RESIDENTS AND FELLOWS

BY AN ATTENDING WHO NEEDS A SMACK IN THE HEAD

*          *          *

I am right.  See, before you’ve even asked me a question, I’m already telling you I know the answer.  Say it with me.  I am right.  Make it your mantra.  You can’t be afraid.  All we have is our authority, and as soon as we start letting any doubt creep into our patients’ minds, we’ve lost our power completely.  This is what separates us from WebMD.  This is what keeps us in business.  This is what their insurance companies are paying for.  Confidence.  Decisiveness.  Answers.  I am right.  I am always right.  I am right, I am busy, and I don’t have time for you.

That last bit is especially important.  Patients are expecting more and more from us.  24-hour access.  Calls back when they leave a message.  An answering service that actually answers.  E-mails.  Web chats.  Doctors on demand.  They’re starting to forget how the system has always worked, and who holds all the cards in the doctor-patient relationship.

Be upfront.  “I don’t have time to hold your hand and walk you through it.”  Leave them wanting more.  It's an old theater trick.  Whether they’re asking about their prognosis, or they’re asking where the bathroom is.  You are the one with the information.  You are the one with the power.  Yield it only when you have to, and tell them only enough to get them to the door.  You tell them too much, and they get greedy and want more.  And pretty soon you’re spending your whole day explaining the pros and cons of eight different kinds of birth control when really you should just be sterilizing any patient who dares even ask you a question.

They want second opinions, let them try.  But don’t make it easy.  “You can look for other answers, but you’ll only be wasting your time.  There are people out there who will tell you anything.  There are always going to be people who will prey on your vulnerability and give you the answer you want to hear.  They’ll drag you down a path of false hope and wishful thinking, dead ends in the maze of life, until you finally get back to the very same place you’re sitting right now.  And we’re just talking about directions to the bathroom, which, as I’ve already said three times, is only for doctors and hospital staff, and we really can’t have you using it.”

People have forgotten that we’re the ones who went to medical school.  Ten years ago, would anyone even think of bringing in a printout of a medical study and asking us to look at it?  Not a chance.  They would accept whatever disease we’ve told them they have, and learned to deal with the consequences.  If your doctor didn’t know something, that piece of information simply didn’t exist for you.  We can’t know about every new protocol, every new treatment, every new cure.  But the way to learn is not from people handing us pieces of the Internet.  It’s from drug reps or the natural course of information-sharing.  They can’t expect to have every chance to survive.  They’re lucky we give them a fraction of the medicine that’s out there.  And we can’t let them forget that.

Don’t admit mistakes.  Blame the patient.  Pretend you have to leave.  Create a distraction.  Hide the ball.  Instead of dwelling on the cancer, and how you should have seen it on the previous scan except you never even looked at it before it went into the file, berate the patient for having the nerve to keep you waiting.  “Why people like you don’t go to the bathroom before you come see me will never make any sense.  I kept you in the waiting room for an hour and a half.  Surely at some point, it could have crossed your mind that you’d be better off going to the bathroom now than waiting until I’m ready to see you.  But, no, let’s waste my valuable time—and the less valuable time of everyone else still sitting in the waiting room.  I know, it’s too late for this visit, but maybe you’ll remember next time.  If there is a next time.  The cancer’s inoperable, and I don’t know how much longer you’ll live.  So this may be the only time I see you.  Thus my last time to teach you this lesson.

“Although I’ll try to squeeze in another appointment, since your insurance has an unusually high reimbursement rate.”