Psychotic Medical Students

Doctor D gets lots of emails from students considering medical school.

Hey, if the practice of medicine is your dream then you should go for it, but be forewarned it isn't sexy or glamorous like on Grey's Anatomy. It is years of drudgery in which helping patients and feeling awesome about yourself will be the exception rather than the rule.

But I pray to God you never go totally off your rocker and spend your precious days off making videos like these:






Doctor D has more relevant material than silly parodies of parodies of parodies, but unfortunately not the time to post it right now.

He's also about 2 months behind on answering AskAnMD emails. Feel free to chastise him the comments!

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!

My Favorite Patient Died Today

I just got a call from one of his relatives who found my number in his wallet:

“The Dude” was one of Doctor D’s first patients. He was assigned me when I was a new doc starting out in residency.

The Dude was one of those people that we all go into medicine to “help.” He was poor, and on disability, and had never gone any further than high school. The Dude also weighed about 400 pounds and smoked 4 packs a day, and he hated taking medicine ...and it was new Doctor D’s job to “take care of him.”

Medically speaking, I never was much good for The Dude. He kept doing all the things that eventually lead to his demise. In the end though, it was he that did me immeasurable good.

He actually preferred residents to our better-trained teachers, “I love these new Baby Docs when they come each year!” he exclaimed when he met Doctor D. From then on Dr. D and the Dude were always together. The Dude had a lot of office visits and hospitalizations. He was the epitome of the “difficult patient” and D spent his first year as a doctor stressing about how to save The Dude from impending death.

But it was The Dude who won out. His infectious kindness and joy in the face of pain and illness inoculated Doctor D against the harsh medical world around us.

One day D visited The Dude in the ICU and muttered, “How am I going to save you, Dude?”

The Dude let out a gravelly, smokey chuckle, “You don’t need to save me Doctor D! You’re just nice to me and I appreciate that.”

The Dude is laid to rest

Our doctor-patient relationship evolved over our years together. I did less telling him what to do and more sitting at the feet of one of the wisest human beings I have ever known. The Dude lacked any book smarts, but I know he was brilliant. He understood how a joyful attitude can keep you alive when every textbook says you should have died years ago.

The Dude had about the most unhealthy body and physical habits you can imagine, but he had the healthiest soul of any person I have ever met. He taught Doctor D that there is so much more to life than diagnoses and treatments.

The Dude promised he would try to stay alive long enough to see me graduate from my residency. He ended up outliving his promise by years. I moved to another state after graduation, but we stayed in touch. I was no longer his doctor, but we remained friends.

I took my son Little D on a road trip when he was just a baby to meet my sage friend. It was well worth exposing the kid to a little second-hand smoke. It was like taking your child to be blessed by a living saint.

The Dude and I would write or talk on the phone every couple of months. I started this blog with The Dude in mind. I wanted to answer questions for real folks like him that didn’t give a damn about medical stuff, but found themselves stuck in doctors offices and hospitals anyway. He's the only patient I ever cared for in real life who knew about my secret identity as Doctor D. He read regularly.

We last spoke about 6 months ago. I had “Call The Dude” on my long list of things to do last month, but I never got around to it. I sure wish I’d called my jolly, smokey old friend!

It came as a shock that he's dead—which is strange considering I expected him to die at any moment for the first few years I knew him, but once you really love someone you kind of expect them to live on forever.

Now The Dude is in a place where he has no need for doctors or medicines.

Enjoy heaven, my friend! I wish I'd told you that you were the best teacher Doctor D ever had!

Happy Doctors Day, Fools!

Yes Doctor D is back, making an early emergence from his peaceful Lent respite:

Happy Fools Day! Which also happens to be Doctor's Day.

Actually the official Doctor's Day is on March 30th, but such an obscure holiday usually gets forgotten, so it's about April 1st by the time the nurses or hospital administrators get around to handing me a card.

"Um, yeah so it's like Doctor's Day so here's a card and stuff," they say as Doctor D suspiciously takes the generic thank-you card expecting to be ridiculed for some sort of foolishness momentarily.

The ironic serendipity of Doctor's being honored on April Fools Day is just the sort of thing that makes me miss this blog, where I may freely ridicule the health profession.

A day for doctors, seriously? That makes about as much sense as National Goat Cheese Month! Apparently the date was chosen based on the first date an MD knocked a patient unconscious. If that isn't a day to celebrate, what is?

While doctors love thankful patients and adoring nurses, we would rather not celebrate doctor's day. We seriously don't need a holiday. A day off maybe, but not a holiday.

Of course, a holiday can serve to increase awareness—in case anybody is unaware of doctors.

I pity the fool who is unaware that Doctor D is back!

I shall return on Monday with an answer to an interesting question!

Until then discuss amongst yourselves: What is the best way to celebrate National Goat Cheese Month?

Of Course, It's All In Your Head!

A patient asks me:

"Doc, are you saying this is all in my head?"

The assumption behind the question: things in the mind are not real. Doctors also display this unfounded assumption. We just obscure our prejudices by using medical jargon like "supratentorial." (First reader to define Supratentorial and use it in a sentence wins Doctor D's prize of the week!)

