Jun 16, 2011

What To Do If You're A "Bad Patient"

Last post Doctor D explained the sad phenomenon of "Bad Patient Syndrome" to a reader who had been branded by doctors as bad. Today in the Clinic of Dr-Patient-Relational-Awesomeness we shall teach you proven therapies for curing Bad Patient Syndrome:

The Super Simple Solution:
Find another doctor. If one doctor-patient relationship didn't work there are lots of other fish in the sea. Move on!

Knowing there are lots of fish in the sea isn't always comforting!

When the 'Super Simple Solution' doesn't work:
Some people seem to get labeled as a "bad patient" wherever they end up. Within a minute of entering the exam room the doc seems to decide that that you are gonna be trouble. Of course, some patients get this label because they really are irredeemable assholes, but most aren't. Many "Chronically Bad Patients" are just people with difficult or undiagnosable illnesses or a personality that for some reason triggers the suspicion of people with MD behind their name.

So if you are one of the unlucky innocent victims of Bad Patient Syndrome, I am sorry. It really does suck. When the simple answer doesn't work the therapy is going to be longer and harder, but it still can work...

How To Overcome Bad Patient Syndrome:

Don't confront!
If medical professionals' totally wrong impression of you is not grounded in objective reality, then you would think that exposing the falsehood would make it go away. After reading the last post you probably wanted to storm into your doctor's office and yell, "I'm not bad! In fact, I'm a great person. It's YOU who are wrong! Your own fucked-up physician brain that has unjustly labeled me! Dr. D said so on his blog!"

While I'm sure it would feel great to tell off your doctors it wouldn't help. It would likely make things worse.

Confrontation: It won't always have positive results.
Bad Patient Syndrome is a prejudice, and like most delusions prejudice is most dangerous when you try and expose it. Prejudice is subconscious. Docs don't recognize we think this way. Your confrontation or insisting on your innocence only confirms our suspicions that you must be a manipulative asshole.
If you directly attack a delusion it will only entrench itself. You have to work on it subtly until it is the prejudiced person who realizes they were wrong. Your doctor must think they discovered you aren't a bad patient on their own, without any confrontation from you at all.

Dr. D only realized he was labeling people as bad patients after he "discovered" that a few "bad patients" were amazing amazing people after all. In retrospect, I think they were quietly working against my prejudice all along.

Don't act suspicious
Okay, I admit this one is hard. Once you're labeled a bad patient everything you do is suspicious. Doctor's prejudice against you seems to find confirmation in everything you do, but this doesn't mean you have to give us ammunition.
The best way to approach this is to imagine yourself in the doctor's shoes. Ask yourself, "If I suspected someone was manipulative, dishonest, or crazy would this behavior seem to confirm my suspicion?" If the answer is YES or even MAYBE then don't do it!
When a patient suspect they're being unjustly labeled as being a bad patient the instinct is to resist. Patient's get angry or argumentative. They beg and plead. They lose control of their mouths and emotions. They accuse their doctors of incompetence or malpractice. They behave erratically and refuse to work with their doctors. These desperate attempts to resist only confirm the doctors' prejudice toward them.

Instead your strategy must be to come across as calm and above suspicion. Try to act as normal and well-adjusted with your doctor as you do with your friends and family.
If your doc seems frustrated with you say in the most genuine way you can, "I know I'm a difficult case, and I realize I'm in the wrong on this. (Take the blame even if you weren't wrong) I'm still new to needing medical help. How can I do this in a way that help you, doc?"
I realize this feels like giving in to an asshole bully who has mistreated you—and in some ways it is—but if you have an illness that needs medical help and the entire medical system is against you then you might have to play along with our delusion for a while. Sorry!

