Saturday, April 15, 2006

Impatient Medicine

I could say I never feel frustrated at work. I could say I cruise through every day with a warm smile and an open heart. I could say I feel nothing but love and compassion for every patient all the time. I could say I never get angry at a patient, never wish they would just shut the heck up or go away and leave me alone.

could say all those things, but I'd be lying like a rug.

The truth is, doctors are just as human as anyone else. We have bad days. We have buttons. We get tired. We get PMS. We feel anger, frustration, annoyance and fear. We don't treat all patients equally all the time. We don't even
like all patients equally all the time.

Now, I'm hardly one of those crusty curmudgeon docs. You know, the ones who bang in, barely look at you, bark orders, scribble in the chart and bang out. I'm usually quite nice to my patients. And I usually DO feel love and compassion. I truly enjoy my work, and feel honored to do it. But there are those times...

I'm going to describe a few patient "types" that predicatably get my dander up. If you recognize yourself here, cancel your appointment and find another doctor! Just kidding. My goal here is to add data to my "doctors are people too" hypothesis, and to raise awareness in people who might inadvertently be pushing their doctor's buttons. I'll alternate gender to be fair, because any of these can come in the male or female variety.

First there's
The Late Mr. X. No matter how far in advance this one made his appointment, he always rushes in late, in a panic, almost too late to be seen. He drops stuff everywhere. He apologizes profusely every time, citing various plausible causes of his tardiness, none of them his fault. He charms his way into the exam room, backing up the whole line behind him. He honestly doesn't mean to be a pain. He was trying to be on time. He was planning to be on time. He probably has Adult ADHD. He's probably late to everything, bless his heart. Bless his heart, but curse his timing!

Laundry List Lily is the patient who schedules a brief appointment for "follow up" or "single problem" or "to discuss something with the doctor; it'll only take a few minutes." Then, when I ask her to tell me about her problem, she pulls out her list. A litany of complaints, none of them brief or simple. She really needed a long visit. Or three. If I address all of these today, it's going to delay everyone after her and make me late. And grouchy. In residency, I was told to Just Say No to the Lily's. Tell her we can deal with ONE problem only, and she'll have to reschedule for the others. This is easier preached than practiced. It might take weeks for her to be able to get back in. She's here now, she's already listed her problems, and oh, what the hell, let's just do it. Lily honestly doesn't mean to be a pain either. She probably thinks problems are easy for me. I think she might have low self esteem, might be unsure that she is worthy of much attention. When in reality she's worthy of much more than she asks for.

The Drama Queen is one of my personal least faves. I always imagine this one with her hand against her forehead, palm out. You know, the old "woe is me" pose. Her highness speaks in dire pronouncements. "I can't breathe." (This is while she is speaking clearly and calmly, thus obviously capable of breathing.) "I can't walk" (after strolling into the clinic with no assistance). "I haven't slept in a year" (blatantly impossible). Doctors are scientists, remember? We don't like broad sweeping exaggerations. We like data. We like precision. "I often cough when I breathe." "It hurts right here when I walk." "I've been having trouble falling asleep for 3 months." Patent impossibilities tend to lose you respect. Perhaps The Drama Queen would be more aptly named The Boy Who Cried Wolf. Remember what happened to him?

Thankfully rare is
Eric the Entitled. In my Student Health Walk In Clinic, this one is often a medical student, I'm sorry to say. He is terribly, importantly busy, and really deserves to be seen quicker than anyone else. He absolutely can't get away from his essential role to make an appointment. He must be seen now. Oh, and he knows exactly what he needs. Don't ask him all these unnecessary questions. Just give him the precise medication he wants. And, of course, call him on his cell the minute his results are in. If you don't, he'll feel entirely free to just drop in and interrupt you so he can have the information at his convenience. Does Eric know he's a pain? Probably, but he just doesn't care. How do I feel about Eric? The truth is I just wanna wring his righteous little neck.

