The Thin Line

From the Washington Post, an article by Sandra Boodman about "difficult patients"...

Being Difficult

(http://www.washingtonpost.com/wp-dyn/content/story/2008/10/20/ST2008102001143.html?hpid=topnews)

While it is good to be knowledgeable and work together with the doctor on a treatment plan, the line between assertive and difficult is perilously thin. And dealing with "difficult" patients can take a toll on physicians.

"The subject of difficult patients has remained largely confined to private conversations among doctors or occasional rants on medical blogs, as well as a smattering of continuing medical education courses and articles in professional journals," Broodman writes. She cites a 1996 study from New York's Albert Einstein College of Medicine which found 15 percent of the so-called difficult patients were more likely to have psychiatric or alcohol abuse problems and were more dissatisfied with their care than those not considered problematic.

The author points out the lack of consensus about what "difficult" means.

"Some doctors regard patients with substance abuse problems or those who don't take their advice as difficult, while others are bothered by patients who exude a sense of entitlement or who repeatedly complain about symptoms for which no physical cause can be found."

A patient quoted in the article thought it was the doctors who were being difficult when they were incompetent, rude, or domineering. Another patient quoted in the article said that she thought her doctor was being difficult when he didn't like being questioned about her treatment plan.

That sort of questioning was acceptable to a small-town family doctor, who described in the article what he considered three difficult patients in one week:

• a 37-year-old salesman who refused regular treatment for diabetes,
• a healthy 81-year-old who wanted lots of unnecessary medical tests,
• a chronically depressed 52-year-old laborer with a neck injury who was convinced it wouldn't heal.

In his mind, his difficult patients were those who

• ignore his recommendations
• demand every new test, whether they need it or not
• show up at his house unannounced at night or on weekends
• complain that they aren't getting better, even though they haven't followed through with losing weight or stopped smoking or other medical advice.

I applaud the patient in the article who challenged her doctor when he made a treatment recommendation for which there was not enough support in the medical literature. From my own experience, I think the reverse is more likely, where a patient demands a treatment or an explanation for their condition for which there is not enough medical evidence to support.