Twenty Things To Say To Your Doctor If You Want To Be A Difficult Patient

1. "Oh, my appointment was yesterday?"

2. "Did you get the paperwork I faxed to my other doctor?"

3. "Your nurse didn't say I should remove all my clothes before you came in?"

4. "You don't mind if I eat in here, do you?  It's just a tuna sandwich, some chips, and a melting popsicle...."

5. "Yes, I'm taking all of my medications, except one of them.  But I'm not sure which one."

6. "I need a refill on my blue pill.  The smaller one.  And, really, I needed it three weeks ago."

7. "Of course I had recent blood work.  I think."

8. "My friend told me not to have any x-rays because of the risk of radiation exposure.  Can you do one without radiation?"

9. "Wait, when I told you I had the flu shot, I didn't mean I had it *this* year!"

10. "I just realized-- that rash you just touched-- it's from the bedbugs!"

11. "Six.  That question you asked at my last appointment... the answer is six.  Maybe six and a half."

12. "Thanks for all of that information, doc.  But I forgot to put my hearing aid in, so if you wouldn't mind starting all the way back at the beginning."

13. "Nope, that's it.  Except for this scab I picked off my body and wrapped in a napkin to show you."

14. "Oh, before I go, can I just ask one quick question about the worst headache I've ever felt in my life followed by left side weakness, a fever of 106, and a bloody discharge from all of my orifices that I didn't think to mention?"

15. "You could do me a favor and not report this visit to my insurance company, right?  I don't think it's covered, and I'm not going to be able to pay the bill."

16. "I know it's *my* appointment, but my wife has something near her rectum that she wanted to show you, if that's okay."

17. "Can you call my children and let them know how the appointment went?  Here are all eight of their phone numbers."

18. "You didn't get those e-mails I've been sending you?  I must have your address wrong-- give it to me again-- I'd hate for you to have missed all of those important political writings I passed along."

19. "I was hoping you could give me your personal cell phone number so I can call you whenever I sneeze."

20. "Sure, we could schedule another appointment-- but I should mention that I'm moving to a different state next week, so this entire appointment, and all of the follow-up we talked about, has been completely pointless."

Thanks for reading, and Happy New Year.

"I Thought You Were Going To Take Me To Bed"

Lovely elderly female patient who speaks not a ton of English.  She comes to the clinic with a cough, nothing too serious.  Uneventful visit.  I prescribe a couple of meds, send her on her way.

As she's leaving, from the lobby of the clinic, she yells to me down the hall:

"Goodbye, doctor.  I thought you were going to take me to bed!"

Everyone turns and looks.  Patients, my colleagues, everyone.  I walk down the hall, confused, to ask what she meant to say...

"I thought you were going to take me to hospital bed!"

"Oh.  Oh, yes.  No, you don't need the hospital."

"Yes, great.  Thank you so much.  See you next time."

She leaves.  Colleagues are being slow to move on from this one.

Limbo

The latest chapter of "there's something awfully wrong with our health care system."  I have a patient who's been ready for discharge for a couple of weeks... but is still in the hospital because there's nowhere for him to go.  He can't be discharged home -- he needs a nursing home.  His wife refuses to have him sent to a nursing home, because she doesn't want to pay for it.  They have too much money for Medicaid, but not enough to afford nursing home care.  The nursing homes don't want to take him without guarantee of payment, since he's not on Medicaid.  So we're stuck holding onto him -- we can't discharge without a safe place to discharge him to.

The usual reaction in cases like this (and this isn't the only time it's come up) is to say that the wife is the problem and she's preventing someone who actually needs the hospital bed from getting care... and that's completely true, except I also understand where she's coming from.  Her husband isn't really her husband anymore.  He has no quality of life, he's non-verbal, may or may not know who he is, or where he is, or what's going on.  But he may linger for months or years, and it'll bankrupt her, and destroy whatever they might have been saving with the hope of a decent retirement.  And then if she ends up with medical costs down the line... perhaps in a situation where she could have some quality of life remaining... the money isn't there.