The Ventriloquist is actually not a patient, but a spouse, partner, or family member who comes with the patient and answers all the questions directed at the patient. "So, Mr. Smith," I say, making eye contact with the patient, "Tell me about your rash." Before Mr. Smith can open his mouth, The Ventriloquist pipes up. "He's had it since we went in that hot tub at the hotel." I listen politely, turn back to Mr. Smith, and, when he doesn't offer anything further, I ask my next question. "Does it itch?" Again, The Ventriloquist. "It itches like crazy! He's scratching a hole in his pants!" Etc, etc. (The extreme version of the ventriloquist is The Controller, who might be an abuser in thin disguise and who is not one bit funny). The Ventriloquist can only be silenced by Banishment to the Waiting Room.

Drug-seeking Dan is one that all doctors know. He comes in different shapes and sizes, he uses varying strategies, but his goal is always the same. Only the story changes. " Someone stole my meds. I lost my prescription. My regular doctor is out of town so I can't ask her for a refill. I accidentally dropped the bottle in the toilet. The dog ate it." and other variations on this theme. The strangest ones are sometimes true ("my ex-wife threw all my stuff on the lawn and burned it"). The other clue that you might have a Dan on your hands is when he says something like, "I have this recurrent pain problem [with no physical findings] and it's back again and ONLY Percocet [or other specifically named medication and dose] works for me."
Dan is looking for a gullible, kindly practitioner to sucker. This used to be me, but I've toughened into a cruel bitch over the years (or so Dan has informed me). To avoid being mistaken for this miscreant, get your meds filled on time by your regular doctor, and keep track of them!

Roundabout Robin has never met a question she didn't like. And she never answers with a single word. You ask Roundabout Robin one of the open-ended questions that work so well with other patients, and you soon wish you hadn't. The answer to "How's your breathing?" might go something like, "Well, I remember back when we lived on the ranch, and my daddy had that old pickup, and we used to ride in the back when he went out to count the herd, and that dust would just blow up in our faces and make us cough like crazy, and I couldn't hardly breathe, it was so awful, but I could never ride up front in the cab because Daddy always saved that seat for his stupid dog..." Get my drift? As a doctor, you learn quickly not to ask Robin open-ended questions. You stick to simple, yes or no questions, figuring you can't go wrong with those. "Have you ever been hospitalized?" That oughta work, right? Only two possible answers to that one. You have, or you haven't. Right? WRONG! Roundabout Robin is incapable of speaking in one-word sentences, remember? "Oh, one time, I was so sick, and my sister, she kept telling me I oughtta go to the hospital, but I didn't want to go because I had a roast in the oven, and I knew I was really sick because every time I opened the oven to baste that roast, I threw up on the new linoleum floor we just laid the week before, so..." Roundabout Robin is the only patient I am rude to on a regular basis. I can't help it. If I don't interrupt her, we'll be there all day, or else I'll end up in the clink for strangling a patient, and then I wouldn't be there for her next time. So I have to be rude, right? Right?

Last (always last),
By-The-Way Bill. Also known in the medical world as the Doorknob patient. This is the guy who, as you have your hand on the doorknob ready to leave the exam room, says, "Oh, by the way, I have this crushing sensation in my chest, like an elephant sitting there...." Screech! About face. Why didn't you SAY SO IN THE FIRST PLACE?! It's always something potentially horrible, this last-minute problem. And sometimes it's more than a potential. In fact, medical folklore is full of "doorknob disasters", where that tossed-off comment sets off an avalanche of major workups and often hospitalization. Like a little Smart Bomb. Bill doesn't actually annoy me as much as worry me.

I'm sure I'm leaving some out, but I'm starting to feel like Whining Winona here so I better quit and think about something more pleasant (like..... flowing myrrh!) before I get really grumpy. I can't afford an Attitude Adjustment on my government salary.


Marianne said...

I think I might have been almost all of those at some point... So, who are your favorite patients?

Peg Spencer said...

Marianne - My favorite patients are legion. I tend to think of them individually rather than as "types", although I'm sure I can think of some favorite "types" if I put my mind to it.

Either way, it's a topic for future blog entries.

As to you being "almost all of these", aren't we all? That's one thing I find fascinating about human beings- we all have the potential within us to be just about anything, even if only to a tiny degree.


Annie said...

This is a brilliant post Peg.

I do some drama work for a doctor who runs communication workshops for other doctors, ie. teach them how to deal effectively with their patients.

