May 8, 2011

How Could You Think I'm A Bad Patient?

Dr. D recently got an interesting letter from a young woman who got along well with doctors and never had significant health problems …then she got sick. She developed problematic symptoms that required that she seek a lot of medical attention.
What really shocked her, though, was the distinct feeling of hostility she felt from her doctors.
I could totally smother you with this pillow!

Her complaints were suddenly greeted with suspicion. Her report of odd pains resulted in a lecture on drug seeking. She was subtlety accused of being a lying hypochondriac and manipulating the system. When she broke down and cried at this treatment she was diagnosed with "anxiety problems." She had suddenly gone from normal healthy person to the bad patient.
In desperation, she wrote Dr. D to ask, "WTF just happened?"
I wish I could say that situations like this are rare, but they aren't. I've written before about Nice Patient Syndrome. Unfortunately there is also Bad Patient Syndrome, and it claims a lot more victims than the former.

While there some despicable patients out there, many of the victims of Bad Patient Syndrome are really nice folks who are getting the run around. The true illness is a mental one in the mind of medical people:

"The fault dear Brutus, lies not in our patients, but in ourselves!"

Why would doctors label you as being a Bad Patient?

1) We Suspect Everyone

MD's are a naturally suspicious bunch.
"But why would doctors who chose this profession because they want to help people be suspicious?"
Doctors have control over work excuses, narcotic pain medicines, and the exams that determine disability. This makes us popular targets of sleazy folks who want to get things they shouldn't. Docs get told more lies middle school teachers and probation officers. After getting burned a few times we learn to be suspicious. We even find ourselves being suspicious of patients who have nothing to gain from fooling us.

Suspicion becomes a habit of mind. Your docs are like the grizzled old detective walking out of an interrogation muttering, "His story doesn't add up. He's lying!"
Sometimes stories don't add up because people are lying, but sometimes they don't add up because the human body occasionally does strange things.

2) Pattern Recognition

It is often the patients with weird or atypical symptoms that get labeled as the bad ones. Diseases are typically diagnosed by identifying patterns of signs and symptoms. Doctors get pretty good at recognizing common patterns. It gets problematic when your symptoms don't fit any known pattern. We might look up your pattern in the books and run some tests and still come up empty handed. This is frustrating!

Learning the patterns of diseases is very useful. A majority of medical education is dedicated to learning these patterns, but sometimes the doctor's mind begins to slavishly adhere to patterns without exception. We start to think that symptoms that don't fit our patterns aren't "real" problem at all.

If your symptoms don't fit into any known patterns then you must be full of shit!

The human body, of course, is extremely complex and each person's body is unique and acts slightly differently from all others. The number of patients with signs and symptoms that don't fit known patterns shouldn't surprise us at all, but if you bring us a pattern we've never seen before we might just blame you.

3) Impotence

Doctor's hate to feel helpless. Our work gives us an incredible (almost superhuman) power to identify dieases and save lives. Like all superheros we are expected to use our powers for the good of mankind. Our patients expect us to be all-powerful and we like to feel powerful and needed.

Then you come along and we can't help. Heck, we sometimes can't even figure out what's wrong with you! Suddenly we go from feeling like superheros to pathetic loosers. Not only are you kryptonite to our superpowers, but you still expect us save you when we find all of our medical powers useless. We hate feeling this way!
What we should do is admit that we aren't superheroes after all and confess that your situation has confounded our ability to help. From personal experience I can tell you this is really hard to do.
Feeling powerless is a huge narcissistic injury to our superhero ego. It is a lot easier to accuse you of being a villainous bad patient who is unworthy of our heroics, that admit that we aren't as super as we would like to be.

4) Of Maybe You Are Just A Manipulative Asshole?

It does happen sometimes, but I believe many of our bad patients are just getting a bad rap. So if you are one of the unlucky innocent victims of Bad Patient Syndrome I am very sorry. It really does suck!

How do you overcome Bad Patient Syndrome? Well, it isn't easy, but Doctor D has some suggestions coming up in next week's post.

What do you think?

Have you ever been the "bad patient" or been the heathcare provider who misjudged a patient?