Of course there are all sorts of problems and inefficiencies with government-run health care.  But there are all sorts of problems and inefficiencies with a hospital ending up in a standoff with an elderly woman, losing her husband, who doesn't also want to lose her financial footing in the process, for no good ends-- her husband will never regain function, he will never be himself again.

"Is your wife home? No, really, because we don't know where she is."

There was a new patient on my list.

I had never met this patient.

I have still never met this patient, because this patient was not in her room.

Her room was empty.

I was confused.

No one knew who this patient was.

No one had met this patient.

And yet she was on my list.

Did we lose her?

Did she leave?

Was she discharged?

Although, if she was discharged, why wasn't there a discharge note?

Cautiously-- somehow thinking I could try to find out if her family knew where she was without revealing that we had no idea-- I picked up the phone and called the number in the chart.

"Hello, I'm calling from [Hospital] about [Patient]."

"Yes, I'm her husband."

"Yes, uh, I'm one of the doctors on your wife's service, and I just wanted to check in and see how things are going..."

"Oh, yes, thanks so much for calling.  Things are going well."

"Great.  So your wife is... doing okay...?"

"Yes.  She seems to be."

[At this point, I'm trying to figure out how I can ascertain whether she is in fact at home with him, or he thinks she is here with us, because both still seemed like reasonable possibilities.]

"Uh, did you have a chance to meet any of the doctors taking care of her?"

"I did, yesterday."

[Okay...]

"Great.  And, uh, for the holidays..."

[Please finish my sentence, Mr. Patient Husband, because I don't know where it's going.  Please please please--]

"..."

[Oh no, I have to keep talking...]

"...if you need to reach anyone here, I can give you a number..."

"Oh, that would be great."

"Great."

"And the next time you'll be here..."

[I was really proud of myself for coming up with that line, because I figured it has to lead me somewhere, right?]

"Oh, she has a follow-up next Wednesday."

[Yes!]

"Oh, great.  So you're with her now..."

"Yes, she's in the living room, resting."

[Yay!]

"So her discharge went smoothly..."

"Yes, thank you.  Thanks so much for calling.  It's great to know that someone is following up and checking in."

"Yes, well, we try.  Have a great holiday."

"Thanks, you too."

Yes, another sterling bit of customer service over here, as we try to make sure we didn't accidentally misplace a patient!  Happy holidays!

"Sorry, doc, getting to the hospital is too much of a hassle."

I get paged in the middle of the night by a patient's wife, someone I've seen in clinic for a while now and have gotten to know.  "My husband had 102 fever, I gave him Tylenol and it's down to 99, but I wanted to know what to do."

"You need to bring him to the ER.  He has multiple sources of possible infection, and there's no reason to risk waiting past the holiday weekend for him to get in to see a doctor on the outpatient side."

"But it's such a hassle to get to the ER."

"I know.  But he needs to get a urine sample and a blood draw, at the very least.  It's possible he can just get a prescription for antibiotics and be sent home -- I'm not saying he's going to be admitted -- but he needs to see someone."

"Maybe the fever was a fluke?"

"You don't spike a fever for nothing.  Something's going on, and the safest thing to do is not to wait until there's a bigger problem, but to get this worked up and see what's going on."

"Can't you prescribe an antibiotic over the phone?"

"I can't.  We need to run tests and see what's going on."

"How about if we wait to see if the fever comes back?"

"I don't know what you think you'd be waiting for.  He had a fever.  Tylenol is not a cure, it's just a mask.  I'm not saying something serious is going on here, but you called me, so this is what I'm telling you to do."

"What if we wait until the fever hits 101 again?"

"I'm not sure what you want me to tell you.  You're looking for permission not to take him to see a doctor, and I'm not comfortable giving you that permission.  Is waiting going to make a difference?  I don't know that the answer is yes, but I don't know that the answer is no."