I can identify with all of your beautiful alliterative patients as I have to 'act' them on many occasions for the benefit of the doctors on the course. We work from a format called 'Communication Skills Decriptors' which include:

'Agenda setting', 'common language', 'ask before tell', 'attributions and expectations', 'empathy', 'what concerns you most?', 'interruptions' and 'touch and go'

Most doctors I've worked with have expressed their feelings of anxiety when patients over-run their appointed time, such as your Laundry List Lily and have an avid fear of By-the-way Bill! That's why the communication skill they like to practice the most are 'agenda setting'.

Brilliant Peg. I came across your blog via Marianne's who came on mine after...oh I don't know - the joys of networking! Keep up the good work!

Acting Annie

Heather said...

That is too funny. I know all of those people.

I need to make a list. Unless it's going on right then, I forget about it. The doc asks if I have any problems and I say no. It's 3 days later that elbow starts to hurt again or I realize I meant to ask about a mole. Then I think, oh, well, next time and I never ask.

Peg Spencer said...

Acting Annie - Thanks for the feedback! It's great that you do communication workshops for doctors. Many of us need the help! Certainly I could use some lessons in agenda setting.

In med school we were taught how to conduct an interview. We had the "Holy Seven" and the "Big Four" questions. All very specific. The holy seven refer to the chief complaint, and are things like When did it start, Where does it hurt, Exacerbating/alleviating conditions, therapies tried, etc etc.

An interesting thing I've discovered in my years of practice is that often all you need to do is ask ONE open-ended question and then SHUT UP AND LISTEN for two or three minutes (usually that's all it takes) and they'll tell you everything you need to know. If not, letting them get it off their chest opens their mind and frees their attention, so then your questions will be more efficiently processed anyhow.

Of course, that doesn't work for Tangential Tillie (I didn't get to her in the post either). She's the one who's thoughts and words go all over the place, and who can't answer a "yes or no" question with "yes" or "no".

Good luck with the drama and role playing - wish I could attend some of your workshops!


Peg Spencer said...

Heather - Lists are great. I didn't mean to "diss" lists. I really appreciate the patient who is organized enough to have made a list so things don't get forgotten or left to the last minute.

I count on lists myself. The older I get, the more I need them!


Dr. Al said...

I have the solutions for you, Dr. Peg. Some EX-LAX would have done the trick for the Late Mr. X, who needed a "jumpstart." A LAP DANCE for Laundry List Lily should help her forget her litany of problems. An ENEMA for Eric the Entitled will make him "slow down" or "speed up," whichever you prefer. Some Vitamin S(ex) for the Ventriloquist; funny how a "love affair" distracts from the quotidian. A BILGE PUMP for By-the-Way Bill should wake him up and get his juices flowing. Drug-seeking Dan requires a DOUCHE, to clean at least one of his orifices. Finally, for you, Whining Winona (aka Dr. Peg), a WRITER'S BLOCK, because your material is beginning to eclipse my own. There goes the neighborhood! I like your writing style, Dr. Peg, and I have solved the problems of this world with my comments. Dr. Al

Dreaming again said...

It was assumed I was the Ventriloquist for my mother. Having been sent to the waiting room by a neurologist ... when they sent her for some lab work, then back into the exam room, they over kindly invited me BACK into the exam room ..where the doctor proceeded to ask ME all the questions and barely looked at my mother.

Extreme ADD ... and can't answer a single yes or no question ... she'll take 20 minutes to give you a 2 second answer.

Our PCP had warned him I was an essential partner in my mother's care ...he thought I was interrupting her ... I was ... because I knew when she was going off into la la land!!

Fat Doctor said...

I'm pretty sure I saw all those patients in my clinic this morning.

neuroticillinifan said...

I'm afraid I'm Laundry List Lily. Why do I do it? Because, as you suspected, I have low self-esteem and don't deem myself worthy of the doctor's time, don't want to be a bother, and just try to get through as much of the list as will be tolerated because I'm sure they are all minor complaints of no consequence whatsoever.

I am also the person who told my therapist last year when she left for vacation, "Oh, you don't need to give me the number of the person covering for you. I would never dream of calling in between appointments and bothering you or anyone covering for you." Ah, one more topic for therapy.

Peg Spencer said...

