Medicine does not compel us to like everyone we treat

Medicine does not compel us to like everyone we treat“Great,” I thought, as I stood at my desk, looking at my patient list early in the morning. She was coming in today. “She” was a patient of mine in her forties, with newly diagnosed triple-negative breast cancer, without nodal involvement. Our first meeting had been several months ago, and it had not been a good one.

I had asked about her history, how she presented; she had been fairly surprised I did not have that information. “You mean, you don’t know?” she had asked. “I would’ve expected you to at least have read my chart or talked to my surgeon,” she said. Then, with a sigh, she had recounted how she got to this point—finding a mass, the normal mammogram, the ultrasound-guided biopsy, receiving her diagnosis. Then surgery, more results, culminating in a referral to me. Every question I asked was met with a furrowed brow, as if I were interrupting her.

“It must be really shocking to be here. No one our age expects something like this to happen,” I said.

She had gotten angry at this. “Just concentrate on the facts, please. I don’t need your pity. What I want is your expertise.”

We launched in to a discussion about her diagnosis, stage, and natural history of the disease. She questioned everything we discussed: “Are you sure your statistics are right? From what I read, it’s more like this . . .” I remember getting defensive, as if each question back to me was a personal attack on my competence as a physician, as an oncologist. I remember feeling flushed as we talked, trying to get my point across as clearly as possible, yet feeling that she did not (and was never) going to “believe” me.

We then discussed chemotherapy—both standard treatments and those available on clinical trials. She had even more questions:

“Why should I get doxorubicin? I heard I’ll be throwing up all day. Are you sure I need it?”

“How is a clinical trial better for me? There’s still a 50% chance I can get doxorubicin, so why is this even an option?”

We covered alternative approaches—ones that did not involve doxorubicin and were available off a clinical trial. I then rendered a recommendation taking into account her tumor, her priorities and beliefs, and what the evidence told me. We talked some more and I fielded additional questions; then I asked her if there was anything else she wanted to discuss.

“Not for you.” She said. I looked to the floor and left the room.

As time passed, I resented having to see her and take care of her because despite what I perceived as my best efforts, I felt we had no real doctor-patient relationship. Each subsequent meeting was tense because I felt more and more certain that (a) she didn’t trust me and (b) she did not like me. I had expected her to find a new doctor—within my practice or somewhere else—but she did not. Indeed, I remember being surprised (and anxious) each time she showed up.

On that day she showed up on my list, I confessed something to my partners: “I don’t like this woman,” I said. They looked at me, shocked. “You should not say that,” one had said. “It’s not her fault she has cancer, and people cope in very different ways.”

Although much time has passed, this patient stays with me because it was perhaps one of my most difficult patient relationships—not because she had questions, but because, as sometimes happens, I felt we did not “connect,” despite my trying really hard to make her like me, and to see that I was a good and decent doctor.

As I developed this blog, I decided to show it to a very dear friend, Dr. Barbara Rabinowitz, whose advice and guidance have been important to me on a number of occasions, particularly when we served on the board of a national organization together. I had wondered what she thought of my experience.

Dr. Rabinowitz:

I do believe we hold high and sometimes unrealistic expectations of ourselves. In spite of your usual ease and rapport with patients, the experience you describe above is far from unknown. According to Haas et al., studies have shown that about 15% of the time physicians experience working with “difficult patients.”

In my experience, health care providers often feel trapped by the resultant negative feelings of these non-satisfying relationships. Though not in this case, difficulties may arise in the physician-patient relationship stimulated by pressures from the health care system itself (time allotted for visits, etc.), from undiscussed differences in expectations between the patient and physician, and the patient’s own previously held (and perhaps undiagnosed) conditions (e.g., personality disorders, etc.). Not uncommonly in cancer care, the free-floating anger at having been diagnosed with cancer may also be aimed at one or more members of the cancer care team.

I believe there is an even greater pressure to “like every patient” in cancer care than in general practice, as in this case, as exemplified by the reactions of your colleagues to your frustrated admission.

Ultimately, I clarified something with my partners: “I did not say anything about having cancer being ‘her fault’—I said I did not like her.”

With that, I realized that even with our white coats on, we possess our feelings, likes, dislikes, and personalities. Medicine requires us to do what is in the best interests of our patients, to “do no harm.” It does not compel us, however, to “like” everyone we treat. As a result, I experienced something interesting—almost liberating. I found that subsequent discussions and encounters with this patient became easier and that I was able to listen to her questions and answer them without getting defensive.

I realized that when I stopped trying to make her like me, I was able to take care of her. The pressure of wanting to be “liked” faded. It dawned on me that I was working so hard to make her like me (and vice versa), that it was affecting my ability to care for her. Once I admitted to myself that it was okay to not like a patient, I was able to do what she wanted me to do—to be her doctor.

At the end of the day, doctors are not a deity—omnipresent and omniscient. We are people—we are fallible, prone to our prejudices and our preferences, insecurities, and biases. I have learned that to become a good doctor, one must be honest with one’s self and exert introspection in order to become self aware; to admit that maybe the difficult patient is perceived as difficult not because of who or what she says, but rather the pressures we put on ourselves to “like” everyone we treat.

To close, I thought I’d ask Barbara to share her final thoughts:

It is important to recognize the unrealistic nature of expectations (on the part of the physician and also of the patient) which, if recognized, can help resolve this issue in some measure. Knowing you so well, I am not surprised that you were able to work this through. However, it is not at all easy to do this.

It is my belief that the very stressful work in which we find ourselves in health care can be aided by having peers who are willing to provide support when we experience any of the difficulties we face, including facing the patient whom we find difficult and whom we “do not like.”

As an administrator who sought and brought Kenneth B. Schwartz Center Rounds to my health care system, I feel strongly about the value of having a forum where health professionals can meet on a regular basis to discuss the “emotional realities” that frequently surface in health care and that may impact our ability to be the best we can be. In these usually monthly forums, where professionals come from all disciplines, the conversation is not about the clinical realities of the case, but on the sometimes unexpected reactions that the health care person presenting had and how it played out for them and their patient/patient’s family. This most often led to others recognizing and sharing similar experiences and to discussing what they learned and are learning from reflecting on the circumstance.