Knowledge is Power
If you have been unjustly labeled as a bad patient this may be the most important blog post you ever read. Understanding the bizarre psychology of the medical mind is of the utmost importance for you:
  • First, you can finally realize it isn't your fault: You really aren't a bad person. It really is a false label that has been attached to you by delusional physicians.
  • Second, you can understand WHY the doctor's mind becomes this way: While our prejudice against you is totally indefensible, you may realize that it is a warped product of our desire to do our jobs right and help people. Perhaps this will allow you feel sorry for us instead of angry with us.
  • Third, you can make peace with the fact doctors are out of touch with reality: It's hard to take a totally reasonable person calling you bad, but you don't mind if a crazy person calls you names because he doesn't know what he's doing. Don't assume doctors are sane just because we have letters after our names! We are subject to psychological trauma just like anyone else--and we get a lot of it in this job. It is quite possible that you are the most emotionally mature person in your doctor-patient relationship. Treat us like your grandfather with Alzheimers and play along. "Sure Jimmy Carter's the President and the KGB is trying to break into your tool shed each night."
"Don't let the white coat fool you. I'm absolutely bat-shit crazy!"

This knowledge will give you the patience and peace of mind to gradually undo the damage of Bad Patient Syndrome:

Your Long-Term Strategy
If you are stuck as the bad patient no mater where you go then stop switching MDs before you get labeled a "doctor shopper." Pick one doctor and stick with him or her. Pick a doc who seems at least slightly reasonable despite their totally misjudging you. This should usually be a primary care doctor, but if you have a chronic illness you may want a doc who specializes in your condition.

Work patiently with your doctor. Don't try to change you doctor's idea that you are a bad patient anytime soon. Your goal is to let his or her mind change on it's own. Your long-term campaign of patience, kindness, and consistency will eventually wear down your doc's prejudice.

I'm not saying this is easy. Changing anyone's misinterpretation of you is hard, and it's doubly hard when it's your doctor and you feel sick and are worried about your health.

As you work with this one doctor you will learn a lot about doctors in general. We are an odd bunch, but we are also predictable. You'll start to learn how we think: what sets off our prejudices, and also what lowers our defenses and makes us humane.
Chances are if you are getting repeatedly labeled a Bad Patient there is something about your style of interaction that sets off alarms in the medical psyche. Work patiently with one doctor to cure your "Bad Patient Syndrome" and you'll likely find the doctor-handling skills you learned will work with every other MD you encounter.

This Therapy Might Just Save Your MD Too:
Yes, you the "difficult patient" could be the one who saves an MD from becoming and eternal asshole!

Dr. D was once near burn out and lost within the delusion that patients who didn't act the way I thought they should were bad. It only took one patient who I had previously written off as a hopeless bad patient to turn me around. He was so damn genuinely nice to me that I suddenly realized I had been calling one of the most amazing human beings I would ever meet a "hopeless trainwreck."

In many ways a "bad patient" has the opportunity to transform a physician and positively affect thousands of other patients in a way a "good patient" never could.

What do you think?

Have any of you who have been labeled a bad patient every tried this?

Do you think heathcare workers are open-minded enough to reexamine their prejudice about a "bad" patient?

Dr. D always looks forward to reading your stories!


C said...

I'm totally a bad patient, but I think it's partly because I'm a medical student and partly because the doctors at student health are... not competent. in March, I suggested to the doctor that she listen to my lungs on bare skin instead of over my sweatshirt (I was having an asthma exacerbation). That did NOT go over well, but seriously that's one of the first things we learned as first years. I also pissed her off when I told her I wasn't going to take HCTZ for my blood pressure anymore because I'm pretty sure it was stress related- and after the semester ended but before I got super stressed about boards it went back to normal. 138/90 is not going to give a thin 25 year old who doesn't smoke a stroke. If I had a choice of doctors I'd find another b/c it's clear this woman does not like me (partly my fault), but I'm sort of stuck with student health. I recognize that I'm a "Bad Patient" but at this point it's due to my view that the doctor isn't doing what she should be.

Pissed Off Patient said...

I think this is a helpful post. I also think what happens is having weird medical stuff just makes you a bad patient even if you are otherwise a normal person. The patient can't win and the 'bad patient' label is applied when they are most vulnerable, most in need of help.

My main wish is that the medical community begins to deal with their enormous dysfunction because it is hurting patients.

I don't get the sense that there's much of a push to improve things so we stop creating burned out doctors. Half the problem is the abusive medical school system.