Doctor D always loves to hear your stories and opinions in comments.


Anonymous said...


EM intern here. I would suggest 5)The cycle of abuse. I love patients, I see myself in them. My father was an alcoholic, my mother was institutionalized twice. I've always been a touchy-feely let-me-get-you-a-sandwich kind of caregiver. Years as a basic and a medic didn't change that.

Lately it's harder. I'm really tired. I'm getting dumped on by a lot of obnoxious people (the winner of the douchebag award this week is an ICU fellow who literally snorted with laughter at my efforts to put in an a-line, and then spouted a non-stop string of excuses as he himself couldn't get it.) My patience is not what it was. I'm angry a lot of the time. I'm not really angry at patients; more often I'm angry at consultants, attendings, seniors, my program in general, the inefficiency and inhumanity and general broken-ness of the system I work in. I'm angry because I've lost touch with my friends and my marriage is strained to the breaking point.

I dunno, maybe these are just excuses, but I feel like the patient is often that one last straw. Sometimes I just have no more pity and good humor for the malignant lunacy waiting for me in that exam room. And even as I'm trying to find it within myself there's another indignity, another demand, another abusive interaction.

Pissed Off Patient said...

I agree with Anonymous. I think half the problem is the way care providers are abused within their own hierarchy. The patients become an easy target for displaced anger.

If they complain they get labeled as bad and stonewalled. There's no way a patient can really fight back, not until something really horrible happens.

I am the bad patient right now, which does not compute. I have a documented medical history, but objective data is ignored. It's Twilight Zone material.

Medicine is really messed up. Beyond redemption I think.


Tracy said...

I've totally been the bad patient, mostly because I take umbrage at having my integrity questioned (read: get really pissed when I'm called a head case). It took me a really long time to get a diagnosis, so when I saw my third doctor at the same neurology practice (for some reason, that seems to be the only place to which doctors refer people in this town), the receptionist called her aside and whispered something as she looked my way and handed off my file. "No, it's okay," the doctor said.

She'd actually administered the EMG that proved I wasn't a head case, which is why I'd booked that particular appointment with her.

I still ended up going to a university hospital for answers, but she and her mentor at the practice helped get me on the right path, for which I am most definitely grateful.

Anonymous said...

I think you hit the nail on the head. If you fall into either the easy to diagnose group, or the interestingly wierd but still identifiable group, no problem. If you have either complex or difficult issues, then you have a problem. I think it is important to realize that not only are the docs suspicious, but if you fall into the complex group, the patient may be suspicious too. I am allergic to morphine, codeine and fentanyl. So is my mother, so was my father, my uncle, my grandmother, etc. We all stop breathing about five minutes after someone gives it to us. Of course, we always tell care providers, but interestingly almost all of us have had the experience, over the generations of having been administered the drug and having the reaction. Needless to say, my entire family is anti-pain medication. We have pretty high pain tolerances and really, really don't want pain medications. We are happy to take ibuprofen, which is what we all do. However, when some bad things takes us to the hospital, say a car accident, or such, we are greeted as if we are maniac drug seekers. Pair up suspicious doctors, with patients who are convinced that the doctors and nurses are, at best, looking down their noses at them for being drug-seekers, or at worst, trying to kill them, and you get some truly toxic scenarios. In the short team, it means that we, and I am no exception, avoid going to the hospital, often making things much, much worse before you end up there, or long term, cause actual damage.

I don't know the answer, but I hope there is one, because the situation is not good.

Anonymous said...

This is a great post and I'd have to agree with others about the cycle of abuse and getting dumped on/taken advantage of. For example the patient at the clinic who missed his appointment, begged to be squeezed in bc it was "urgent" only to ask for a Viagra prescription. When you can see upwards of 30-40 patients a day your patience wears very thin for cases like that.

It's also a fact of life that doctors like to label things...easy case, tough case, the patient who's a "rock", the malingerer, etc. Putting things (and people) into boxes isn't always nice but it's done constantly.

Lois said...

My doctor really like me. We had a very good relationship and worked to keep my thyroid problems in check.