While this structured program is not available in every setting, finding colleagues with whom we can speak and seek support should be available to all. There are some articles and brochures regarding working with difficult patients, and reading can be helpful both in the release of the pressure that comes from knowing one is not alone and in receiving “helpful hints” for managing such relationships. However, it is my opinion that nothing trumps sharing openly with a trusted colleague to help work through feelings we may not have anticipated when we moved into a helping profession.

Don S. Dizon is an oncologist who blogs at ASCO Connection, where this post originally appeared.

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  • James

    True. But in the new world order of patient surveys your patient has to like you if you want to get paid by your new hospital executive overlord.

  • karen3

    And on the other side, it can be a significant burden to have to be the doctor’s buddy and entertainment when feeling awful. It’s a really gift when the doctor doesn’t make the appointment be about his or her feelings, his or her ego and lets the clinical relationship be the clinical relationship. Maybe this poor lady just wanted to save her “social energy” for her friends and family and do business with you. Is that so bad?

    She may have been doing all she could to keep it business rather than breaking down emotionally, which would have done no one any good.

    • drdondizon

      Hi Karen3. Yours is a very honest post, which reflects the lesson I learned. You are correct; my ego has nothing to do with you and really, has no place in any doctor-patient encounter. Having said this, part of what drew me to medicine was the opportunity to care- and in doing so, I treasure the opportunities to learn about people, not just their disease. Ultimately though, clinicians should not have a preconceived notion of how the doctor-patient relationship evolves. We not only need to meet the person coming to us for help on her terms, we must accept that too. Some patients are quick to share family pictures and stories of how their weekend went; others just want to know specifics on their therapy and focus on medicine. And I’ve come to realize, that’s just fine by me. DSD

      • Laura

        Dr Dizon: you strike me as a caring, compassionate doctor who genuinely cares about his patients. For people like you, to deal with a patient who doesn’t excel at respect, effective communication skills, good coping skills, etc. is really hard. She sounded condescending and very critical. You’re a human being! Who wouldn’t have been put off by her approach? I am sure you are not the only person in her life who feels defensive around her. That being said, I appreciate your honesty and efforts at being the kind of provider she needed; “just the facts, ma’am.” It must be challenging to quickly discern with a new patient what his/her needs are.

    • Guest

      It is not bad to save social energy for a non-clinical situation but there is a way to communicate that in a respectful manner. The patient would not like it if the doctor spoke with her in the exact same way she as communicating with the doctor. “You mean you didn’t take your medications again? You’re still smoking? I do not want to stand here and waste my time with you. What I want is your compliance, not your excuses.”

    • Suzi Q 38

      “She may have been doing all she could to keep it business rather than breaking down emotionally, which would have done no one any good.”
      Exactly.
      She definitely was rude, though. That being understood and defined, it is time to move on and see if her behavior improves.
      Hopefully, when she begins to like and trust her doctor more, it will.
      Dr. Dizon stated that this was to be their second visit, and the first one did not come off very well. The days are gone when the patient sat compliantly and did not ask questions was basically told what the treatment plan was. Some want choices and why.
      This particular patient appears to be more angry and complex. She would definitely not be in the majority of any physicians patient list, thank goodness. But she still deserves help within reason. She will be a challenge.
      Most anger is fueled by fear.
      An angry person or patient is fearful of something or someone. In this case, what she fears is obvious.
      If I were Dr. Dizon, I would not receive her anger as anything I did or said. I would try to understand her fear a bit, then try to tailor my visits to making her feel more comfortable. If you are providing a service, to be really, really good, not just O.K. or marginal, you should think about delivering what the patient or client needs and wants. She wants a cure for her cancer. Maybe he can’t deliver that. She prefers a more direct and factual approach to getting medical information and treatment. No “warm fuzzies” (I prefer the warm fuzzies) Try it her way, but make sure to have another person with you for feedback and documentation.
      If she continues to be rude, ask her why she is. Directly ask her!
      You may be surprised at her answer, or maybe this is a signal for her to move on if she is not happy.
      If all else fails and he has done his best with her, I would politely tell her that her rudeness has no place in your visits, to “leave it at the door” when she comes in. Have another staff member with you, and I bet she will better.
      Also, once she gets over the shock and used to her fate, she will accept and be calmer.
      She is definitely not angry with the doctor, as she has had only one visit with him.

      Every patient is different. She is no exception.

  • azmd

    Every patient has his or her own way in which they wish to be helped. Not all patients wish to have a warm and fuzzy relationship with an empathic doctor. Some patients see the doctor as a knowledge worker whom they wish to pay for an efficient rendering of expert opinions, and they don’t appreciate having their time with the doctor (short as it is these days) wasted with touchy-feely stuff like whether the doctor likes them or they like the doctor. They have done a lot of research and they want to have a meaningful discussion of their medical problems. The interesting part is to figure out which patient wants what, and deliver it.

    I personally, when I am a patient, don’t particularly appreciate having my time wasted by my physician making small talk with me, or making half-hearted stabs at being empathic about my situation, whatever it is. I suspect I am not the only patient who feels this way.

    • Cris

      Exactly.

    • azmd

      And also, outside of being polite and professional in my interactions with my physicians, I do not feel that I have a responsibility to make sure they “like” me, just as I do not feel any need when I see my patients to have them behave in a friendly or ingratiating fashion.

      • PCPMD

        Bottom line – if your presence makes your doctor have heartburn every time you come in, change your behavior, or change your doctor. Either way, it’ll be for the best for everyone.

        Incidentally, I don’t know why Dr. Dizon didn’t return her co-pay and show her the door. That would’ve been smart business after all (you know, the attitude everyone else seems to be advocating here. Nothing touchy-feely like caring for your patient and their plight. What’s-in-it-for-me-ism all the way baby!). There’s certainly no scarcity of patients out there, and they all pay you the same – might as well work with people who appreciate your input and don’t nauseate you (and don’t take up a lot of your time with silly questions). Anything less would be bad business. AmIRight?! Who’s with me?!

        • James

          Once physician pay is influenced by patient satisfaction surveys you actually will see more of this type of behavior

        • drdondizon

          Hi PCPMD. Thank you for your honesty in this post. It is truly appreciated.

