Mar 27, 2011

What Is Nice Patient Syndrome?

A reader writes:

"My doctor says I'm one of the nicest patients he's ever met. He says that really nice people always get the rare incurable diseases. How can that be?"
Oh no! You've got Nice Patient Syndrome! Your prognosis is grim!

There's only one cure: Do something horrible quick! And I'm not talking about saying a dirty word or two. It takes serious antisocial mommas-lock-up-your-babies-cause-there's-a-crazy-person-with-an-axe behavior to save you from the terrible fate of Nice Patient Syndrome!

Why would the nicest human beings end up with the worst diseases?

Ask any doctor, nurse, or therapist... We've all noticed it. The most saintly human beings any of us have met seem to be the ones that get the rare, miserable, and rapidly fatal diseases. We are all astonished at the sheer angelic goodness of these patients, and we tweet message after heartfelt message about how our patients heal our hearts than we could ever heal them.

Ever notice how this shit only happens to the nicest people?

Nice Patient Syndrome really does bring out the best in the assholish medical profession. We give hugs, we fluff pillows, we do bake sales in our spare time. Dr. D once bought a ton of medicines for a nice patient who couldn't afford them. After their untimely demise we go to the funerals of our nice patients and tell their relatives how we never met a better human being.
I'm sad to hear that your doctor thinks you are wonderful, because that means have a really scary disease.
And here's the real kicker: You aren't half as nice as all the doctors and nurses who are fawning over you think. And they aren't crying for you when their eyes well with tearsthey're crying for themselves.

Mental Distortion
One thing you have to realize about healthcare workers is that all of us have been traumatized, whether we admit it or not.
Your average graduating medical or nursing student has seen as much death, pain, and misery as a soldier returning from a war. Most of us wouldn't admit that this affects us. In fact, we pride ourselves in not letting it get to us. "I'm a professional dammit, and telling the 3rd person this week that they've only got months to live doesn't keep me from doing my job professionally!"

We usually do a passable job of managing (suppressing) the emotional effects of our jobs. The first few dying or crying patients may have gotten to us, but we don't feel it anymore. We promise! Just another day at the hospital...

Many of the particular quirks of doctors and nurses are psychological defense mechanisms resulting from the mental trauma. Our experiences may turn us into jerks, but we'll turn patients with scary diagnoses into angelseither that or monsters.

Fear of Dying

Doctors and nurses cannot do our work if we're afraid, but it is anxiety-producing stuff we see every day. We are the ones that watch everyone suffer and die. We watch young and healthy people get awful diseases. We see miserable people that we just can't fix. We get the fact that everyone inevitably dies someday (and many deaths are not pretty) shoved in our face daily.

Watching strangers suffer and die actually isn't as hard as you'd think. The real mental anguish comes when we reflect that the same sort of thing will eventually happen to ourselves and the people we love dearly. Dr. D does a good job taking care of sick and dying kids, as long as he doesn't wonder if this might happen to Little D someday.

We need to find some way to think of you as different from us.
If you are totally different from us then whatever awful thing is happening you to won't necessarily happen to us.
I hate to admit it, but first we look for the bad in you. If you've made some shitty decisions in your life or you are rude or manipulative with us then we conclude you deserve it. "This sort of stuff happens to assholes like youKarma, bitch!"

But if we don't find some reason to hate you we conclude that you must be a saint. You are too good for this wicked world! This burden was laid on you because only a truly superb human being like you could handle it.

"Look, we really need you to do this for us. You don't mind, do you dear?"
We'd rather admit you are better than us than to admit you're just like us.
We feel safe from the fear of ending up in your shoes as long as you are absolutely different from us. "That sort of terrible thing happens to assholes and angels but not normal dudes like me!"

The Complications Of Nice Patient Syndrome

There are plenty of advantages to Nice Patient Syndrome. If you are going to have an awful disease it sometimes isn't so bad to be surrounded by healthcare workers who think that they aren't worthy to be in the same room as you. Trust me, you've got it much better than the ones we conclude are assholes! We'll bend over backwards for you. You can and should milk this!

