The gift of a “bad patient”

Yesterday I received a call from a friend – a truly brilliant person who takes great responsibility for everything in her life. She researches nutrition and eats only healthy foods, exercises regularly, works hard and studies to increase her value to the clients she sees at work, and seriously considers her actions in nearly every circumstance. She had just seen a new physician, who had noted an elevated laboratory value and wanted her to start a new medication. After extensive research of the medical literature, she came to the conclusion that the benefits of taking the medication weren’t established in people like her and that there were considerable side effects. When she explained this to the physician, he countered with, “well, I won’t label you as a bad patient yet.”

My immediate reaction was that she should have stood up and left the room. After all, he was being arrogant, dismissive, insecure, and clearly didn’t want to engage in a collaborative relationship.

As healthcare providers, we know a lot. We attend school, training programs, ongoing CME, meetings, read continuously, and communicate with our colleagues in order to stay abreast of the newest developments and obtain other perspectives on our difficult cases. We work hard to know what we know. But if we’re honest with ourselves, we will admit that there’s probably more that we don’t know. Consider some of the things you were taught during your training that are now known to be false. How much of what we now believe is true will be proven wrong in the future? So why do we hold onto this illusion that we know – and are supposed to know – everything?

When a person’s life or health is at stake, it’s certainly comforting to have a sense of certainty that what we are doing is the best option – that it will work. But do we actually know that for any given patient? Patients often get better – or worse – in spite of what we do. We can perform the same procedure or give the same medication to two different patients and they each have a different response.

Patients generally are very understanding of healthcare providers who explain that they are unsure – that the precise answer is unknown. I often tell my patients that I want to cringe when I think of what we used to do in treating our patients’ vein disease. At the time, we thought it was a good idea, but we later found out it didn’t work as well as we had hoped. I follow by saying that I hope that in another 20 years we’ll look back on what we’re doing now in the same way, because that means that we’re continuing to make progress. Consistently, I watch them smile – they get the fact that medicine is an inexact science that is continually evolving. They are happy to reap the benefit of the advances that have been made thus far.

How different would the interaction between my friend and her new doctor have been if he had welcomed her interest in her own health? He might have learned something valuable from the literature she had reviewed. He might have gained an understanding of what she values in her life, allowing him to be a more effective physician. He might have questioned his own knowledge and belief in order to either strengthen his commitment to the plan or develop an even better one. He certainly would have earned her trust – and that is something that is absolutely crucial in the doctor-patient relationship.

How many gifts did he throw away by not countering with something along the lines of, “You seem to be very committed to your own health. What a great patient you are!”

About Helane Fronek

Over the past 28 years I have had a fascinating and fulfilling career in medicine, initially practicing as a general internist and then as a procedural specialist, caring for patients with vein disorders. As Assistant Clinical Professor of Medicine at UC- San Diego School of Medicine, I’m thrilled to be teaching medical students crucial communication skills along with many other aspects involved in the practice of medicine.
This entry was posted in building relationship with patients, effective communication in healthcare, first impressions, physician coaching, physician communication, Uncategorized and tagged , . Bookmark the permalink.

2 Responses to The gift of a “bad patient”

  1. says:

    I love all your posts, and this one even more.
    I assume doctors need to be confident in their judgement in order no to panic or delay urgent and important decisions, however this should not impair their ability to autoanalyse their knowledge and behaviour. Confronting with others’ experience and skills, comparing practices, gathering information from multiple sources, we have so much to do to improve our own medical practice !
    Thanks for your blog. It should make readers own high value CME credits.
    All the best.

    Suggestion for further posts: the Doctor becomes a patient himself. ….

    • Dear JJ,
      How wonderful to hear from you! Yes, it’s a difficult balancing act for us as we are often expected to be “the expert,” which we assume means that we are expected to know everything. It’s been my experience that patients actually don’t expect that from us – rather, they expect us to be knowledgeable and to be willing to gather more information on their behalf. When I was a resident, we were assigned an attending physician who was quite out-dated and would tell the medical students about using rotating tourniquets to treat acute pulmonary edema. We had to “de-brief” the students each time this person attended our rounds. While hopefully not quite so dramatically, our knowledge base continues to be proven incorrect as new discoveries are made. So we need to constantly question what we “know” and be open to considering other explanations when our theory doesn’t fit what we’re seeing. To me, that’s one of the marks of a good physician.
      Looking forward to seeing you in November!

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