          The situation where you and your patient do not meet “eye to eye” is a difficult one and yes, I will admit the notion of whether or not I should- to use your phrase- “show her the door” certainly was one I remember considering.

          Fortunately for me, at the institutions I have worked, there have been individuals available to help navigate such doctor-patient encounters. I’ve worked with them in their capacity as social workers, patient advocates, and nurse specialists. Their role is to objectively evaluate the situation from both the patient and the provider’s perspective and to find a solution that will enable the patient and ensure she is getting taken care of- this sometimes involves terminating a “less than ideal” doctor-patient relationship in favor of a more suitable provider.
          In the situation I wrote about, the patient was not “difficult”; rather I had realized that the expectations of the “ideal doctor-patient relationship” made “interactions with her difficult”. Getting rid of the “ego” aspects on my own side (and my own expectations) helped me see how I could be of help to her.

          I like to think clinicians have the ability to adapt their approach to what the patient needs. Still, when we cannot decipher what those needs are, clinicians should not be expected to continue what can develop into a truly antagonistic doctor-patient relationship. In such situations, we have an obligation (I think) to admit this is the case. However, rather than termination of that relationship, we must then help our patients find a provider who might be better able to support them. I hope your hospitals and institutions employ others to help navigate that kind of transition. DSD

        • Pam Littleton

          I feel sorry for for your patients, PCPMD. I truly do.

    • drdondizon

      hi azmd. Thanks for your posts (above and below). I think you pegged it correctly with your first statement: Every patient has his or her own way in which they wish to be helped.
      Ultimately, medicine is a human endeavor, isn’t it. Yes, as clinicians we train deliberately and work hard to know our craft as well as we can, so our patients are helped (in my case, it’s in oncology). But, knowing every trial, statistic, and treatment out there is only half of the practice of medicine. Medicine also requires empathy, compassion, and communication.
      With this blog post I hoped to impart exactly what you speak about- individualization. There are some patients facing a very difficult diagnosis with a choice between bad and worse options. Some patients want to discuss the data, pros/cons. They don’t care to discuss much else. Others require more than just an acknowledgement of the research they have done and a discussion of the medical aspects of their condition. They will want a conversation with their doctors- a combination of expert advice, humanism, and yes, compassion.
      At the end of the day, though- it cannot and should not be about my ego or any of our egos. It has to be about that patient, that person- meeting their needs as opposed to ours. And on their terms.
      It is a lesson I for one find has proven to be quite valuable.

  • Cris

    We are not teenaged girls and this is not Facebook. I don’t care whether you “like” me, any more than I care whether my plumber or pool guy “like” me.

    Just do your job.

    • azmd

      Of course, it’s also important to be cordial to your doctor, since a defensive, anxious doc is probably going to be less efficient at retrieving and communicating the information you need.

      • Cris

        Of course it is. But how do you communicate to a doctor who is wasting your appointment time with saccharine and condescending platitudes (“It must be really shocking to be here. No one our age expects something like this to happen… bla bla bla”) that you came seeking their expertise, not for pastoral care or casual friendship?

        • Cris

          I already have a minister I can seek counsel from (for free). I already have friends who will commiserate with me (for free). What I don’t have is an expert in treating this disease, and that is why I’ve hired one. That’s it in a nutshell.

          • azmd

            That’s fine, but it’s usually a good strategy not to get your appointment off to a bad start by overtly criticizing the doc for not being familiar with your history before he or she enters the room. You probably wouldn’t get an appointment with your pool guy off to a good start by opening with a critical comment, either.

          • karen3

            azmd, I can tell you have never had a debilitating chronic illness. If I can forgive the doc having a bad day, the doc should be able to give me the same grace. Especially if the reason I am there is that most of my days are bad days. It would be lovely to be able to be sick and yet cheerful and witty, but sometimes tired and cranky are what is left in the barrel.

          • azmd

            Actually I have a child with a debilitating chronic illness and have spent far more time in the last two decades interacting with various physicians, specialists, therapists and other assorted medical providers than I would have wished for. My comments on this blog are informed very much by my experiences being a patient, (or a patient’s mother) not just by my experiences as a physician. I am sure it’s very difficult to have a debilitating illness, but I doubt it’s any more difficult than having a chronically ill child, quite frankly.

            I very pointedly did not suggest that any patient be cheerful and witty for the benefit of the doctor, actually quite the reverse. I just suggested that it’s counterproductive to start off your appointment by insulting your doctor.

          • drdondizon

            Hi Cris. I respect your input and thanks for writing. As with much in medicine, there cannot be a singular approach to the doctor-patient relationship. Our approach to patients, their diagnosis, and their treatment has to be individualized. And it has to be the best care we can provide. Fortunately, I have learned you can do both. DSD

          • Guest

            Your attitude reeks of garbage! Doctors are not “hired help” and if you do not respect them for the help they are providing you, you will never be respected as a patient or even as a human being. It’s a 2-way street!

          • Guest

            ‘Doctors are not “hired help” ‘

            Unless a doctor is providing his services out of the goodness of their heart, and not being paid for their time and expertise, they actually are.

            Doctors are professionals that people hire because they have expertise in a given field, just like accountants, lawyers and dog trainers. One should be courteous to all hired help, but the idea that doctors are gods before whom we must genuflect is old and tattered. Get over yourselves.

          • Guest

            I think that the idea of having any further intelligent discussion with a person who says that doctors and dog trainers are in the same category is a lost cause! Congratulations!

          • drdondizon

            Hi Guest- Wow. I hope you get the sense that the idea physicians are gods is long past- it’s far more rewarding when doctors and patients actually develop plans together- at least for me. DSD

        • Suzi Q 38

          You shouldn’t fault a doctor for trying to be nice.

      • Suzi Q 38

        True.

    • PCPMD

      So you want a robot for a doctor … careful what you wish for, that’s probably the direction we’re headed.

    • Guest

      Maybe you should have you pool guy or plumber take care of your medical needs if you feel there is no difference in your interaction with them vs. with a physician. You just come across as a d*****-bag with a huge problem of a sense of entitlement.