"You're not very helpful."

"I'm telling you to take him to the ER."

"He can't walk well enough to get into the car."

"I know.  And I know it's a hassle.  It doesn't have to be our ER, if that's not possible.  You can call a private ambulette to take him here, or you can call 911.  We can send his records wherever he ends up.  I'm not trying to make this difficult for you, I'm just telling you that he should be seen before the end of the holiday weekend."

"How about tomorrow?"

"I don't know why tomorrow is different from today, but I'm just his doctor, I'm not going to force you to do anything."

"Okay."

"Okay what?"

"Okay, if you're not going to force me to do anything, we're going to wait until the fever comes back."

"As long as you realize you're taking some amount of risk this becomes more serious."

"You're not helping."

"I'm trying my best."

You know, there's a tremendous health education problem in this country, and probably everywhere.  I feel like people think that if something is really an emergency, a doctor is going to force them to do something.  That they're not going to be allowed to refuse tests or refuse treatment.  That if a medication is really important, they won't just give you a pill, but they'll inject something into you against your will.  That if you're really in danger, you will be dragged, kicking and screaming, into an MRI machine, into a hospital bed, into an ambulance, wherever.  That nothing is serious unless you are physically being detained.  That we are magicians, we can see the future, we know everything that's going to happen, when it's going to happen, and how to avoid it -- and that we can hold off terribleness as long as you can come up with a good excuse for why it shouldn't happen.

"He can't have pneumonia, there's a snowstorm, and we can't get to the hospital today!"  "Oh, why didn't you say so?  We'll forget the pneumonia and hold off until Tuesday, when the streets are clear."  "I can't take my pills, because I dropped them down the sink!"  "Oh, you dropped them down the sink?  Then I'll snap my fingers and cure your infection on my own.  And, I'll magically make your insurance company send you new pills without you even having to call them."  "The fever's a fluke.  I don't want to go to the emergency room."  "Okay, well, as long as it's a fluke."

Guess what?  You're in charge of your own health.  You want to call a doctor and ask what you should do?  Great.  But if you're not going to listen, why are you calling?  Are you just trying to see how much the doctor is going to insist, and then decide, based on tone of voice, whether to take the advice seriously or not?  Your health-- surprise-- needs to matter a lot more to you than it matters to your doctor.  Because even if your doctor cares, your doctor doesn't care enough to chase you down and force you to be smart about your choices.

Your doctor is going to feel sad, and maybe even guilty, if something happens to you that could have been avoided -- but sad and guilty are a lot less serious than dead.  Your doctor can be really sad and really guilty, but you are still going to be the one to suffer the consequences.  You are still going to be the sick one, the sicker one, or the dead one.  Not your doctor.

There is only so long someone will stay on the phone with you and explain why you should do what he just told you to do.  And a lot of times, that amount of time is zero seconds, because it is more important to deal with the people who actually want your help than the people who are pretending to want your help, or think they want your help but actually have no interest in your help, no matter how many different ways you try to say the same thing.

If you are not going to go to the hospital, under any circumstances, don't ask whether you should go to the hospital.  Ask something else.  And ask someone else.  Ask your plumber what he thinks you should do, because he might have a different answer.  My answer, apparently, doesn't really matter.

Blood In The Urine

"Oh, before we finish up, I also wanted to mention... I've been having more blood in my urine recently."

"More?  What do you mean?  You had blood in your urine before?"

"Sure, always."

"What?"

"I've always had some blood in my urine.  It's just how I am."

"That's not normal."

"Well, for me it is.  Except the last few weeks there's been more of it."

"How much blood are we talking about?"

"Oh, a fair bit.  Like, it colors the whole toilet.  Funny thing is, it only happens when I urinate sitting down."

"Hold on, explain to me what you're trying to say."