Dr Al - Hey, thanks for the treatment tips! I'll add those to our protocols right away! ;) Oh, and hey, no need to muzzle me with writer's block (unless I'm having writerrhea). There's room enough for the both of us in this wide wild West!

dreaming again - I guess that neurologist ate crow for dinner, eh? Thought you were being a busybody when in reality you were being a helpful caretaker. Your mother was lucky to have you.

bigmamadoc - You did have all those pts in clinic this morning. Thanks for taking over for me while I slept in!

Peg Spencer said...

neuroticillinifan - But you ARE worth your doctor's time. That's what she's there for, to take care of YOU. And how are you to know which are minor problems and which are major? You didn't go to medical school; she did. It's her job to figure all that out.

And if you're worried about bothering your doc, just remember that there's more stress caused by trying to solve a bunch of problems in a short time than any one of the problems causes on its own. It's better to overschedule the time. Then, if you're done early, she'll thank you!

Thanks for commenting.

dribear said...

perfect!! You nailed these patients on the head. Not literally I hope. I'm just mad I didn't think of this for my own blog!

You should really consider submitting to Grand Rounds.

anafaran said...

How about we turn the tables on you doctors on Dr. Peg's blogsite? I would like to submit to you all of my least favorite doctors. One actual experience per blog.
A) Anal-compulsive anus probing GI Doctor: Oh, you have been having bloody diarrhea for two days straight? Jump up on this table, kneel like a dog and let me have a look? I'm sorry, I say, Is that English you just spoke? He proceeds to stick something long, hard and sharp in my bottom. After I descend from my airborn position, he pulls out the implement covered with blood and says, yes,I think you're right about that. $180 please!

anafaran said...

B) Baby in cervix, tee-time approaching Doc!
Dr. Birdy, Gee, I do believe this baby should have popped out by now, labor started 36 hours ago, Pit for dinner last night, second round of Pit for breakfast,(out in hallway, but still audible, tee time at 10 am to nurse)
Hmmm, looks like baby is moldy. MOMMA!!!!!!!!! baby messages me through neurons, do what you must to get me out, me no want to meet you moldy! OK, Doc Birdy, do it, cut me loose from distress. To the OR, and tap that baby in the hole for me!

anafaran said...

C) Impertinent cancer Doc!
What are you here for, ma'am?
I need a second opinion. My hometown doctor says I have breast cancer so I'd like your opinion as well.
Doc: I see looking at your biopsy report, needle localization and x-rays that yes, your doctor was correct in his evaluation. I see you have had 4 children, all by C-section and I'm guessing by pendulous shape of your breasts, you nursed them all. Wouldn't you like two nice perky breasts now? You're only 36 and insurance will cover them!

anafaran said...

D)There was also Dr. Dick Slice-Me Dastardly the Dermatologist who exised living tissue beneath the fungus that was growing on my fingertip from the chemicals I was using at my layout job at a publishing company. When I screamed at the sensation of the assault of scissors snipping subskin, he lifted his hand as if to slap me so the waiting area of patients wouldn't get edgy.

anafaran said...

E) Dr. Edna, the Leave No Stone Unturned Enduring Endocrinologist. Yes, Mrs. Anafaran, your daughter has a mysterious condition. She is not ovulating, however, there appears to be nothing wrong with the system. We'll run tests, and for three years straight she ran the marathon of tests we never knew existed, with zero convincing final analysis. But being patient at being too patient, can deplete bone mass in our maturing patient too.
Have patience with us patients, will you doctors? We'll continue to have patience with you.

anafaran said...

I'd like to 'excise' that one typo in the Baby Doc blog. Dr. H meant the baby was moulding to the cervix but to an untrained mama it conjured up images of mold as found in Roquefort and exise isn't a word, but excise is.
FYI, I love and respect nearly all doctors who have treated me.

Anonymous said...


I don't think I'm any of those. My type wasn't on the list at all - Avoidant Abigail, the patient who darkens the door maybe once every 10 years or so. I'm not sure how doctors feel about that. Are you frustrated when patients don't come in very often, or do you figure it's OK as long as we're healthy?

Peg Spencer said...

dr ibear - I've only recently heard of Grand Blog Rounds. I thought it was more for clinical stuff, but, having looked at bigmamadoc's Grand Rounds this week, I see it's eclectic. Even includes a post from your handsome twin!

