Better to Best: Thoughts on Global Health Care Systems

Difficult Patients.

Posted in Doctoring, Medical School (General) by reshmagar on August 30, 2011

A few weeks ago for my family medicine rotation, we were asked to write about a difficult patient encounter. I’ll share with you all what I wrote as this pretty much sums up how I feel on a daily basis on this rotation.

During my first few days at my site, I have not had an extremely difficult patient or interaction that has stuck out in my mind more than others. In fact, almost all of my patient visits have been a bit difficult in a strikingly similar way. None have been difficult because the patients have complex, multi-systemic illnesses or because they were extremely abrasive. Most of the patients have a trusting relationship with my mentors and get along with them well, regardless of their condition. Instead, I found the patients regardless of their age or background to be difficult not because of their presentation but because of what my mentor and I couldn’t do for them.

From one patient to another, I’ve seen a pretty similar problem list – high blood pressure, high cholesterol, and prediabetes/diabetes. Many also are overweight or obese. Many others used tobacco. The age of the patients ranged from elderly women who were now afflicted with COPD and other chronic conditions to teenagers just entering middle school. The blood pressure and diabetes were easy to manage by either titrating up their medication, refilling current prescriptions, or adding another to their daily cocktail when what they were already taking wasn’t cutting it. While my mentor and I were in the back discussing the patient and grabbing any samples they might need, my mentor would lean over to me and say, “Now comes the hard part. We have to talk to them about their weight/smoking.”

We always left the best for last, jokingly bringing up the smell of cigarettes we noticed as soon as we stepped into the exam room or asking them if they remembered what the doctor had discussed with them the last time (this usually was their cue to say “You told me I needed to lose weight…” and smile sheepishly). It was almost like watching a play where different patients played the same character repeating the same lines over and over again. My mentor reminds them of their promise to lose weight or stop smoking from the last visit. The patient would look away while my mentor reads out their weight changes or tells them again that they were at risk for COPD. Often times, the patient will then say, “I know, I know. I’m trying to but it’s just not working.” End scene.

Maybe it’s the comfort of knowing that the patient will return within a few weeks or months. Maybe it’s past experience of having patient after patient who comes in with increasing weight or no change in their smoking habits. Maybe it’s a mixture of both but this would be the point where my mentors give vague suggestions about how to lose weight or stop smoking – eat more fruits and vegetables, less carbohydrates and junk food, start exercising, stop eating out, stop smoking, do you want the patch, do you want Chantix, do you want gum. The patient nods along, answers appropriately before agreeing with the doctor that yes, things should change.

I find these encounters the most difficult. I always make it a point when talking to the patient about their treatment plan try to give them a concrete goal to achieve by the next visit that more often than not, surprises them, as they cannot give their usual responses. Instead, they now have to reserve to responses my mentor and I don’t like such as “no” or “I don’t know” or “maybe next time”. One patient came in for a routine follow-up exam was surprised to hear she had gained weight within the last month. I asked her further about eating and activity habits and found out that during the summer, she wasn’t working and instead sitting at home more. Additionally, although her portions at meals had become smaller, she was still eating a lot of starch-heavy foods and soda. When I told her about programs in her community that offered free group exercise classes as well as websites with recipes, she was startled and sputtered out “no” saying she could not see herself exercising in front of others. I instead tried to tailor some exercise around walking her dog and received a vague “I’ll try” to that. I left the room feeling frustrated and voiced my concerns to my mentor who nodded in commiseration and responded, “You did what you could do. She’s hopeless.”

This happened again the next day with a 17-year-old girl who reported smoking a pack-per-day since she was 13 years old. I was later shocked to find out that her mother had a similar history and now was suffering from severe COPD. I asked the girl if she would like to quit smoking to which she said she would but didn’t know how. I told her of the various options and suggested maybe trying to cut down on the number of cigarettes over the next few weeks before we saw her again. I set the goal as a half-pack per day and offered the patch. She nodded and said, “yeah, okay we’ll see.” I tried other tactics – bringing up her mother’s history and telling her that while her mother’s condition was irreversible, hers wasn’t. I also did a lung exam on her that showed decreased breath sounds and wheezing. She told me that she noticed she lost her breath often to which I responded that it was possible for her to not feel like that anymore by not smoking. At the end of the visit, despite the positive responses I had received from her, I got the feeling that she would return as she was today – looking older than she is and reeking of cigarette smoke. I could only hope that she would at least try this month and that my shpiel would be repeated again.

I tell myself I should be patient and that in time, there will be some patients who change and some who don’t. It’s difficult though to watch them walk out the door and wait for the next time they would come. It’s difficult to think that they will often walk out the door and my mentor will either wait till the next time or just give up somewhere down the line in order to preserve their relationship with the patient. I understand the reasoning behind this but I wish I could do more…or at least do something.

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