"When I sit down to urinate, there's a lot of blood.  Also, it must splash back up on me, because I can usually see it when I wipe."

"I'm trying to wrap my head around what you're telling me.  Is it at all possible that what you're noticing isn't from your urine at all, but it's bleeding hemorrhoids?"

"And those would be where?"

"Your anus."

"Wait, so you think this may all be connected to the burning I feel when I move my bowels?"

"Uh, just from what you're saying, I think it might be."

"Oh, wow, doc -- you're a genius!  All this time, I thought I had blood in my urine, but I think you may be right -- I think I'm actually bleeding out of my anus.  Whodathunkit?  Wow, my wife is never going to believe this."

"Maybe we should take a look just to be sure I'm on the right track."

"No, no, what you're saying makes total sense.  I have to rush -- I have another appointment -- but this is great -- so I can just use some of that over the counter stuff -- the Head and Shoulders?"

"Uh, not Head and Shoulders.  I want you to follow up with a specialist just to be sure -- I can give you a referral."

"A neurologist, right?"

"No."

"Are you saying she needs hospice?!" ("No!")

I have an elderly patient in for a routine visit to the outpatient clinic, and find she has a fever and signs of infection.  I give her daughter a call.

"Hi, I'm calling about your mother.  It seems she may have an infection."

"Are you saying she needs hospice?!"

"No, I didn't say anything about hospice.  I'm saying she may have an infection, and I'd like to admit her to the hospital."

"I hear great things about hospice."

"Again, I didn't say anything about hospice.  Let's try to clear up this infection and see how she does.  There's no reason to be talking about anything beyond what will hopefully be just a few days in the hospital."

"You know she's DNR, right?"

"I do.  It's in her chart, and very well-documented."

"But you still want to treat her for this?"

"Well, I do think we should try treating her with antibiotics to solve this acute problem.  I don't think this is necessarily going to lead to something worse.  Anything can of course happen at her age and in her general condition, but I think we should see if we can clear up this problem and she can return to her baseline-- which is pretty good, considering."

"I was told the DNR meant that she wouldn't be treated."

"It means she won't be intubated, or resuscitated if her heart stops, but her heart is still beating.  She's in good spirits, she just wanted me to call you and give you the update."

"I don't want any heroic measures taken."

"We're just going to admit her and give her some medication."

"So no hospice?  Just hospital?"

"One more time, I have not said anything about hospice.  You're the one who keeps mentioning hospice."

"I just hear great things."

"Your mother will hopefully recover just fine."

"Be sure to give me a call as soon as you start thinking about hospice."

"I'll tell your mother I gave you the update.  Bye."

"I'm afraid..."

"So, I have to tell you, you are in really good shape for a hundred years old.  I don't see a lot of patients in the kind of shape you're in."

"I'm afraid, though--"

"Well, I know, at your age there's really no guarantees of how much longer--"

"No, no, I'm not afraid of dying.  I'm afraid of being in a wheelchair."

"Uh, you're walking okay now."

"Yeah, but slower than I used to."

"You're a hundred!"

"I know, but I used to be able to walk great.  And now I have the cane, and, down the road, who knows."

"I think you're doing great."

"No, I can barely walk around the block."

"That's a long way to walk."

"It is not."

"For someone your age, I promise you it is."

"I just don't want to end up in a chair."

"There are worse things.  You have your mind..."

"No, it worries me."

"Well, we're going to do our best to keep you as active as we can for as long as possible."

"I hope you do better than my last doctor."

"Why, what did he do?"

"He retired."

"I'm still pretty young."

"For now."

"I'm too busy-- come back later!"

I get called to do a consult on a newly-admitted hospital patient.  I knock on the door.

"Hi, I'm [me].  Your cardiologist wanted me to come see you, and--"

"Oh, can you come back later?"

"Uh, I guess... why?"

"They said I'm having physical therapy, and I wanted to get ready."

"This won't take long..."