So maybe I will submit next time. Thanks for the vote of confidence and the suggestion.


Peg Spencer said...

anafaran - Ouch. Sounds like you've had some BAD doctors. I'm sorry to hear it. Unfortunately, every professional barrel has its bad apples. But, unlike fruit, one bad apple doesn't spoil the whole bunch, fortunately!

Thanks for sharing your stories. Here's hoping for no more of those in your life!


Peg Spencer said...

anon- Speaking only for myself, I'd rather people check in once a year or so for a general physical and "tune-up". I consider myself a health educator as well as a healer, and like to think I can help someone stay healthy by prophylactic counseling. In addition, although you may feel fine, unfortunately there are health conditions that don't cause symptoms for years. If you check in regularly, we can find those early and treat them before they get serious.

So, Abigail, call my office and make an appointment. I promise not to chew you out for taking so long!

Thanks for stopping by.

anafaran said...

Well, thanks to the unpretentious nature of you and your bloggers and the diversity of your medical topics, Dr. Peg, I was at last able to find a venue to wiggle in those remarks in one spot, about the bad apple doctors. It almost reads like something in a RD mag lying around waiting areas.
That's off my mind now, whooshew! Seems carrying around the memory of pain grows into a bigger monster than the actual experience -sometimes ! I guess since I'm 50, that's not such a bad average. A bad apple only once every 10 years. Dr. Peg's blogsite rocks apples!

Anonymous said...

Thank you, Dr. Peg, I will try to improve myself. :)

I became really phobic after an adverse event several years ago. It was horrible - first it was misdx'd, then I needed surgery to fix the damage, no one was talking to me about what was going on, etc. etc. It got to where I dreaded seeing doctors of any kind because I kept getting blindsided with bad stuff.

I did manage to straggle in last year and wasn't yelled at, at least not too much. And I made it across the parking lot without having my knees buckle under me. ;)

Cheers! I really like your blog!


Doc NOS said...

When I was a resident I loved Demanding Homeless Addict.

Who knew what he had based on his vague complaints, all you can be certain of is that he's drunk, high, or simply insane or various combinations of all three.

echrai said...

I LOVE this! Absolutely love it! After all, every profession has some variation of these and I can recognize all of these in my own arena. Thank you for the grin and giggle.

Peg said...

Welp, I gave in and added two more Impatients. But I'm done. Really. No more whining.

For now.


Abby - When I hear a story like yours and anafaran's, it makes me knot up inside.

Echrai - ain't it the truth about types in every profession? Hmmm...I wonder what "type" I am?

Peg said...
This comment has been removed by a blog administrator.
peg said...

By the way, that deleted post up there? It was mine. I messed up and posted the same comment twice. Just telling you so you don't think I go around playing Censor.

marybishop said...

Peg, you're so cute...scrolling down your comment section -- of course I saw the deleted post and wondered: what did someone say to piss off the Doc?

Then your explanation...I'm the same way...I refuse to change a comment, even if I don't like it.

anafaran said...

What is to be done about the Homeless Addict? Although I'm not without a home, sometimes I think, at some point in my life, I easily could be, especially with the skyrocketing cost of housing in this country.
Are these the poor souls that we see on the street corners begging or under the highway overpasses sleeping in cardboard? How do they actually get past the receptionist at the front desk? How do they prove they can pay for services? Can anyone enlighten me? If I was without a home and an addict as well, I think I would be literally beside myself with worry and if I could get past the receptionist with a convincing story that I could pay my bill, then I might very well be slipping into the offices of doctors, on a regualar basis, looking for someone who might hear my worries and demands, to perhaps even sweet talk some drugs from a doctor who has just been paid a visit by a friendly pharmaceutical rep. Would there be any empathy among our doctors who post blogs here? I don't know what I fear most, the possibility of being homeless or the possibility of being without medical care when I most need it. Dr. Peg, could you please sometime open up a discussion of the future of medical coverage in this country. I know my son and his new wife bought their first little bungalow, but they can't afford medical coverage and doctors' visits. I guess that's a choice they made, but should it be a choice they are forced to make as a young couple. Don't get me wrong I'm not looking to give them a handout and they wouldn't want one either, just asking.

