Challenges of the worst— and ‘best’ patients

Can you practice medicine without patients? Certainly not in primary care and most branches of specialty care. Even pathologists need patients for a steady stream of specimens. It’s usually the concept of being able to directly help people, as much as the fascination with medical science that entices us to become MDs in the first place. The doctor-patient relationship is considered sacred. One of the biggest draws of family medicine is the ability to really know your patient in a long-term relationship while providing continuity of quality medical care. Healthy professional relationships between individuals who respect and trust each other are likely to be more effective for both the art and science of healing. Even if we loathed it in med school, we all have a working knowledge of rudimentary statistics. That is: 95% of (pretty well) everything falls within the bell-shaped curve, with 2.5% on the far left (below this) and far right (above this). Blood pressures and pulses, heights and weights, efficacy of therapies and side-effects, all follow this simple rule. We use it to guide our decision-making, and the more experienced we are, the more our “spidey senses” are subconsciously perked when something starts to fall outside these parameters . . . when the trajectory of our diagnostics or therapeutics are not following the predictable and expected course. These stats might also hold true for the relationships we have with our patients—the vast majority are solidly right up the middle (50th percentile) and we don’t give them a second thought. The long list of patients who don’t provoke any emotion, just another busy clinic day. They are literally 95% of our practice (although not necessarily 95% of our day). The so-called 80:20 rule does exist, in that 20% of our patients generally take up 80% of our time. But what about the 5% who fall at the extremes? The outliers. The potentially less desirable and even unhealthy relationships. Low end of the spectrum These are well-known patients to you and your staff. They are a mixed bag of difficult patients mostly related to disordered personality type rather than medical problems. Perhaps counterintuitively, the most complicated patients with the longest list of chronic medical conditions are likely not in this group. Patients who fall in this far end of the spectrum group generally struggle with all their relationships. They may have had failed marriages, revolving door jobs and brushes with authority figures. They are generally not happy nor likable. Sometimes unpredictable, disruptive and unsettling to all those in the reception area, they can be aggressive and frustrating for staff as well as non-compliant and complaining to us as physicians. The most common diagnosis that defines this group is borderline personality disorder (BPD). Other personality disorders can be represented especially in the “group B” cluster (including histrionic and narcissistic) as well as those suffering from significant addictions. Group A (paranoid, schizoid, schizotypal) and group C (avoidant, dependent, obsessive-compulsive) personality disorders are represented but may also fly under the radar. BPD is a severe and chronic disorder characterized by a pervasive instability of affect and interpersonal relationships, marked impulsivity, and a high frequency of comorbid anxiety and mood disorders. Patients with BPD are at risk for suicide, repetitive self-destructive behaviours and substance use disorders, and sustain clinically significant distress and impairment. Patients with BPD have often been described by primary care physicians as difficult, demanding, manipulative, noncompliant, disruptive, and the “most psychologically challenging patients a primary care physician ever encounters.” As such, any relationship with BPD patients can be extremely challenging. They demand time and attention and generally aren’t easy! They require hard work. On busy clinic days, sometimes it is difficult to find the “extra time” and attention that might be required. There are so many things that are taken for granted in an MD-patient relationship that must be actively attended to and managed if we are to have any success. Well-defined boundaries and rules are crucial. Clear and direct communication in a calm environment may be the only approach that works. Identifying and diagnosing personality disorders and educating staff around these diagnoses can be crucial in supporting these patients. Having a working knowledge of their issues gives us at least a foundation to try to build a working relationship, challenging as it may be. High end of the spectrum As much as the lowest 2.5% causes us to break out in a cold sweat, we must be careful with the upper end of the spectrum: our absolute “favourite” patients. These are the patients where seeing them on the day sheet might bring smiles to all the staff in the clinic. These are well-known and universally well-liked patients. They are always pleasant and polite to a fault. Their disposition is generally cheery and uplifting. They come early to their appointments and are chatty with everyone on a first-name basis. They commonly bring coffee, cookies and Christmas gifts. So how can they possibly pose a relationship challenge? These relationships can be unhealthy. When things are going well and there are no “asks” there are generally no problems. The dilemma arises when there is a “special request” to bend (or break) the rules on their behalf. Their special status is called upon to get them to the front of the line (or snuck in the back door when no one is looking). The challenge is that these patients want and need their relationship to be personal and informal as opposed to professional and more formal. They want to be like friends, colleagues or family. They want us to be indebted to them so when it is time for “payback” we will deliver. We feel guilty when we can’t return a favour—even if it is something we really wouldn’t do for any other patient. Once a “special status” is achieved, it is very difficult to reverse. What seems like a great relationship can sour quickly if this patient perceives that we are not keeping up our side of the bargain, even if this is never explicitly stated. Sometimes staff get caught up in the middle and start manipulating things “behind our backs” to ensure these patients get what they want in an expedited fashion. Mid-spectrum The key is: Stick to the middle. Our overarching goal should be to keep encouraging our extreme relationships to move closer to the peak of the curve. The mundane 50th percentile. These relationships are generally solid, professional and predictable. A goal of “average” seems unappealing, yet this is likely where our relationships are most effective and therapeutic. In the end, this should always be our primary objective. As physicians, we don’t have to be loved by our patients and we don’t have to love our patients. We do have to build strong and trusting relationships that are put together over time by consistency, hard work and dedication. Hopefully in the end, we will like and respect our patients as they will respect us, maybe even like us back! Dr. Ted Jablonski retired his family practice to focus on acute primary care leadership, sexual medicine, and transgender health in Southern Alberta.

Challenges of the worst— and ‘best’ patients

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