  • http://twitter.com/riotofcolor1 riotofcolor

    I think you will be better off if you stopped labeling patients as “difficult”, and instead referred to the interaction as “difficult for you”. The advice from Dr. Rabinowitz was appalling. She ramped it up even further by suggesting the patient may have a personality disorder!

    I agree with everyone who already noted the appointment is about the patients’ medical problem first.

    • drdondizon

      Dear riotofcolor- you are correct. Period. Patients are not difficult. Interactions are difficult, and this statement itself reflects a personal viewpoint.

      The more vivid point you make for me is the notion that patients should not be labelled. I’ve had “difficult” patients sent to me in second opinion in the past and readily admit a sense of wariness when I meet them for the first time. It turns out that more often than not, the difficult label gets used when patients are informed, ask questions, and challenge dogma. And more often than not, I find these patient consultations challenging. Indeed, they help ensure that I am abreast of the latest developments in my field.

      In the end, we must be careful not to affix a label on patients- no matter what it is. It’s not fair and it’s not appropriate. DSD

      • Suzi Q 38

        True, but affixing labels on patients is a reality and done every day.
        In the old days, the doctor would put a red mark on the outside of the chart, to remind h/her that the person waiting in the exam room was the “difficult” patient.
        I wonder what happens now, with EMR’s. There must be a new code word or letter…although that would be tough if the medical records are ever ordered and reviewed by others.

        If you are in a private practice, you can refuse to treat that person, similar to a restaurant that states “We reserve the right to refuse service to anyone.”
        If you work for a teaching hospital, the people in charge may frown upon playing “hot potato” with difficult patients.
        Doctors may be viewed as only wanting the easier cases with the more pleasant patient personalities. This is only natural, but having more patients is usually the goal for most hospitals.
        Furthermore, seeing those patients is the right thing to do.
        Not everyone that has a terminal or difficult disease will be happy or easy to work with.

        On the other hand, she was rude.

    • Laura

      For patients who do have personality or psychiatric disorders, they can be very challenging to take care of. I think your suggestion as labeling patients as “difficult for you” as opposed to “difficult” is helpful – to a limited degree. There are people who are just plain difficult, though, and honesty and a commitment to professional, compassionate care is what Dr. Dizon was striving for. To negate the reality of psychiatric patients who also have cancer is not really helpful, though.

    • PCPMD

      Actually, many people do have personality disorders. You know the type – anxious, hostile, confrontational, contrarian to the point of being comical. If you’ve never had the displeasure of meeting these “difficult” people, consider yourself fortunate. If you have, why would you believe they act differently in an exam room, under stress, meeting a stranger for the first time?

      • Suzi Q 38

        You are so right.
        Your new patients may have a myriad or psychological and social behaviors. My sister is a borderline schizophrenic…. a bit paranoid. She trusts no one.
        Imagine her going into seeing her gynecologist or PCP.
        Other patients may have OCD, but be totally functional on a daily basis. You may just feel the “tug of war” during the visit because h/she wants control of the conversation and the treatment plan.

  • meyati

    What-your clinic allows a patient to change doctors? I had to fight-call and call, email and email, for about 6 weeks. I had a doctor that didn’t want to answer questions at all-then sent me on my way without follow-up or basic lab work. I was diagnosed with an aggressive rare skin cancer. I hate him. My new doctors are honest-and seem to accept me the way I am, with my fears and jokes-with laughter. I saw a dermatologist-and my radiologist asked me if he was good. I told him that I didn’t know, because I had never met one. If I had met a good one, I wouldn’t be in his office. I kept asking about this thing for quite a few years..

    • drdondizon

      Hi Meyati- Hope you are doing well now. Thanks for posting as well. I hope everyone takes your story as one of empowerment- of not settling for less than you expect and searching for better. DSD

    • Suzi Q 38

      The hospital I go to does, but apparently, it is difficult to actually get to change.

  • Edward

    Yes. Well said.

  • drdondizon

    Dear Amy. Thank you for calling me out as you had done. You are right. There is no place for my ego in any one of my patient’s medical care. Often patients can teach their doctors as much as we hope to teach them. Caring for patients such as the one I wrote about and some who have found themselves in a situation as you do have helped to inform my own approach as well.
    I wish you well.

    DSD

  • T H

    I see these patients daily when I work my ER shifts. At my facility, it is myself and a PA-c… so handing them off to a partner is not an option. Neither is ‘dismissing a patient from my practice’ – EMTALA and all that.

    Surprisingly, it isn’t only the drug-seekers.

    Maintaining professionalism is hard, especially when (after the third time in 10 minutes about being berated about the wait times over which I have little control), all I want to do is slap the person silly. It is even harder when the patient expects ‘her nurse’ and ‘her doctor’ to be at the bedside to explain every blip, beep, and squiggle that is on the monitoring suite. And then there are the patients who can be admitted on any given time that they present to the ER – if it’s not their COPD, it’s their angina. If it’s not cardiac, then it’s their kidneys/liver/etc.

    So… what to do: I try (with a fair amount of success) to remember that I don’t see people when they are at their best. It doesn’t always help, but it usually does. I always use polite words when I speak, even when I am obviously irritated. An irritated ‘thank you’ or ‘please’ is better than other words that might come out of my mouth. And silence is always an option.

    • drdondizon

      Dear TH: The ER can be a place of high anxiety, as I am reminded of since the events of the last week. Although the tragic events regarding the Marathon bombing rattled Boston to its core, it has also brought out the strength and resilience of its ERs, hospitals, and response teams.

      Your approach is an honest and thoughtful one. Yes, maintaining professionalism can be hard (perhaps harder in some places in medical practice compared to others), but it can be done. DSD

  • Guest

    So going to the doctor’s office and actually having to provide a “history” is considered painful and an inconvenience? I do not know why I am surprised because I have patients who react the same way when I ask them questions about their history. “Can’t you see my records? Why are you asking me all this over and over again? Don’t you doctors communicate with each other? This is such a waste of time!”

