Patient loads and time management
are your most pressing practice problems, according to
the results of a National Review of Medicine survey
conducted this past February and March. With over 1,500
responses, the results can be taken as a good indication
of the current concerns of the profession. Future columns
will delve into the results in depth; this column has
a look at one of the often overlooked causes that push
large patient loads to the top of the list of your colleagues'
practice beefs: the difficult patient.
THE
'SPECIAL CASES'
Even if you're seeing more than 75 patients a week —
and 70% of you are — your practice life would be
easier if you didn't have to deal with those 'special'
cases — the drug abusers, the alcoholics, those
suffering from personality disorders, dementia or, heaven
forbid, those others without identifiable medical symptoms.
Then there are the doctor shoppers, the know-it-alls,
the no-shows, the busybodies, the referral junkies and
those whose personalities simply rub you the wrong way.
Wouldn't it be nice if you could tell some of your least
attractive patients to "take a hike"?
GIVE
'EM THE BOOT
Perhaps you can. That was one of the suggestions from
the physician-audience at a recent Manitoba conference
on difficult patients. You have to be cautious, of course,
but in extreme cases where you believe that you can
no longer help the patient, check with your provincial
college for the ground rules and then send a letter
to the patient with a copy to the college suggesting
they seek medical help elsewhere.
In milder cases another strategy
would be to see if you could arrange to swap the patient
with a colleague in exchange for one of his or her 'hard'
cases. If a personality conflict is the cause of the
grief between you, it could work.
Striking a patient from your list
is a last resort. And you can't dispatch patients willy-nilly
into never-never land simply because you don't fancy
the cut of their jib. Yet every practice is stuck with
patients who aren't pathological but are just plain
irritating. What's the solution? There are a number
of techniques that have worked for other practices;
consider trying them on your 'worst' patients.
THOSE
PESKY PATIENTS
The busybody You know the type. This is the mother
who insists on being told every detail of the medical
conditions of her grown children, the spouse who demands
to see his or her partner's medical records. "At first
I thought I could humour this kind of patient out of
it," says a GP from St John's, NF, "but after a couple
of years at it, I realized it was impossible. This kind
of person has no sense of humour, don't you see. Now
what I do is cut them off right at the pass. As soon
as they begin noodling around I get very serious and
say in a low voice, 'Now you wouldn't want to see yourself
called up before the medical board for aiding and abetting
a physician in the breaking of the Hippocratic Oath,
would you? It's a serious matter and we could both find
ourselves in a good deal of legal trouble.' That usually
shuts them up."
The doctor shopper "If I
suspect a patient of seeing more than one physician
for similar complaints, I address it right up front,"
asserts this New Westminster, BC, IM. "I warn the patient
that going from one doctor to another with similar complaints
is unethical at best and illegal at worst. I hint that
they'll be in serious trouble if the provincial health
plan gets wind of their shenanigans."
More serious is the doctor shopper
who is in fact addicted to prescription drugs. A suburban
Calgary physician says he gets a couple of calls a winter
from a patient who he suspects is pulling a fast one.
"They get my nurse on the phone, often late in the day,
and tell her they've had a skiing accident or fallen
off a horse or a bike and have a bad sprain and need
their prescription for this or that painkiller topped
up, they often have the brand name for it. I ran into
a case like this when I was first in practice. A girl
in her early 20s called on a Friday and said she needed
a refill for a particular drug. I knew the family and
I gave it to her. Turned out she had an addiction problem.
Bad call on my part and one I've been careful not to
repeat."
The self-educated patient
He or she makes it clear that they know more about medicine
than you do. They've been on the net and have already
done the diagnosis and worked out a course of treatment.
All they want you to do is write the script. "I go one
of two ways with these patients," explains a St Boniface,
MN, family physician. "I either congratulate them on
their research and then insist that I do some of my
own 'just to make sure' or, if it's appropriate I tell
them a little story. I say a fellow came in here a while
ago wanting Viagra. Didn't want me to examine him or
anything. Just wanted the prescription. I wouldn't give
it to him until I took a look. Turned out he had testicular
cancer."
The unmanageable patient
Every now and again you encounter a patient who simply
can't be dealt with, who is abusive with staff, threatening,
even violent. The patient may have a substance abuse
problem or a severe personality disorder. Should such
a patient appear at the office and make a scene there
may be only one solution — to call the police.
Says a Montreal inner city psychiatrist who works extensively
with street people, "I'm good with my patients and have
an excellent rapport with most of them. I've been able
to help a lot of people, especially kids, who were really
messed up and I'm proud of that. I also have an obligation
to my staff and to myself. If we ever feel things are
getting out of hand, I have strict instructions: get
to the phone in the back office and dial 9-1-1."
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