Every illness you ever had was "all in your head." Seriously, where else could it have been? You have never felt a symptom, whether it was a broken ankle or a broken heart, that wasn't felt in your mind. Your mind is your consciousness. Every pain, cramp, anxiety, or ache is felt exclusively in the mind. Your mind is not a part of your body. Your body—as you know it—is a part of your mind.

Doctor D, has had a couple brain-dead (literally not figuratively) patients. Trust me, they never complained of anything! They never had any symptoms. They never felt bad. And their bodies didn't survive long without minds.

Many doctors hold to this absurd theory that your body is a separate entity from your mind and physicians should focus solely on the body. But the human mind keeps getting in the way and annoying these stupid doctors. Of course it does! The mind and body are completely interwoven and inseparable.

This crazy idea that the mind shouldn't interfere with the body has spread from stupid doctors and now created a stupid culture. It is tricky to actually figure out what is going on with a person because everybody now denies their mind has anything to do with their symptoms. Lots of patients refuse to answer when Doctor D asks about their feelings about their symptoms or illness. I can understand why. They're worried that Doctor D thinks they are nuts. Having a mind doesn't make you crazy, it's loosing your mind that is crazy!

So Doctor D has some ideas for how MDs and patients can overcome our anti-mind biases and improve doctor-patient relationships:

• First, doctors and patients both need to acknowledge that all symptoms are real. If you feel it in your mind then it is real—period. We don't say that happiness is "imaginary" because it is a mental state. We shouldn't say that any discomfort is imaginary. Fibromyalgia and panic attacks are just as real as pneumonia and broken bones.

• Second, doctors and patients both need to acknowledge that the mind is real and it matters. I know this sound obvious, but some doctors still think only Psychiatrists should pay any attention to patients' minds. No matter what the disease, ignoring the person to focus solely on the body will lead to disaster after disaster in medicine. Patients also need to be willing to discuss their mental attitudes and recognize that the mind plays a role in illness and healing.

• Finally, we need to understand that different symptoms need different treatments. Not every symptom needs a big work-up or a strong medicine. It is my job to help people distinguish dangerous symptoms from ones that are not. Shortness of breath that starts when your girlfriend breaks up with you merits a different work-up than shortness of breath with unilateral leg swelling and a low pulse ox. Both are real problems, but not the same problem. Understanding your mental and emotional experience of your symptoms helps me better diagnose you and avoid giving you treatments or work-ups that could cause you harm. In order to successfully negotiate these interactions a patient must trust that the doctor has taken the first and second step and isn't assuming they are crazy.

What do you think? Does it bother you when your doctor asks about your mental state when you report physical symptoms? Or does your doctor seem to be biased against the mind and imply you are crazy if you bring up your feelings? Do you think that these 3 steps can improve doctor-patient communication? Doctor D would love to hear your thoughts!

Is The Patient Crazy—Or The Doctor? (Friday Links)

Doctor D found a great blog by a patient with lots of physical maladies who used to be reporter for the Associated Press. Now she is "Sick Momma" and blogs on her life as a chronically ill mother and wife. As D was enjoying her blog and came across this post about some conditions he'd never heard of.

Apparently Sick Momma believes that many doctors suffer from a mental disorder which causes us to attribute symptoms we don't understand to a patient's mental state. Whatever!

Patients expressing unfamiliar complaints to their physicians often induce the "It's All In Your Head" (AIYH) or the "That's Impossible" response in doctors suffering from these behavioral problems and personality disorders.

Physicians fixated upon the metaphysical belief system of "If we don't know about it, then it doesn't exist" are suffering from a mental defect or psychological condition known as "Doctors with Unexplained Medical Beliefs": D.U.M.B.

Excuse me? I'm the doctor, so I'll decide what is a disorder and what isn't!

And I've never heard of these "behavioral disorders," which leads me to suspect they don't exist! Since I have no idea what put these crazy ideas in Sick Momma's mind, I shall diagnose her as depressed and put her on Prozac. I shall continue to add psychoactive medications until she learns not to challenge my god-complex!

***

Actually this is an interesting problem: What should be done about symptoms that make no sense? Lots of patients and doctors end up these situations.

The doc is thinking, "This doesn't sound like any disease I know about. All these symptoms are subjective sensations. Maybe it all is in this patient's head?"

The patient is thinking, "This doctor doesn't know what is causing my symptoms! What an ignorant doctor! If my doctor has never heard about this it must be something rare and horrible!"

It is a tricky impasse. Each can't help but have these impressions sometimes. We all want to prove we aren't ignorant or crazy, but then again we all want to be agreeable. Often these situations end up with either unnecessary antidepressants, unnecessary testing, or both.

We need better ways of discussing strange symptoms. Hence, in next week's reader question Doctor D shall provide some answers! (or perhaps some humble suggestions)

Until then, what do you think? Has a doctor ever told you your symptoms were all in your head? Have any of you healthcare providers ever had a patient who had nutty symptoms? Doctor D would love to hear your stories!