There are, however, disadvantages to being though of as the nicest patient.
  • You aren't a real person to us. Your goodness we keep fawning over is a creation of our own mind.
  • We tend to be paternalistic with "Nice Patient Syndrome" patients. We don't want to bother your pretty little head with the dirty details of your disease, so we just make the decisions for you.
  • We expect you to handle pain bravely. All that goodness makes you more resistant to pain than mere mortals! We rave about your fortitude in the face of pain, and you want to keep our respect so you won't tell us how much you're hurting.
  • When we do treat your pain we will knock your ass out! We adore you so much that if you do mention you're hurting we might Michael Jackson you by accident.
  • You actually aren't what we imagine you are. We sometimes send people to meet their maker convinced they have far purer souls than they actually do. You are yourselfthe good and the bad. Don't buy into our delusion!

How To Handle Your Sainthood

Rule #1: Don't try and convince us that you are a normal person. Sure, you are just trying to be humble, but insisting you have flaws is actually very threatening to us. If you are just like me then whatever scary thing that is happening to you could just as easily happen to me.

"I think the world of you Mr. Smith. That's how I keep from wetting my pants when I read your chart."

You can't change us. We are damaged goods.
We are frightened by your suffering and Nice Patient Syndrome is a deeply-rooted defense mechanism that isn't going away.
If you try too hard to prove you have faults you might suddenly get labeled the asshole patient that deserves this and can't die soon enough.

Rule #2: Accept your sainthood! Learn use your new-found powers:

  • Speak clearly and directly. Your words carry a lot of weight with us, but you have to sometimes speak forcefully to overcome the narrative running in our heads of whatever we expect an angelic person would say.
  • Kindly but firmly demand control of your care. This is your disease, your pain, your death! Don't let your doctors and nurses take over just because they adore you.
  • Defend your fellow patients. Just like you aren't the angel we think you are, the asshole patients aren't half as bad as we think they are. "Difficult patients" are the victims of the same splitting defense mechanism that created "nice patients" like you. Don't try to convince your MD or RN your fellow patient isn't that badit won't work. Just remind us to show more kindness to the assholes. We'll do it if an angelic patient like you asks us.
  • Ask for lots of extra ice cream. We'll keep bringing it till you get a stomach ache!

Dr. D loves to read your thoughts in the comments.

A lot of you who read this blog have some really scary diseases:
-Have you ever been on the receiving end of Nice Patient Syndrome?
-How did you handle it?

Healthcare Peeps:
-What is your experience with Nice Patient Syndrome?
-Do you agree with Dr. D's theory of the condition?


tracy said...

Uh, oh. Now i know why my lovely Internest hugged me THREE times at my last appointment.....

Anonymous said...

Brilliant article; really enjoyed it. The amount of projection and transferring most professionals (and people generally) bring with them to their work is staggering once you start thinking about it.

Not all of it is unhelpful of course, as you rightly point out. The key is trying to retain insight into what we're experiencing.

Anonymous said...

Awwww @#$#$%! That's why I nicknamed my patient "Mr. Awesome." And I'm only a student...

Anonymous said...

I am a member of the Really Nice Patient with a Lousy Prognosis Society, with the additional honor of being A Really Interesting Case (“a highly unusual presentation of an extremely rare disease,” as they say to me). Doctors give me their card with a direct number scrawled on the back, attendings have made special trips on weekends to check on me when I’m hospitalized, I get praised, I get all the time in the world during clinic appointments, I get told what an incredibly pleasant patient I am, and more than anything else, there is a constant subtext that “this shouldn’t be happening to someone like you.” I eat it all up, but I’m just a normal person. And I’ve glanced into other hospital rooms and felt a bit sad, wondering if the other patients are treated as though it is a merely ordinary, acceptable thing for them to get sick and suffer.

Ha ha---what you wrote about pain is true. I get told frequently that I have a high pain threshold (this may be true, actually), but then when they gave me Demerol for a biopsy, the surgeon requested a dose so large it made the nurse anesthetist’s eyes bug out before he asked if he heard correctly. The biopsy results sucked but, thanks to the drugs, I have a very pleasant memory of the whole episode.

It’s also true that there’s a downside to being a Nice Patient---I think my doctors often withhold information if it’s unpleasant. I have to do my own research and then ask if xyz is likely in my case, only to be told, briefly and sadly, “Yes.” A couple times I have accidentally discovered that important tests were done with bad results, and no one was ever planning to tell me.