    Most doctors see 20-30 patients every day in their offices. I sincerely apologize on behalf of all my medical colleagues for not taking the extra 3 hours after a 14 hour work day to memorize every patient’s history before I walk in to the consultation/exam room. I am sorry that we, in the medical profession, like to actually TALK with our patients to obtain a history rather than going through a mountain of paperwork. I am sorry we cause such great inconvenience to patients when we prefer that you come for a face to face interview, when we can clearly just read your novel and administer care over the phone. For all this and for everything else that we physicians do in order to try and help you, I sincerely apologize!

    • azmd

      I love it when my doctors actually take the time to take a careful history from me. What I find a little off-putting is having to arrive 15 minutes early to an appointment to fill out my own medical history form. There’s really no way the doctor can get a true idea of my history from a series of checks on a list, in my opinion. I also would never expect a doctor to have walked into the room having already reviewed my chart. There’s just no time, and most reasonable people understand that.

      When I am on the other side, I feel that taking my patients’ histories myself is a crucial way to get to know the patient better, as well as formulate my own thoughts about what is going on and how I can help. But every once in a while you run into a patient who feels that it’s a hardship to provide the history, usually because it’s painful for them to have to review with you.

      • Suzi Q 38

        “But every once in a while you run into a patient who feels that it’s a hardship to provide the history, usually because it’s painful for them to have to review with you.”

        Sometimes I have to try to speak slowly, to make sure that I don’t cry in the process of talking about it (medical problem).

        The physician that best managed my first visit was actually a neurosurgeon. He had a really good NP that worked with him.
        She came in, talked to me briefly about my chief problems and complaints, then took the relevant copies of paperwork plus the CD of my latest MRI’s to his office. I guess then the neurosurgeon reviewed my CD and the NP got him started with what my chief complaints were and what I wanted from him. Plus, I had mailed some medical records to him prior to our visit. He preferred to do this in his own office.

        By the time he got to me, he was ready for any question that I might have. If I wanted to add more, I did, and he listened.
        He asked and I answered questions, and vice versa.

        I was very pleased because I didn’t have to compete with the computer and the doctor seemed comfortably familiar with my
        medical condition.

        I would not be impressed with a doctor that was not a little familiar with my case if I had mailed my medical records to h/her office a month ago.

        You can say that no one has this kind of time…this is not true.
        Some doctors do.

        • azmd

          With all due respect, if you can’t get through a visit with a doctor without regressing into tears, you need to get therapy to help you with your emotions. The doctors you are seeing are not trained to help people with their psychological problems, and their day is not structured to try. You may run into practitioners here and there who feel sorry for you and take time away from their other patients in order to spend extra time with you, hoping that it will help you regroup and get back on track, but it’s not realistic or reasonable to expect that every doctor you see will do that at every appointment.

          • Suzi Q 38

            Get off your pedestal, doctor.
            I didn’t say I cried every time., or cried at all.
            I should hope that you could READ.
            I said that I had to speak slowly just in case I felt like crying.
            There is a difference.
            I definitely hope I would not run into YOU.
            I am sure the feeling would be mutual.
            We would definitely not be a match.
            Maybe you should find a different line of work, one that doesn’t involve people and their sad illnesses or cancers.

          • Guest

            When a doctor tries to show compassion, they are greeted with “Just concentrate on the facts, please. I don’t need your pity. What I want is your expertise.” People really really really need to make up their mind about what they want!

          • Suzi Q 38

            Her statement was not nice.
            Your statement ” People really really really need to make up their mind about what they want!”

            Is simply an oversimplification of what you will encounter with patients each day.
            The point is that every patient may want something different. That is the dilemma of dealing with and serving people that are individuals and therefore unique.

            His patient is an angry one, but not at him. I can only guess that she is angry about her cancer and her future.
            If she continues with this behavior, she needs to be politely “called out:” on it with another witness in the room.
            She can try to realize that she has been rude, and adjust her behavior. Or, she can be nicer and then tell the doctor directly what she wants.

            I would definitely ask her to tell me what she wants if she continues with this attitude and behavior.

            I would though, understand that she is definitely different, definitely angry, and wants her health professionals to be “on top” of her care.

    • Quill

      We know you’re short on time – after all, we know as well as you do that you cram 20-30 of us in each day. It’s frustrating, though, when a doctor eats up 12 of the 15 minutes he’s allotted for my appointment getting me to go over information he or she has already been given. There’s no time left for me to ask any of the questions I’ve got. 95% of the appointment I’m paying is used up for your benefit; very little is left for me to get anything out of it. So you can see there are frustrations on both sides.

      • azmd

        Actually I do inpatient work so I only see 10 patients a day and have lots of time to answer their questions. But I think the outpatient docs are “cramming” 20-30 patients in per day because they are accepting people’s insurance and insurance reimbursements have sunk to a level where in order to meet your office overhead, pay malpractice premiums, pay back educational debt and still have enough left over to save for your children’s education, a PCP needs to have a high-volume practice. It’s very unfortunate, and when I am a patient on the receiving end of it, I don’t like it very much myself. So I try whenever possible to see docs who have direct-pay practices in order to ensure that they have time to spend with me. It’s more expensive but I think it’s worth it.

        • Quill

          I am sorry for any misunderstanding, I was reply to Guest with his comment that “Most doctors see 20-30 patients every day in their offices.”

          Also, because I have a high deductible/catastrophic policy, I pay the first $5,000 in medical expenses every year in cash, out of pocket. It does tend to make me hyper-aware of trying to get value for money.

          • Quill

            I will add that courtesy is always called for. Politeness and consideration for others costs nothing, and usually pays a pretty good dividend :)

          • Suzi Q 38

            ” I remember very wealthy friends of mine telling me back in the 80′s that they had this wonderful new health insurance where they just paid a $10 copay and “the doctor’s office takes care of all the rest.”

            My PCP collects $15.00 from me for each visit and then the insurance pays the rest.
            If he wanted me to file for it, I would.

          • drdondizon

            Well said! DSD

        • Guest

          Well said!!!

        • drdondizon

          Hi azmd- Wow- $10 copays… Haven’t seen that since I was a resident in the 90s! But, you’ve stated the pressures on primary care really well. Sad when the “business” of medicine starts interfering with the “art”. Hopefully there is a better way.