Then, I got sick, very sick. Initial referrals were fruitless as I was told all tests were negative. Specialists fell by the wayside. My doctor cared but didn't know what to do. He treated my severe B12 deficiency with self-administered shots and the D deficiency with prescription level D.

Eventually it was found that I have progressive MS but the story continues with a 'growing' Polyneuropathy, Radiculopathy and swollet Parotids etc.

I have had to fight to be diagnosed and then to find the right combo of MS pain protocol. I am so tired. I use my blog to record this path. You might be interested. It's called My Ragged Soul.

Yesterday's essay is about this very topic. Called, Taking Back My Power

Aviva said...

Great post again, Doctor D! :)

The Nerdy Nurse said...

Nurses and doctors make the worst patients.
Clever post. Both entertaining and informative. The superhero complex plagues many healthcare providers, if you give us a problem we can't solve, it often makes us angry and anger breeds poor attitudes and behaviors.

Nicole said...

A good post. I got sick last month (basic upper respiratory infection) I usually get sick once a year, and it usually takes a week of antibiotics, antihistamines, cough meds etc for it to clear up. For years my docs gave me these same things when I got one of my upper respiratory infections.

This past winter I got sick again. Same exact symptoms as every other time, but the new doc refused to give me anything. When I asked him to at least give me some cough medicine (because nyquil doesn't help me sleep) he acted like I was a drug-seeker. Told me to go take some mucinex over the counter. I took the mucinex and came back 2 weeks later with an ugly cough. Got a different doc, and she gave me the usual stuff (including the cough medicine with codeine) and it cleared up in a couple weeks.

Whats so hard about abx + cough medicine + expectorant? Is prescription cough medicine really so addictive?

John MD said...

Reminds me of the hilarious Seinfeld episode ("The Package") in which Elaine can't get help for a bothersome itchy rash because she has been labeled a "difficult patient." Truthfully, I find myself getting very frustrated when what I tried didn't work or didn't reach a clear diagnosis. But I try to always, always listen to the patient (again if necessary) and make sure they know I heard them....and then I usually refer them, but always with plans to see them back afterwards.

Anonymous said...

I have been and occasionally still am the bad patient., but never on purpose. I am blessed to have a rheumatologist who doesn't blame me (or at least doesn't treat me like she blames me) for not being a textbook case, and for having complications that are rare.

I've had docs, though, who were dismissive, rude, and a contributing factor to my eventually taking anti-depressants from their failure to diagnose/missed diagnosis that I got stuck in because zebras, though rare, do exist.

Mindi said...

Or maybe you all just have fibromyalgia, which your "doctor" doesn't believe in. Throw in a positive rheumatoid factor which might explain why your joints hurt all the time, but your doctor was sure you were faking it, so did NO labs! It isn't always the patient - I found that out after 7 years of trying to figure out why I felt like a pile of dog crap on a hot afternoon. Sometimes there are just bad doctors. Seriously, Dr. Seven was the FIRST doctor to do labs.

Anonymous said...

Uh, yeah, I have been labeled this patient. But in the end I was able to throw it in their faces! Four years undiagnosed hypothyroidism in my twenties...labeled took my high school graduate mother to diagnose me. Had to fight with the mentally deficient MD at the college health service to run the test. Sure 'nuff good old Mom was right. Same thing with my ankle problem in my mid-thirties and my gallbladder two years ago, and probably my current medical "mystery." Doctors, in my opinion, suck at their jobs.

Anonymous said...

Ever heard the phrase "significant somatic focus"? Well, it means you're translating emotional probs into physical symptoms . . . or for some other unknown reason. Well, I recently heard that one, despite the fact that MRIs, EMGs, NCS and on and on confirm advanced degenerative disc disease, throughout the entire spine, stenosis in multiple areas, multiple compressed nerve roots in multiple areas, so yes, I do focus on my body probably more than the average person ~~ because it frickin hurts !!! But I've had 2 moderately successful lumbar surgeries, and will soon have a triple cervical fusion, which I hope to be helpful, I work at physical therapy very hard, and want to return to work..... am outward-focused, as active as I can be under the circumstances, but a brilliant 2nd opinion MD (that I decided to see, just to make sure surgery was necessary) decided I was "too somatically focused" to allow him to agree with my MD and surgeon and physical therapist, that this surgery was likely to have a good outcome . . . I'd like to have him just slip into my body for a few days; maybe he'd be a bit more curious, and a bit less judgmental and suspicious. Problem is: your medical record notes don't ever go away, so can really cause problems down the road with insurance denials; etc. They can always deny claims, citing "she's a head case, exaggerating, just lazy, doesn't want to work" or whatever, and that leads to having to undergo psych evals just to get your claim paid. So some careless assumptions on the part of an MD can bring chaos into a patient's life. You've probably figured out, I'm annoyed. Thanks for listening.