Doctors do to patients what was done unto them.


Anonymous said...

Hi Dr. D,

I see where you're coming from (and appreciate most everything you write). But I'm having a hard time swallowing this advice. I went through 5 years of every medical test under the sun and was told I was crazy in about 50 different ways...when it turns out I was getting pneumonia repeatedly. I was diagnosed, and undiagnosed, with asthma about 20 times. It's really easy to blame a patient for being non-compliant and not taking their meds when you as the doctor can't get your story straight. And it's really really hard as the patient to be well, patient, when you're having that much trouble breathing. I really should have been in the ER much more often, but my doctors so minimized my symptoms that they had me very confused. I finally had major, major surgery to fix the problem. Because after 5 years of going through hell I found one doctor who knew something about my rare condition and hadn't only read about it in a textbook.


Anonymous said...

Oh...yeah I don't know if that was clear. My pulmonologists (I stuck with about 2 in the end) had me go off the asthma meds since I didn't have asthma according to them, and then I would get accused of non-compliance by other well mostly cardiologists, who kept saying the problem wasn't my heart but couldn't really diagnose me with asthma either. But really, why wasn't I taking my inhalers again?

Tracy said...

I did get very angry and very vocal with a neurologist once, which certainly didn't help me prove that I wasn't a nutcase. But nothing would have. I know in my very center that the guy's mind was made up. So I took the neuropsych he recommended, and he ordered the EMG he didn't think I needed. The EMG turned out to be the first abnormal test I'd EVER had, and eventually led to the testing that DID show what was going on with me. Of course, it only led to that testing because I still PUSHED for that testing (with a doubtful but more rational neuro at the same practice). Everyone in the office was happy to leave the diagnosis at cramp fasciculation syndrome. (Which, hello docs, is caused by something, not always the same thing.)

My condition (atypical [sodium-channel] myotonia congenita, a kind of potassium-aggravated myotonia) is supposedly very rare. Since it took me years to be offered more than the standard ANA panels and my story is not unique, I have some doubts about rarity statistics.

My new neurologist, the university specialist who diagnosed me, said that he hears of patients called crazy all the time, and that "it's heartbreaking."

K said...

Doctor D, I like your post. I first started reading it as a patient and then as a nurse. It's a toughie. I know at work (in my PICU) I used to often mislabel my patient's parents as "crazy" and "difficult" because so much of my work is based on current circumstances and at times sudden critical situations that even our best attendings can't explain. And then, we get the wrath of the parents: "this is supposed to be the best facility in the state and all you can tell me is 'we're watching it?!'" and so on. I am now of opinion that when a person or their loved one are ill, they are SO desperate for answers and their psyche gets well, screwed up, for lack of a better term. They almost become irrational because of their anxiety and fears. It's nice when the problem gets solved fast, but it totally becomes a permanent state of anxiety when the patient becomes "chronic." It messes with their own mind (in your case, with adults) and in my case with the parents'. I have been trying to put myself into their shoes and think: "how would I feel about this if I was on THEIR side of the bed?" and it usually makes some kind of sense. That said, I have had situations where I wanted to pull my hair out and no, those parents/patients would have NEVER been able to redeem themselves, even with all the great advice you're offering. Period.

That said, as a patient, I used to be a "bad patient" but I learned my lessons. Partly because I realize the infallibility of human kind and that despite what our society thinks, doctors are still human beings and they don't know everything - and when I find a good doctor, I STICK to them as hard as I can and I let them know they're appreciated. At work, or my personal ones. Because I can see when they don't know something, but I have learned to TRUST that they will figure it out. I think TRUST is a biggie. If one doesn't trust their doctor - it's a bad relationship from the start!