          DSD

      • drdondizon

        Hi Quill,
        Being short on time is not an excuse for not hearing you or answering your questions. I am a specialist but have seen my colleagues in primary care under the constraints you mention. I wish I could see it getting better, but even I have my doubts. Unfortunately, the reason for burn out among clinicians isn’t the patients themselves- it’s everything else. So yes, I do see the frustrations you mention and how they may come to bear- on both sides.
        Thanks for sharing your thoughts- DSD

    • drdondizon

      Hi Guest- And first off, thank you for posting. I hope that you never give up talking to your patients. I’ve also learned that the medical record can be inaccurate and can help inform assumptions about patients that perhaps are not warranted (eg, reading someone described as “difficult” by another provider). There is always something to be learned by verifying the history. Fortunately, your experience talking to patients mirrors mine- that the vast majority want to make sure you get it “right” and do not mind going through it again.

      Hope you are doing well. DSD

    • heardoc345

      It is ALWAYS important to ask patients some questions about their history, especially considering that in the age of EMR, a large percentage of “History” is pure garbage, propagated by a number of specialists who don’t bother to talk to the patient — EVER. Amazing how many diagnoses are pure “chart lore.” Even more amazing how many patients I have seen who are maintained on coumadin for atrial fibrillation they never had or other dangerous medications with no indication, because someone added something erroneous to the history.

      • drdondizon

        Hi heartdoc345. I share your sentiments on the reliance of medical records and am amazed about how much needs to be clarified when you actually sit down and take your own history. Yours is an important thought so thanks for sharing. DSD

  • Suzi Q 38

    My friends that are physicians say that I am a difficult patient.

    For one thing, I am way too comfortable with physicians and I view them as knowledge sources that are here to help me and hopefully get me well.

    No pedestal for them to sit upon. I am respectful and friendly.

    I have tried to be really a really nice and kind patient, and that did not get me anywhere. I am that way with my PCP, and maybe my neurosurgeon, because I have known my PCP for t least 12 years, and my neurosurgeon because he cut into my neck and operated on my spine. I woke up after the surgery so very pleased that I could move my fingers, walk, talk, and other bodily functions. I forgot to ask him if it was really he that did my surgery or that very nice female “fellow” of his that came to see me before and after the surgery. I can “take it” if she really did the surgery…joke’s on me.

    A couple of other doctors have been really really good, so I have been on good behavior. I sing their praises regularly on those Press Gainey forms, and I get treated well in return.

    A couple of other doctors have just delivered bad medicine on my behalf, so I have not treated them well lately. It is almost as if I had to have the last two visits to push their face into what happened to me due to their lack of treatment and care. I wished both doctors well, but told them how I felt. I also told their nurse that I would not be seeing them again.

    They are too young and incompetent to be my doctors. They can deny it, but I have way too much proof.

    Two other doctors had to intercede on my behalf to make sure that I got the medical help that I needed, so I am happy that not all doctors dishonest when there is a problem at their cancer teaching hospital. I am so grateful that the good ones still exist to offset the mistakes and lack of concern by the others.

    Anyway, this really nice, young urologist got me late in the treatment “game.” Sad to be him, LOL… I was now experiencing urinary incontinence in addition to my neuropathies in both hands and feet, weaknesses in my legs and arms, burning sensations on my back and the top of my buttocks, and bowel problems…none of which I had before my hysterectomy a year and a half prior.

    When he said “hello,” I did not even smile, as he was my 4 TH specialist and I finally found out why…undiagnosed spinal stenosis. All I needed for the last year and a half was an MRI of my cervical spine. I had asked for tests repeatedly, my PT had wanted tests also, but I was given the “pat on the head” and ignored. that is what I get for being nice.

    By the time I met the urologist, I was through with being nice. It was all business. I made him step it up early, and explain everything he wanted to do. I know that he could sense my controlled impatience and anger, which was given unjustly to him because of the treatment of a couple of inept and lazy doctors.

    So when the hospital called me before my surgery and said that I needed another round of an antibiotic because of a UTI, I hit the ceiling, I was so mad. Called his office and reminded him that I had wanted a urinalysis after my prior Cipro treatment. He declined to do this because I was supposedly asymptomatic. I didn’t understand because in reality, I was being stupid but didn’t know it. All I knew was that my surgery was about to be delayed due to my perception of him not doing his job.

    He told me through his nurse that if I didn’t like the way he did things, that I was to get another doctor, LOL.
    I told the nurse that while I was offended, that I think that would be best, as I was ‘on a roll.”

    Luckily, my regular PCP wrote me the RX for the Cipro and the hospital allowed me to have the surgery.

    When I called the patient advocacy department and explained the situation, I asked her to get me another urologist.
    Then something interesting happened. The physician that was the head of the department refused to do so. He told her that the two of us needed to reconsider. He explained to patient advocacy that I just asked too many questions. I explained to him through patient advocacy that that is the way I am given what I had been through. I told him that if he could not deal with my questions, then get me another doctor. He agreed to deal with my questions, and so I have decided that I have mistreated him because I was angry at others. It took me about 3 months to realize this.

    Maybe it was not you, Dr. Dizon, it was the ineptness of other medical staff plus her cancer that she is angry at. You have to have your “A” game with her….She will be a challenge, but in the end, she will accept her fate and respect you for hanging in there with her.

    • Guest

      All I am saying…..is give peace a chance!!!

      On a serious note, all I wanted to actually say (before Lennon got in my head) was that there is no reason to show the kind of disrespect that they lady demonstrated. Contrary to popular belief, doctors do not walk into a room expecting to be pleased. Everyone in the profession knows that the patient is the focal point of the visit. Doctors do understand that all patients (and especially ones with complicated or terminal illnesses) are going through a difficult time and, believe it or not, really want to help everyone they come in contact with (all 30 of them). Of course, exceptions will always exist, but no excuse is adequate when someone lashes out in an unprovoked manner (stressing on “unprovoked”, which this lady’s behavior clearly was). When you’re trying to cross the street with 8 heavy bags of groceries and a good samaritan offers to help you, if you are the proud person who does not want to accept it, politely say “Thank you for your offer but I can manage” or “Thank you for saying what you did to try and empathize with my illness but I would really appreciate it if we only focussed on my management because that would really help me.”