"I'd rather you come back later."

"Okay, do you know what time physical therapy is?"

"They said they're coming any minute."

"Okay, I'll come back in an hour.  You should be back by then."

"Oh, but that'll be lunchtime."

"Okay..."

"At least you can let me eat lunch in peace."

"Okay, I'll come back after lunch."

"I can't nap?  It's like torture here."

"I think I'm just going to do a quick exam now, if that's okay."

"No-- I said it's not.  Come back when I'm not so busy."

"You're in a hospital."

"I know. And I'm very busy today."

"I think your doctor may have called the wrong kind of consult anyway.  I'll let him know I quickly saw you."

"Goodbye!"

"Goodbye."

Family Meeting Rules

1. Turn your cell phone ringer off, or at least set it to vibrate.  Or just answer on the first ring.  If you speak softly, no one will notice.

2. Set the tone right away, by repeatedly looking at your watch and acting like you have somewhere else to be.  Talk fast.  Keep things moving.

3. Always book a room that's already occupied with something either remarkably frivolous or extremely sad.  "Oh, yes, we'll start the family meeting about end-of-life care for your mother just as soon as these residents finish up their planning meeting for next week's costume party.  The intern about to talk to you about DNR status will be dressing like a sexy cat."

4. Please don't make eye contact.  Someone might think you're listening.

5. Make sure at least three people are on speakerphone.  Doesn't matter who they are.  Makes everything a lot clearer.

6. Do not call the patient by the correct name, ever.  The less you seem like you know, the fewer questions anyone will ask.

7. Never reveal your name and title.  "I'm one of the people on the team" is as specific as you should ever be about your role in the patient's care.

8. Small talk always makes a grieving family feel better, so be sure to interrupt their crying with questions about the weather.

9. Just like with fortune cookies, medical news is always more fun to deliver if you add the words "in bed" to the end of every sentence.  Usually it's accurate, too!  "He's having trouble sitting up... in bed.  We took his blood... in bed.  He's doing as much physical therapy as the hospital is able to provide... in bed."

10. Use medical jargon whenever possible.  "His creatinine is elevated," repeated over and over again is much more effective than just saying he's in kidney failure.

11. Contradict the other doctors.  You always want to seem like you're discussing the patient for the first time, now, in front of his family, and that none of you agree on the same plan.

12. Use words like "death" and "dying," whether or not they apply to this particular patient at this particular point in time.  After all, everyone will die eventually.

13. "How quickly will he be ready for discharge?  That depends on how much you're looking to donate to the hospital.  Cash only."

14. Doctors are too important for follow-up.  "A medication list?  That's the social worker's job.  Checking his labs again... uh, let's say that's also the social worker's job.  She'll also be performing CPR if his heart stops."

15. End abruptly, and without warning.  In the middle of a question, if possible.  Run out of the room.  Hide in a closet.  Never be seen again.  Feign ignorance that this meeting ever happened, and accuse anyone who insists otherwise of being crazy, especially the patient himself.  "We talked about you?  Nope, no one ever talked about you.  You're hearing things.  More Haldol, stat!"

Follow these rules and your family meeting will go, uh, about as well as most of them do.

"Your office broke my wheelchair!"

I get a phone call--

"Yes, my husband had an appointment in the clinic earlier this week, and you were his doctor..."

"Sure, is everything okay?"

"No, everything is not okay.  Your office broke my husband's wheelchair."

"I'm sorry, what happened?"

"Your office broke his wheelchair.  You owe him a new wheelchair and I was wondering where I can send the bill."

"Uh, I'm not sure I'm the right person for you to talk to.  I can give you the main number and you can ask for, uh, the clinic manager, I suppose."

"No, I'm not going to talk to a secretary who has no power to do anything.  I know how things work.  Only the doctors have any power."

"I'm sorry-- I really don't have power.  I'm just a fellow, and I'm only at the clinic one day a week.  I have nothing to do with billing or reimbursement or anything like that."

