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Culling of the Herd

Culling of the Herd

When was the last time you were asked for advice and the person asking for the advice did not accept any of your opinions about the situation? You gave not just one or two options, but three or four solution variations and they were dismissed as impossible. I experienced that circumstance just within the last two weeks. It made for a frustrating day.

First and foremost, caring for the infirm is a complex, complicated job. It requires a great amount of grace and front end analysis to determine the genuine medical needs of a patient. Taking a medical history is the first step. A doctor evaluating a patient for the first time should not dismiss the value of a detailed time-table of a patient's individual health biography. One of the most important aspects of history taking is how the patient conveys their information during the interview. Some patients bring a handwritten detailed chronological summary of their history, an invaluable document for their medical record. The patient knows their history best. The second is that the patient arrives early enough to the appointment to jot down some notes. The third avenue is to interview the patient, but most of the time the patient gets distracted while recounting their walk along the path through the forest of their disease. Either way, history matters.

One major goal of the interview is to determine if the patient believes they are a helpless victim of their illness verses someone who can conquer any and all obstacles. Another is whether they believe that their malady resulted from their own behavior, or a punishment by God or a random event of which they had no responsibility what-so-ever. Some patients show up to my office as their last resort, others come to the Stone as a way to get a second opinion. Regardless, many have been told by multiple physicians that their symptoms are mostly factitious primarily because their practitioners fail to grasp the totality of the patient's complaints much less suggest a therapeutic plan to remedy the situation. Patients who routinely come for medical advice, follow-it or at least give it their best effort. I appreciate their hard work since I try to give my full one hundred percent to them.

Compassion has left the healthcare industry on a bus to the land of economic prosperity. If you are a square peg patient, you won't fit in the routine doctor's round and narrow diagnoses hole. A pass off to a nurse practitioner is a sign: no one wants to manage your case because it requires work. Some of the nurse practitioners I know have a great amount of knowledge about medical treatment because they have been practicing medicine longer than many of the young physicians who hire them. Their knowledge is limited to what they were taught in graduate nursing school over a two-year period of time.  They try to practice in synchrony with their vertical thinking medical director, but many of their medical directors have long since ceased practicing medicine.

A woman recently returned to our office three months late for her one month follow-up exam, the second of four routinely scheduled visits. She had a plethora of excuses related to her inability to make the second appointment on schedule. One or two unannounced events that disturb one's two week follow-up appointment is not atypical, but to recite more than three random events that prohibited their return to the office in a timely fashion signals either a patient who has absolutely no control over her life, or one that is savvy enough to find excuses that might seem worthy to an honest and compassionate physician. Being kind to patients often conveys that one is naive. People who know me would probably not describe me as naive.

After the long litany of excuses, she revealed that when she followed the prescribed program, she had great results, felt better, had cleared up her brain fog and lost about fifteen to twenty pounds. But the boredom with her food plan overwhelmed her commitments to her health; the food restrictions thwarted eating out, her busy work schedule and her desire to eat the same unhealthy food with her child and husband for dinner altered her path. She started eating sugar as she did prior to her initial visit, she gained the twenty pounds she lost plus ten more, and she could no longer find the time during the week for food prep, so her eating greatly suffered. In a demanding style, she asked me for other potential options.

As I sat and listened, I came up with four separate options for changing her food plan and possibly changing her medications. She vetoed every one of the options, adamant that each of them were impossible to implement given the complexities of her lifestyle and dedication to her only child. I asked her for her thoughts about solutions to help make things work, giving her full license to create her own plan. Afterwards, I would just adjust her suggestions to enhance her success. She sarcastically remarked, "You're the doctor. That's what I come here for. That's your job."

After thirty minutes of absolute frustration, I grew tired of her desires to accomplish something that was impossible. She was absolutely unwilling to listen to any plan that might infringe upon her current lifestyle in any way. She wanted to eat whatever, whenever and with whomever, and not follow any kind of healthy routine. Her fantasy of losing seventy pounds or more without making any changes might as well have been a Walt Disney ride in a fantasy park. Her wanton lack of discipline is what got her into an obese mess. What I don't understand is why she returned to see me in the first place. I may sound a bit cynical at this point which tends to fall out of character for my blogs. This was a very difficult problem to address in a face to face situation.

I finally said, "Look. I appreciate your faith in me. You're not willing to change. Accept your body and honor it as it is. I'll still prescribe your medication. Eat and enjoy life. Discipline without joy is mere suffering."

She grabbed her purse, put it on her lap and said, "It's time for me to go. I've got something to do." I wrote on her chart as fast as I could as she repeatedly asked if her prescriptions were written. I realized at that moment she needed me for her prescription refills. I showed the prescriptions and told her the staff had to copy them. "I am writing as fast as I can. Please be patient." As I got up to exit the room, she followed me. I asked her to stop at the receptionist. She did. Her prescriptions were copied and the originals were given to her. She settled up and during the process, the receptionist asked to schedule her for a yearly visit to continue her medications. The patient replied, "I don't think I'll be needing that." Then she stormed out of the office to her automobile. Once in her car, she threw her paperwork up in the air, probably screaming a few four letter expletives in the process.

I remember an old saying: You can please some people all of the time, and you can please all people some of the time, but you can't please all of the people all of the time. What I didn't know is that a few people can never be pleased, ever. I felt sorry that she made her way to my office to get three or four prescriptions, when a nurse practitioner in general medicine would have gladly given her medication and she would have avoided confessing her sins to me.

I have been looking for a way to cut down on my patient load. She just made it easier for me and much harder for her. She'll have to find some other healthcare provider to give her acceptable options if there are such a thing and her prescriptions.

I think I've experienced a culling of the herd.

Doc

Posted by Amanda Sanders at 10:43 AM
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