      • Suzi Q 38

        What you say is true. It is quite cathartic to be fortunate enough to have this means of giving my opinion. The best part of it is I get to complain about my situation without being so mean to my doctors directly.
        By the time I actually do get around to filing my formal complaint, it will not be as harsh as I felt a week ago.
        I thank all of you doctors for that.
        I do not think that what the patient described did was nice or proper. In a general sense, there was no excuse for it.
        On the other hand, we do not know,( Dr. Dizon or you for that matter), what she had been through with other health professionals or what her life has been like for the last few months or years.
        Some patients are so sweet and easy that maybe it is a joy to go to work for and with such patients.
        Other times, you get a jerk, and you are forever changed.
        This is not unlike the experience that you or others would have in other professions that do not involve something so personal: Life and death.

        Think for a minute about that.

        There is also the off chance that she is a jerk. Always was and always will be, for whatever reason. Maybe a bad childhood, combined with a few failed relationships and now add to that her health problems. We can only guess.

        Anyway, if she in fact had no prior reason to be angry, and was just a jerk, Dr. Dizon will not be able to change her.
        She will never see the fact that she is being unreasonable or unkind. She is maybe older, and WILL NOT CHANGE, sadly.

        If is the above, there will have to be what I call a “summit” meeting of sorts. The very next time she is rude, she should be told gently that she is being rude. A nurse or other medical professional should also be in the room to document this.
        It maybe does not need to go in the EMR, but in the notes section in your iphone. Also, with someone else in the room, maybe she will be on better behavior.

        The next time she is rude (with the nurse present), I would tell her that she was rude. She knows she was rude. She is just angry at her situation so she is taking it out on the good doctor.

        Kind of like my father in law that had 3 strokes….we moved him into our home because his second wife of 3 years had left him and taken a lot of his money. She then filed for all of his assets. His first wife, my MIL, had died of lung cancer 5 years prior. He was an angry man, and tried to destroy any relationship in his path. he was not nice to his doctors, either.

        It didn’t make sense, why treat us bad when we were the ones that stepped up, moved him into our home, and cared for him?

        No, it doesn’t make sense for Dr. Dizon either, but I kind of understand a little of her pain.

        Dr. Dizon, you are more patient than most doctors, but maybe you are “cut above.”
        On the other hand , there is no place for volunteering for abuse. You can change the situation if it is really bad.

        Good Luck.

        I

        • drdondizon

          Ultimately this patient and myself maintained a very good relationship. It’s about expectations- on both sides. I learned to let the doctor-patient relationship develop on its own pace, without assuming anyone will “like” me. In Oncology (and probably in most areas of medicine), the diagnosis and treatment IS scary and there is so much that is not under his or her control. I’ve learned it’s best to let the patient tell me what her needs are, and I’ve learned to evolve as they change.

          DSD

      • Guest

        “if you are the proud person who does not want to accept it, politely say “Thank you for your offer but I can manage””

        The good samaritan is offering his or her help for free, out of the goodness of his or her heart.

        You have been hired to do a job. You are not a good samaritan, you are in it for the money just like everyone else, and I’m am paying you for your services. Big difference.

        • Guest

          Are you paying the doctor? Really? Your $20 co-pay is hiring him or her to be your slave? Cool!

        • drdondizon

          Hello Guest- Maybe I am naive (even after all these years it might be true)… But none of us chose medicine (and in my case, oncology) for the money. Medicine is an honor. If I wanted wealth, I would’ve become a banker.

          Cheers- DSD

      • drdondizon

        Hi Guest! I am all for peace. I appreciate your sentiments about the profession and truly believe clinicians (note, I hope to encompass all of us who render care) try their very best to understand patients. I’ve seen illness and stress handled in various ways- none of them can be deemed “correct” because we are all individuals and no one can tell you how you are supposed to act. I think, as some others have stated, one’s reaction is somewhat informed by prior experiences in medicine. But that works both ways. The patients I remember even today are those in which interactions have touched me, happily and sadly, and those in whom I feel I did not do enough (or treated lesser than was deserved). I guess I hope that physicians take their experiences and actually learn- learn how to listen, cope, and respond. Alongside the technical aspects of medicine, we can achieve better for our own profession.

        Take care, DSD

    • drdondizon

      Dear SuziQ,
      I always appreciate what you have to say. So no sorries, and no “pleasantries”, unless they are sincere! lol.
      Unfortunately, I think many people have an experience in medicine that leaves them wanting. Whether its the patient who “just wants answers” or the doctor who just doesn’t know, but can’t quite bring himself to admit it- there are lots of things that can go awry; afterall, we are all human. I guess that was my point in the end- we are all human. What medicine compels us to do is to treat the patient as our priority- the one sitting in front of us, and without judgments. Whether she “asks too many questions” or whatever the issue is, that is the issue as we in clinical medicine perceive it. I think admitting that it is a perception is one step in helping to resolve any conflict.

      I do like the idea of patient advocacy for the exact reason that you state as well. Sometimes, talking through the issue is important. Rather than fanning the flames and leaving both sides not quite “satisfied”, its often nice when an independent person can ask both doctor and patient to be “adults” for awhile.

      It may not result in “reconciliation” but it is certainly a well regarded effort.
      Best always to you!!
      D

      • Suzi Q 38

        Thank you, doctor.

  • Guest

    The point is not about disliking patients who are educated and well informed about their diagnosis and management. Believe me, it is more than welcome because they are easier to treat since they are definitely more invested in their care and are more likely to be compliant with therapy recommendations.

    The point is that this lady’s attitude was bad. She was rude and confrontational for no apparent reason. As far as I can tell, Dr. Dizon did not provoke this by being rude or incompetent or unprofessional in any way. Maybe you are not giving us all the facts, Dr. Dizon. If you, Amy, met a person at a gathering and they behaved this way with you without being provoked, you too would jump right down from your high horse and kick them till the word “difficult” was etched on their body with the bruises administered by your steel toed boots. Everything Dr. Dizon said was being met with a cynical response and there is no need for that, period! If you do not agree with your physician and strongly feel you are right, there is a way to say it politely. Not because you are talking to a doctor “on a pedestal” but because that is the right thing to do! I do not think that Dr. Dizon disliked her as a patient. She was disliked as a person because of her attitude and not because of her knowledge and involvement in her care.