Peg said...

anafaran - If you want to find a blog about medical policy and politics, you might try Medical Blog Networks

If others want to discuss that stuff here, you're welcome, but for me this blog is for relaxation, creative writing, sharing experiences. Sorry.


peg said...

I just re-read my comment and it sounds a little "short". I'm not trying to run you off, anafaran. Quite the opposite. You're welcome here anytime. I'm just responding to your request to write a certain type of post with a "no, thank you".


difficult patient said...

Don't forget to screen these difficult folks for domestic abuse . . .

difficult patient said...

BTW--I really like your blog (I'll be adding you to my links . . .)

sowellfan said...

I'd have to say that I'm often 'The Ventriloquist' for my 'Drama Queen/Laundry List' wife. I understand the problem that you're talking about, but sometimes the patient themselves has trouble getting the pertinent information across. In our case, my wife has a complicated (12 year) history relating to her back/neck pain problems, so whenever we go to a new doc to talk about these issues, they want to hear what the history is. My wife, though she's an English major, and should be able to concisely state the history, can't seem to do that, and she only gets the doctor confused (What do you mean, you didn't move for 3 years? Were you in a body cast?)

I've gotten pretty good at giving a two-minute rundown (perhaps being a stereotypical engineer helps in that regard), and then I leave things to her. That seems to work pretty well for us.

Peg Spencer said...

difficult patient - Thanks for the reminder about abuse. Man, when I read your comment, it was like opening the lid of an attic trunk. Long-forgotten memories wafted up into my consciousness, faces of the many victims of abuse I've seen. Another post has begun to simmer.

Thanks for linking to me - I'm honored! I'll visit your blog soon (I'm between patients now)

sowellfan - I wouldn't call you a ventriloquist. I'd call you a spokesperson or advocate. Big difference.

David Harmon said...

Regarding patients: besides domestic abuse, you should be alert for various types of less-than-obvious mental illness, diagnosed or undiagnosed. OK, psychotic episodes are obvious, but say, mood disorders, may not be.

Depressives can be "Absent Abigails", or fail to follow-up on instructions, or be too "shy" to mention complaints. Bipolars have all that in their depressive phase, but in their hypo/manic phase can show drastic failures of judgement ,or more obvious issues. Anxious patients may seem to be listening attentively, but actually be in "mindlock", with higher functions turned off. (A good hint is if you ask them a question that needs thought, and they recite your prior words verbatim instead.)

For "Dubious Docs", I've got a couple:

The Gadgeteer, who reduces a physical exam to taking fluids and whatever observations are needed to justify using (and billing for) The New Machine on the patient of the moment.

The Psycho Pharmacologist: Overly fond of sampling his own wares, this guy threw out his hyphen by accident during a cleaning binge; it got mixed in with the empty cigarette packs and ashtray residue. ;-)

That Girl said...

Funny post. I wanted to say that sometimes I go along with my VERY shy partner because he will go to the doctor with say, chest pain and a headache, and will mention the headache but not the chest pain.
So he'll come home with a migraine persciption and Ill be like "What about the chest pain?"
"Oh I forgot to say."
It's annoying, has lead to ER visits later, and if it makes me a control freak so be it. It often KEEPS me from being an abusive partner (KIDDING!)

Giovanni said...

I like "Roundabout Robin"; I have those in my practice as well. In group therapy, when one highly extroverted client steals the show, and there is 'time' to consider, it's frustrating to the rest of the participants and I have to delicately move things forward.


peg said...

David Harmon - Thanks for the pointers about mental health diagnoses. Also I love your "dubious docs" selections. We really need a whole list of those, as there are many I'm sure! It would probably be better written by a patient. Care to take it on?

that girl - The Ventriloquist is the one that has generated the most comments, as people recognize themselves or a part of themselves. It was not my intention to minimize the crucial role that family members and significant others can play in a patient's care. Those helpers are not the same as the busybody ventriloquist I described. Sounds like you're more of a helper. Kudos to you!

giovanni - I can imagine Robin could really grind a group to a halt. You must be a skilled therapist to be able to, well, shut her up without causing resentment and disharmony.

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