Belinda said...

Thanks Anonymous for your post. I work in a teaching hospital and see first hand the bullying and abuse that goes on. I am a CTICU RN. 8 years ago, during the prime of my life was dx with RA and Sjogren's syndrome. Had lots of problems with RA, been through the different meds. More control over the disease than in the past, but have started having neuro symptoms, I believe r/t sjogren's. Vertigo, fleeting hearing deficit, blurred vision, temporal h/a, occipital h/a, pain with eye movement, and severe fatigue to the point where at times I just need to lay down no matter where I am. I've been to ENT, neuro, rheumy, and ophthalmology. My last visit was with ophthalmologist 3 weeks after the onset of the ocular symptoms, and after being on taping dose prednisone (starting at 100 mg daily) for 3 weeks. The ophthalmologist told me "I don't see enough evidence to say that you have symptoms from Sjogren's" He was almost hostile. After 3 weeks on steroids, you probably wouldn't. I have a moral and legal obligation to provide care to patients. If I am neurologically impaired, I am negligent in attempting to provide care to patients. I have to be able to survive and pay my bills though. My employer tells me to go out on disability (a lot less money than I am accustomed to making), I have no idea what is written in my medical records, because I never even considered disability until the neuro symptoms began showing up. My doctors act like they never heard of severe fatigue with RA or Sjogren's and they act like neuro symptoms don't happen unless you have a tumor. Thinking about writing a letter to be included in my medical records detailing my symptoms and that I sought medical care for this. I check and double check my actions at work, home, driving etc. I cannot even take care of my own home anymore. If I spend a few nights on duty, I pay for it dearly for the next few days. I truly believe that being a nurse has actually had a negative affect on my medical care. Doctors seem to hate nurses.

Anonymous said...

To "anonymous" who spoke of being labeled as too somatically focused to expect a positive outcome from surgery: I'm an RN and I could have been the one writing your post, nearly verbatim! As you said so aptly, of COURSE I was somatically focused -- I was in extreme pain -- for nearly 2 years!! (Duh.) As in your case, the second opinion "Mr Second Opinion Doctor", as I over-politely refer to him, was the one who gave me that label. My own doctor and physical therapist and neurosurgeon all three laughed, pointing out clearly that I don't live that type of lifestyle, and my own doctor had known me for over ten years. I never went back to this second-opinion jerk. I had the surgery, with a good outcome. I doubt this doctor has any idea what this sort of label does to a patient, emotionally--especially when they're already worn down from having so much pain. And, as you point out, this information never goes away from your electronic record... and causes problems with insurance companies, etc. My own doctor said that the usual protocol, following this sort of labeling, would be to send me for a psych eval; eg., to make sure this wasn't all in my head. However, because he had known me for so long, he didn't require that. He did write a rebuttal opinion in my record (bless his heart). But this kind of practice of labeling patients with this sort of thing is done much to cavalierly. And it can devastate a patient in so many ways --- forever.

Anonymous said...

Many MDs come from a streamlined background of life experiences; often from a protected background, focused studying in work during colleg, med school (which is not so much an academic place anymore but functions according to "I pay a lot, so I determine what I learn"), residency; organizing the personal life in between. Limited time for travel, reading or other experiences. Not the best set up for thinking outside of the box in a field that thrives on "pattern regocnition". Nor to being able to reflect on oneself. Much of the labeling of "bad patient" is defensive and reveals poor professional attitudes.

Anonymous said...

Sounds like fibromyalgia

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