I think in American society, the medical and legal systems are SO inflated when it comes to pride in being in it, that when a patient walks through that door, they think 1) you make the big bucks, you're gonna charge me "up the a**" so cure me, 2) you went to school for all these years, so you're capable of "fixing me" and etc. I've heard it a few times already. And that's just it, because things are so inflated, people elevate a doctor's level of understanding, even if it's unfounded. So expectations rise based on truly nothing. On the other side of the coin, a doctor's opinion of self (and from what I've noticed, the younger the higher) is pretty high, too. They feel they've earned it (which they have) and sometimes tend to say things on a higher level unsuspectingly without meaning to hurt anyone's feelings, but come across as something different to the patient. (I've heard this from a couple of parents when my attendings steps out.) This elicits a defense mechanism in the patient and here comes the "bad patient!"

Pissed Off Patient said...

K: I have had issues because I don't elevate the doctor's level of understanding.

They get really mad/threatened when I mention I was premed for 2 years to figure out my diagnosis. (To date not one single doctor has caught the HPA axis suppression, it has always been me asking for the testing.)

So I don't mention it anymore, but I still have to push against their inertia as a result of that education,of what I know, which causes problems anyway.

Damned if I do, damned if I don't.

Really, I expect incompetence at this point. I don't even care if the doctor knows anything anymore, I just want them to be willing to work with me.

Case in point, the endo now has an odd take on the diagnosis, but does seem to be listening to my input and working with me, not telling me how it's going to be. At the moment, the diagnosis doesn't matter, if it ever does then this relationship will fail too.


Linda said...

My identity as a bad patient started after my primary care MD was unable to figure out a medical problem I had so I was told it was all in my head. After being referred to 2 other in-network docs, their conclusion was also that I was wasting their time with my psychological complaints. One doc never asked me any questions – I was greeted with, “Well, I read your file, here’s your problem, I know it hurts but there’s nothing wrong with you so just ignore it and after awhile you’ll realize that it’s all better.“ After a few years of putting up with the problem, I went to someone outside the group for another reason, was treated with respect, the doctor found the second problem was a result of the first problem, treated it and it went away. I assumed I’d go back to my primary care MD and she’d now treat me better because it was a proven fact that I wasn’t just a lazy whiner headcase but I’m still treated like a bad patient. If I go to someone outside the network, I’m treated as though I’m a normal person who had something unfortunate happen. All I can figure is that there’s a big red “Loser” stamp or code word on my file that my regular doctor and any others in–network see that will follow me all my days. I’m polite to everyone in the doctor’s office because that’s how I was raised but it twists my stomach into knots every time I have to go. I’m not accustomed to being disliked – it doesn’t happen anywhere but the doctor’s office.

Library-Gryffon said...

I was a bad patient my first year at one university with Student Death. Of course they assumed, usually correctly, that everyone coming in with sinus headaches (which I've since found out were mostly migraines) was just looking for a note to get out of an exam or term paper. When I came flat out once and said I didn't want a note, I wanted to know if there was anything I could do to make it go away, or at least go away faster, so I could write the paper, I suddenly found myself in the "good patient" group.

Old MD Girl said...

Dr. D -- The only way to avoid being labelled difficult is unabashed ass-kissing. Do it to EVERYONE in the office. The front desk staff, the nurse, the fellow, the attending. EVERYONE. And when you talk to the doctor, be as direct direct and pleasant as you can possibly muster. If you want to add something to your story and need to interrupt, act really meek and apologize for interrupting, and say you were just mentioning it in case it was important. Cater to the drs ego. If you are a difficult case, at least the doctor is not going to think you are manipulative or crazy -- probably. And they will like you and be more inclined to help because of it.

I often use student health as well, and have found most of the practitioners to be borderline incompetent. You know what helps? Reading up to date ahead of time and plain and simply directing my own care, which they seem to expect anyway since I am a med student. If they resist, you can always say, "well, I was looking at up to date, and it said XYZ. What you do think of that?" I realize that most patients are not able to do this, but for me it has helped a lot.

Mostly though, it's the ass kissing that's been the biggest help.

charlotte dentist said...

This article brings up some interesting questions. I think it would help if everyone would realize that both doctors and patients have bad days. I try to give people the benefit of the doubt. However if they continuously act crazy... ummm.. you may be dealing with "bad patient."

xx said...

Hi, thanks for this post. Just wanted to say this is also called "confirmation bias."

