Friday, September 9, 2011

Difficult Patients

It is interesting seeing some doctor reactions to difficult patients.  Yesterday I was with the sports medicine doctor in the morning, he treated me to Starbucks (I just got some tea) and got some cookies for the medical assistants and receptionists.  We saw a few patients, but none were particularly vexing diagnoses as I recall.  Kind of a slow morning.  I'll probably ask him for a recommendation near the end of family medicine, but I'll be asking my main family medicine doctor for one sooner.

With the afternoon doctor, it started out with him relating a difficult patient he had had that day.  A middle aged lady had emailed him asking for a refill on her Valium, which he doesn't like to prescribe and it had been a long time since he saw her, so he asked for her to come in to discuss prescriptions.  He ended up prescribing it to her since she has been on it for a while and has no history of abuse.  He also ordered a thyroid panel because she was obese, and he had told her this, but perhaps not in the clearest phrasing.  When we put in a prescription or lab order, we have to also plug in a diagnosis to justify it, and in this case the thyroid was justified with a diagnosis of obesity, which is technically true.  The woman called later that day furious that he had written 'obesity' as a diagnosis on her chart - as if this was news to her, and was insulting and she just went ballistic.  The doctor of course tried to explain that it is medically true, and it isn't a judgement in any way, but merely an assessment based on BMI, and that Kaiser can offer weight loss classes and counseling.  This did nothing to placate her and she just kept going on and shouting she expects someone to come out to her place to bring her healthy meals similar to a Jenny Craig program or something similar - and that she's so angry she might just leave Kaiser (which the doctor would not have a problem with - in private practice, physicians can much more easily drop difficult patients).  Because he was so frustrated with it he put something about her being a difficult patient in her chart, but later he knew that'd be just starting a war and added an addendum to change it (sort of like writing an angry letter and then fishing it out of the mailbox).  

We also saw a patient with "dizziness" following a fall from a roof, which ended up being benign paroxysmal positional vertigo.  We did the dix-hallpike maneuver where you turn a patient's head to one side as they lie back on the table and when you turn their head in the direction of the affected ear, it produces uncontrolled eye movements.  It was a pretty positive test with this patient, and so there are Epley maneuvers where you have them roll back on the opposite side to try to dislodge the piece of debris in their inner ear which is causing all the problem.  It's a benign condition that usually self-resolves in 2-3 weeks, so that was a relief considering there was concern about concussion in this man initially.

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