"That's what you all say, but I know how it really works."

"I really have to get back to my patients.  You should call the main number and talk to the office manager."

"Do not hang up on me.  You were his doctor.  This is your fault."

"I'm sorry you feel that way.  But I can really only deal with medical issues.  You need to call--"

"You're not even going to ask what happened with the wheelchair?"

"I really can't--"

"We were leaving your office, and as we were folding the wheelchair up to get into the taxi cab, the leg support completely broke off, and now we can't even use it."

[silence]

"Doctor, are you still there?"

"Yes.  I can still only tell you to call the office manager, but from what you're saying, it sounds like it wasn't anything that happened in the clinic itself, but what happened with the taxi cab."

"My husband would not have been getting into that taxi if not for his appointment with YOUR OFFICE."

"I suppose that is true."

"See?"

"I'm going to need you to call the office manager.  But here's what you can do.  Tell her that if she has any questions about what happened, she can ask me, and I can tell her exactly what you just told me."

"Okay, thank you, doctor."

"You're welcome.  Have a good day."

Rock Star

There's one doctor at my hospital who might be seen as a rock star within medicine.  No one outside of medicine has any reason to have ever heard of him, but at least within the hospital, he is indisputably the most famous person we have.

He's on the wards for a week every year.  I don't know if it's part of his contract, or he likes to pretend he still sees patients, or what the deal is, but 51 weeks a year, he's giving talks or writing books or traveling around the world or whatever else he does, and one week a year, he's actually being a doctor.

Somehow, I won the lottery and I'm the fellow assigned to the ward he's on last week.  At first, super excited, since any face time with this guy is surely a good thing, right?

And then he asked me to go in and close the shades in the patient's room before he walked in, because he preferred to deliver bad news in dim light.  "The aesthetics are better."

Okay...

"And when you're rounding in the morning, give the patients a heads-up that I'll be their doctor this week.  I want to give them a chance to get used to the idea, so they're not distracted when I come in."

"I don't think the patients necessarily know who you are."

"Don't be stupid, of course they do."

Okay...

Is it bad that I spent all week hoping he would make a terrible mistake?  Not that I wanted anything bad to happen to a patient, but just something a little bad, to make him realize that maybe it wasn't just about him.

"I want to draw that patient's blood.  I think it looks better if I do it."

"Phlebotomy is right outside, I can just get them."

"No, I want it to seem like I really care."

"I can get phlebotomy, it's fine."

"No, I'm going to draw her blood."

Seven (painful) sticks later, we got phlebotomy.

"She has bad veins."

"Maybe you're just out of practice."

"I don't think so.  And, like we talked about, I'd really like you to get in right at 5 tomorrow.  I don't know when interns became so lazy."

"I'm a fellow.  And I've been trying to get in as early as I can, but if you're not getting here until 9:30, I'm not sure why I need to be in at 5..."

"I just want everything to be ready, so I'm not wasting my time."

"It's only been taking me 45 minutes to pre-round..."

"But I want everything perfect.  It shouldn't be my job to have to wake up a sleeping patient."

"Sometimes they fall asleep."

"Well, if they're asleep, they're not ready for me to see them."

His knowledge is actually great, which is the most frustrating part.  He knows what he's doing, he's up to date despite not actually practicing, he somehow makes the patients feel like he cares, and he remembers everything anyone says to him.

It's just hard to appreciate that when he changes his white coat every time a patient even breathes near it, and he's ducking out of a rapid response to take a call from a magazine writing an article about best vacation spots for doctors, or whatever it is he spent twenty minutes being interviewed about while he was supposed to be running a code on a patient six feet away.

Is it that I'm jealous, or is it that we worked together for a week and then I passed him in the hall this morning-- he's giving a talk to the medical students on how to eat a healthy lunch, or something else super-critical to patient care-- and he didn't even recognize me?

Oh well...