Anonymous said...

I'd like to see a post on bad doctor syndrome,
why is it always the patients fault? Are doctors capable of any form of self introspection?
Patients are putting their most precious asset in their doctors hands, they are completely vulnerable
The doctor/patient relationship is not an equal, balanced relationship. Patient's sometimes feel like they are standing in front of a judge, pleading their case.
That's crappy healthcare service

Anonymous said...


I think that "bad doctor" syndrome is in the news all the time. Google "how to protect yourself from bad patients" and you will find nothing but articles about "bad doctors"

It is almost impossible to find any helpful information for doctors to protect themselves from predatory patients.

There are patients who try to use sexual advances on the doctors, or bribes, or threats to get prescriptions they want. Patients who lie about illnesses, won't follow treatment courses and then attempt to sue the doctors..the list goes on and on.

Most doctors are not rich, in fact, many are barely making it after paying ridiculously high malpractice insurance and attorney fees.

Sorry..but I feel for the doctors more than the patients. Most are not trained as well as they should be, not paid at all what they should be and expected to cure people who won't follow their advice and get angry that their cholesterol isn't going down after being put on medication, and lie about the fact they have not changed their diet and in many cases are eating worse than before they were on the medication....etc etc

Anonymous said...

If you feel more for Dr's than patients, then my advice to you is
1. Don't ever get sick
2. For the love of God do not become a Dr. or any other form of healthcare professional.

Anonymous said...

I have tattoos up and down my arms and wear baggy clothes. 90% of the doctors ive seen have treated me like shit. I have Transverse Myelitis and need painkillers along with a variety of other drugs to counter it. I was getting drug tested once a week for 2 months, passing everyone btw. I switched doctors because i thought this was ridiculous and the new doctor i saw, made negative comments about my clothes and tattoos. I wanted to knock his teeth in, im friendly as can be, but not fake, make direct eye contact and still i get this label right off the bat because of how i look. I never in my life have been so frustrated with the entire medical system from doctors to insurance. Its always something with these dumb painkillers, i think doctors need to remember that i didnt ask for this, im 26 years old and have trouble playing with my children, have trouble walking without a cane. I DONT WANT THIS!! Too many doctors have grown suspicious in the wrong way.

phlebotomist 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.

phlebotomy schools MD

Anonymous said...

it all seems hopeless sometimes. I have Aspergers, and my manner is seen as abrasive. I am so afraid to go to any doctor that when I do NEED to go, I often cannot. I've had to leave from the waiting room before being called simply because I knew that by the time I got inside, I would have done more harm than good. I have dealt with depression all my life, and have come to not trust the profession. I've met some really good ones and some really bad ones, so I understand the prejudices involved. But the doctors don't seem to realize that they have an enormous capacity to do MAJOR harm on a psychological and in terms of reputations. I have reached an absolute limit to how much rejection and hurt I can deal with yet my health is such that I must rely on it if I am to control my diabetes, blood pressure and Hep C's damaging effects after 25 years. I am not able to function in that world, and no one is able to see me as anything but a problem. I have no one else I can go to, and now must accept that I am going to die for wont of any medical care. It is a harsh reality for me to accept. The tide has turned in the doctor-patient relationship. I find it hard to see it as Doctor & patient; it feels more like technician & customer. The impersonal nature has become the norm. "Do it my way, or I won't waste MY time on you." I will die from this label, as surely as if I was infected with any terminal disease. And the scary thing is ... this guy does not even realize what he has done.

Anonymous said...

1- thank you for enabling anonymous comments. I wish everyone did. I don't like my name or alias plastered across the internet so it can be used against me.

2-You, MR. D. (the title 'doctor' was revoked by a really crappy neonatologist who liked to play frankenstien with my kids and who threatened to sick the government (social workers) on me when I dared to question his judgement). Anyway, you are quite wrong about thinking that someone can overcome the bad patient syndrome. Physicians are awful sources for pain medication unless you have something that is measurable and that's just the way it is. Its not necessarily the physician's fault either b/c of fear of lawsuits.

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