    • drdondizon

      Dear Guest- In your post you summarized how I viewed our interactions prior to my “realization”. It’s just as important to realize that as clinicians we cannot assume there is an appropriate response to bad news or a new diagnosis. What we can do is meet our patients in their turf, in order to do what we can. Sometimes their turf is a little rough- but ultimately, that is a road she must travel, not us. DSD

  • truefirst

    I think people who work in other “caring” professions will recognize the cognitive dissonance of being a compassionate person who truly wants to help others and then coming up short with someone you don’t personally click with. Providing excellent, humanistic care to that person requires reframing our own expectations, as Dr. Dizon describes. Thanks for sharing!

    • drdondizon

      Dear truefirst, thank you for your comments. And I could not have said this better. It is all about reframing your expectations. Most assuredly. DSD

    • C.L.J. Murphy

      I am glad that I bothered to scroll down this far in the comments section. Not that all the earlier comments weren’t interesting, because they were, but this is the one that nails it, for me. Both the “problem”, and the “solution”.

      • drdondizon

        Agreed! D

  • elizabeth52

    I have firm views on cancer screening and non-evidence based routine exams. I had to shop around for a doctor who’d respect and accept my informed decisions. I found a quietly spoken and patient female GP…we don’t always agree, but we’re always respectful and polite to each other. We work together…and she knows I don’t just do as I’m told, I won’t always agree with her, but I also, take full responsibility for my decisions. I know some women avoid all medical care to avoid coercion and consults full of lectures. Some get their pills over the internet or “manage” with the pharmacist, that should never be necessary.
    It’s really worth the time to find someone who’ll work with you. There are doctors I couldn’t work with, but fortunately, there are great doctors out there, and one is the right fit for you.
    I know doctors can’t patient-shop and some people can be very difficult, I know that from my own line of work. No easy answer there…

    • drdondizon

      Dear elizabeth52, thanks for this post. I think you are spot on. The doctor-patient relationship is just that- a relationship. I think modern medicine has since moved away from paternalistic medicine and more towards participatory medicine. In the end, finding a doctor who meets your needs is the best of circumstances. There are so few absolutes in medicine (in evidence-based lingo, so few “level I” recommendations), surely- there is room for interpretation, discussion, and negotiation. Stay well, DSD

  • querywoman

    I suspect this woman liked and respected you more than you realized, since she stayed with you. You could have terminated her as a patient, but perhaps you cancer docs and others who do a lot of final-stage med don’t do that much.
    Teachers, etc., don’t like all their students either.

    • drdondizon

      Dear querywoman, yes- I think my assumption of what constitutes a “good” doctor-patient relationship was not in line with what she thought it was. She wasn’t looking to be friends (as others have posted) to go have coffee with or to joke around with. She wanted a partner to treat her cancer. Period. I had interpreted it as her “not liking” me and so, I had “not liked” her right back. While we did not become “good friends” as we continued to work together, I learned to respect her needs and engage her by addressing her questions and treating her collaboratively. That’s what she needed, and indeed, it is what she had always wanted.
      And yes- I have heard that about teachers too!

      Have a great weekend, DSD

  • Susan Sanders

    “First Of All” There are doctor people and there are non doctor people. I happen to be a non doctor person. I don’t believe at all in Western medicine and I don’t “Buy Into” the profits it stands for! Or the tests! At All. Never Have. Never Will. I rather pay a fine then be coerced by the Government at any level to purchase something against my belief system. Doctors need to accept this reality. Not everyone wants the same things or believes in them. I am an alternative, holistic person threw and threw. So.. were my grandparents. It is our family belief system and no amount of insurance or coercion is going to change my mind. No bullying or pressure from anyone in those avenues and whom chooses to walk that path. This is suppose to be a free country. This is why the Constitution still exists. If not.. the way we are being treated by the Government who has a vested financial interest along with the lobbyist and Wall Street; we might as well say the USA is becoming a Communistic Society that is trying to “Dictate” to the people what they have to have. It is a choice. It will in my life continue to be a choice. My doctors are in Mexico. My doctors are also of the natural. Yes.. if you have a car accident or..need a surgery then so be it. Go to the hospital.They can and will bill me for this. I spoke to a man whom is American Indian. He has the same belief system. His family is not allowed to go and see doctors, I get it. Just like your allowed when in a hospital or an emergency room to refuse testing and treatments. You have that right. However the medical community is so … extremely closed minded to people like me. They label us as “Difficult” instead of accepting and even asking the right questions. I was told my Holistic doctors are quacks by a medical doctor. There is no decency or understanding. Especially… if your not an “Easy Sell” and won’t buy into their lies and fraud. My mother was killed by doctors. I seen it first hand. I was in meetings etc. etc. I know what “Really” goes on. They are great salesmen. They know how to use scare tactics and convince you to try drugs. They know how to hook you and whom they can and can’t. They are bigger drug pushers then the ones over the boarder and there should be drug testing for employment based upon the drugs they prescribe to everyone. They sell their chemo the same way!

    master

    • drdondizon

      Dear Susan,
      The tension between Western medicine (in your words) and naturopathic care has always existed. For the record, I grew up in the South Pacific and I still remember my mom taking me to natural healers for their advice and treatment on a number of occasions. I would hope that American medicine is more tolerant and open-minded when it comes to the benefits of complementary and alternative medicine. More and more we are seeing benefits when the two are combined (eg, use of hypnotherapy to help with hot flashes, accupuncture for nausea due to chemotherapy).
      But, I do take exception to the notion that physicians are “salesman”. Modern medicine is still built on ethical principles to respect patients (autonomy) and aim to treat them without doing them harm (beneficence).
      I am sorry if your experiences with “us” has been so dismal as you relate. Truly, you deserve better. Ultimately, you do have the right to be treated the way you desire, including the right to refuse therapies that we may recommend, and you deserve nothing less than our respect for those decisions. I would hope that all clinicians reading this agree with me. DSD

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