Tuesday, 19 Mar 2019

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A Least Favored Patient

Sasha D just doesn’t like me.  I’ve seen her four times in the clinic, and each visit was a tense battle of misunderstandings, with both of us leaving dissatisfied or worse. The failing wasn’t in the diagnosis, but rather the malalignment of our goals and inability to listen. Despite my efforts, my words, the diagnoses and treatment suggestions haven’t been well received.  

The problem must be the unreasonable patient or her expectations. Maybe I should have suggested a second opinion, transfer of care or bus ticket to Buffalo.  Or should I worry that she is a new entry on my “least favored patient” list?

But, isn’t caring for the least favored part of the job? Like medicine, serving the “least favored” is often part of the calling or pledge. It may even be the strongest example of spirituality, patriotism or high moral fiber. 

I believe that nearly all physicians consider, manage and care for all patients equally. Nonetheless, some patient-physician relationships fall outside the limits of normalcy.  Some patients are superlative, inspiring, or even good friends with whom you exchange first names, recipes, and tall tales with. Others stand out as a medical challenge and in the course of contesting the problem, you form bonds that solidify the relationships success.

But what of the minority and unsavory end of this spectrum?  What do you do when communication fails, trust is compromised and visit is a bust? 

Before you write off the visit, charges and patient, wisdom dictates the need for an approach to these situations.

I would refer to you to a previous blog ("My Approach to Difficult RA"), which focuses on the correct diagnosis, optimizing therapies, knowing the options, pitfalls and speaking from strength and certainty, especially when the patient's behaviors are contrary to your guidance.  

The article doesn’t address the confounding problems of bad behaviors, mental illness and limited resources or support.  These will frequently widen the chasm between what you prescribe and what the patient does. Here it is important to identify that which you control and then identify other obstacles and your guidance is for them to be addressed. 

With a least favored patient, it can be challenging to find the resolve to do the job, listen, talk constructively and leave the patient with fair plan for next steps. The easy out is to dread the appointment, lapse into ugly talk, disagree about your disagreements and schedule an unreasonably distant return visit.

Billy Joel was once asked, “Of your many songs, which is your favorite?” His reply was stolen from his parents - “they're all my favorites, they're all my children; there are times when it's easy to like them more than others but in the end you love them the same because they are born of your intentions and love”.

It would be great if our patients were treated as our children, equally and with the same devotion and love.  Yet whoever said that raising children was easy or came with a clear-cut manual? 

You will have many, many more patients than children or songs. Thousands will traverse your exam table each year and while all will have high expectations, they will differ dramatically in their stories, commitment and ability to relate.  You cannot have the same approach to all.

Favored patients make your job easy, especially when they think you’re brilliant, wonderful, and humorous. Life is grand when the king and subjects live in paradise.

It's not so grand when your patient doesn’t respond to therapy or when your usual efforts are insufficient. Harder still when the patient disagrees, is noncompliant or has cognitive, psychological, or family issues that get in the way of optimal care. 

It is ultimately up to the provider to understand and overcome what stands in the way of a favorable relationship. You may discard, fire or neglect the patient who you feel is not worthy of your expertise.  But maybe it’s not your expertise they are asking for or need most.

“Not worthy of my time” doesn’t appears anywhere in the Hippocratic Oath or even in your own early ideals when you started your medical training. 

Providing medical care is more of a commitment to the patient, than a commitment to science. Empathy, understanding and listening are incredibly hard when you think you have all the answers. 

In these instances it’s up to you to change your game, attitude or effort as you deliver what the patient wants most – guidance and alternatives.  


The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He a Professor of Clinical Medicine at the University of Texas Southwestern Medical School.
Dr. Cush is the Executive Editor of RheumNow.com and also Co-Edits the online textbook RheumaKnowledgy.com. 
Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.

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