I think the phenomenon of splitting described here applies more generally too, beyond the world of medicine. Just the other day I was speaking with someone who has metastatic cancer, and he said that he thinks the fact that everyone keeps telling him he is “brave” is a sort of psychological horse trading---“I’ll give you the honor of being noble and brave, and in return I get to feel healthy and safe.”

Well, this post explains a lot of odd behavior in the medical world, but it also just made me laugh more than I have in a long time. And now I’m inspired to capitalize even more on my Nice Patient status while I still can. Thank you, Doctor D.

Doctor D said...

A quick clarification:

I'm not implying that healthcare workers are "bad" or should feel guilty for creating nice patient syndrome.

With our work we need psychological defenses. Certainly Nice Patient Syndrome is a better than other knee-jerk reactions, such as blaming the victim or cold indifference.

I still find myself doing it all the time. My concern isn't that we adore people with bad diseases. My concern is that we don't realize that what is happening or why we do it.

Being enamored with our patients can sometimes be a good thing. The real problem is when our mental narrative takes over and suppresses the real-life patient. Realizing what is going on helps us use the positive parts of the syndrome without letting the problems get out of control.

Doctor, know thyself! (This applies to nurses, med students, therapists, etc. too)

Anonymous said...

Mmmm......I love ice cream!

I think I've been treated both as the bad patient, and as the saint. I have an extremely rare congenital defect. I've been told countless times that I'm "fascinating" as a patient. I like what anon. 10:31 said a lot.

I was wondering why everyone told me how kind I was the last time I was in the hospital....I was just trying to be polite and make a bad situation bareable. I am not perfect, but I try. I feel bad for medical professionals because I know you must get a lot of crap from people at times. For instance patients do die, and sometimes families blame you. No wonder you need defense mechanisms (like the rest of us).

One thing that really bothers me though is when I've had doctors who see me as being all bad, and then all good, and then all bad...I find these are the doctors that I do best to get rid of and move on from. It just gets in the way of having any kind of productive relationship.


SuzRocks said...

I think I might forward this to all my friends and family, so they realize why I'm so screwed up- and why dead bodies don't bother me in the slightest.

You're so dead on, I didn't even realize it- my patients are all either perfect or assholes. Druggies or saints. Gang-bangers or the poor guy who stopped to help a car on the side of the road and got hit by a car.

rapnzl rn said...

Dr. D. I wholeheartedly agree, being the professionally 'damaged goods' that comes with oncology nursing. In my world, there are an inordinately large number of folks with 'Nice Patient Syndrome'.

Thanks for the validation.

Dragonfly said...

Brilliant post!

Anonymous said...

gasping for breath
awaiting with bated breath
the soon return
of dr d

please do return...

Nyllrap said...

I loved this post, having been labeled as "a really nice person" with "the patience of Job" by my surgeon. This was during a 6 month hospitalization due to necrotizing galltstone pancreatitis, with lots of complications and what I was later told was a 97% mortality rate for someone with my severity of disease. Eight operations and 2 years later and I am doing great, am alive and kicking. I recently saw my surgeon in a store and he really seemed delighted at how well I am doing now. I was delighted to be able to thank him, once again, for saving my life. I do have to admit, I was a good hospital patient...I knew early on it was going to be a lengthy illness and didn't want anyone taking too long to give me my dilaudid. Plus, why make a bad situation worse by being a jerk?

Abigail Cashelle said...

Yes, absolutely!! Thanks for this amazing perspective Dr. D. As one of those patients with a puzzling conditions, I'm overjoyed to finally be considered a nice patient. After years of doctors being annoyed by my existence, it's reassuring to know that this illness doesn't always make me unwanted.

At the same time, I have to say that the doctors who help me the most are those who actually listen & take the time to get to know me. They don't just praise me for being tough. They talk a lot about my critical thinking skills, which means, of course, that I have the power to veto their treatment considerations.

But you're right. They do tend to praise my purported angelic goodness. While it is nice to have support, it doesn't give me much of a gauge of where I actually stand on the scale of things. Sure I can be bossy and make people do things for me that they should have done already, but it's not always a character trait.

Thanks for the perspective. It's definitely challenging me to look at things a little bit differently.


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