Too-smart patients

There are a wide variety of difficult patients, who are difficult in different ways, but today I had an encounter with a particularly difficult patient who really ruffled my feathers.

To start with, we were running late (as most doctors' offices usually are), so in those situations I am always 100% prepared to be completely apologetic and assuage any anger over time issues. So I entered the room, introduced myself as the medical student and explained that I would talk to the patient first, and then the attending would come in to examine her (since they all need pelvic exams, I don't do them by myself). She listened to most of my intro, then cut me off to explain that she had a severe allergy to latex and to ask if there was ANY chance I might have latex powder on my hands.

No, I replied; our gloves were all latex-free, and I pointed the boxes out to her.

"What about your coat?" she asked, eyeing my white coat suspiciously. "Is there any chance you have latex powder on your coat?" When I replied that I was fairly sure I didn't, she pressed on. "Have you been in the operating room recently?" (In the OR, we use latex sterile gloves unless the patient has a latex allergy.)

Not since last Tuesday, I told her, and I wore scrubs (I was wearing normal office clothes today, so they obviously hadn't been in the OR), and I had showered multiple times since (yes, I actually went so far as to reassure her that I had showered since last Tuesday, because I could tell she might ask me that on follow-up).

But she still wasn't happy, and continued to grill me -- had I brought my white coat into any part of the OR; had I put on the white coat over my scrubs after surgery was over, etc. -- so I offered to simply take off my coat and leave it in the hallway.

And I could tell it was simply going to get worse from there.

Note, I'm not saying having a latex allergy is in any way a problem, or that her request that I remove my coat inappropriate; it simply would have been more easy, efficient, and pleasant for her to simply, in one sentence, explain her allergy and ask me to leave my coat outside. The whole 20 questions thing was the problem. Plus, she had a very interrogative and condescending way of speaking, which definitely continued to grate on my nerves.

Now, coat off, I attempted to proceed. At this point, she protested about being seen by a medical student and requested to defer my whole interview.

I completely understand that being seen by a student is annoying, and I am always grateful to patients who put up with having me in the process. And normally, if someone requests that I leave, or that they bypass my part of the process, I am happy to oblige. However, we were already running an hour behind, and my attending was running more behind than I was. So I explained that in actuality, my aim was to streamline the process, since the doctor was running so far behind, and that I would make sure things went forward quickly from there. This seemed at least somewhat satisfactory, so she allowed me to proceed.

I can't really explain the way in which she was talking to me, but she was a very low talker, looking mostly at the ground but with her eyes cocked up at me at an angle, and her voice had very little inflection or emotion in it. From a body language point of view, the message I got was, "I am exasperated at having to talk to you, and I disdain your very existence."

Ugh.

Then she started dropping little medical terms here and there, and I actually didn't register them at first (sometimes my brain doesn't switch back and forth between patient-speak and medical-speak, so a patient using medical-speak doesn't register as unusual right away). She was there because she had an incidental finding of microscopic hematuria a few months ago on a routine physical, and she was here as part of her workup. Every time I asked a question, she would sort of sigh in exasperation, answer as though I was a complete moron, and then add way too much medical detail. Finally, when she offered that she had jaw surgery back in January and had been on NSAIDs post-operatively and she knew that NSAIDs can cause microscopic hematuria, and upon my asking what type of NSAID she had been on, responded with, "ibuprofen, 600 mg TID," my brain perked up.

TID? That's prescription-speak for "three times a day," and only healthcare people use it. So I asked what she did for work, and again, she was so suspicious of my reason for asking. "I'm a consultant," she replied.

SERIOUSLY?!?!? Consultant? That term means absolutely nothing, and all of you know it.* It was like pulling teeth getting any reasonable answer from her. Finally, it came out: she was a consultant for a life sciences firm, and she was involved in drug development.

Ahh, it all made sense now. The problem was, she was smart. But unfortunately, not smart enough when it came to this particular situation. As much as I find it exasperating to work with unintelligent patients, there are definitely times when an unintelligent-but-helpful patient is a thousand times better than a PhD who won't listen to what you're trying to tell them.

I tried to screen her for incontinence, which we do for all of our patients, and she wouldn't have any of it. "I filled out your questionnaire, and you can read my answers there. I don't have any of those problems, and that's not why I'm here." Hidden message: you're an idiot. However, in reality, I always ask those questions again, for two reasons: 1) My attending expects me to, and 2) patients change their answers ALL THE TIME.

On I went, reviewing her lab results with her and getting verbal and non-verbal feedback from her that indicated she KNEW all of this and I was clearly an idiot. (I should point out that I could tell that she didn't know all of this and I was trying to be a good doctor by explaining it all to her.) Finally, when she said, non-chalantly, that 11% of the population had this condition and in most it's completely benign, I was finished. People who drop statistics into conversations to impress you are 100% annoying.

There's definitely a problem with being too smart. You think you know everything, and don't want to hear any different from anyone else. If that's the case, then why even go to the doctor? I actually had another doctor as a patient today, and she acted like a totally normal patient (which, granted, is unusual for doctors), not using medical terms unnecessarily or making me feel like a lowly medical student. So why do other people feel the need to put me down or act like they know everything that's going on?

I briefed my attending on the situation, warning her that the patient was rather difficult and would ask her to take off her white coat. In she went with her white coat, and the patient didn't say a thing. Argh. So you're only going to be obnoxious to me? That's even worse. Fortunately/unfortunately, she continued to speak with that same voice and affect, like she was wasting her time being there and was only half-interested in what the doctor had to say. I guess I was glad to see that at least some of her attitude was constant, and not just directed to me.

Again, she cut off the attending and threw out her 11% statistic that made her sound so smart. I mentally rolled my eyes, and then the patient said, in explanation, "I read through the literature to try to ease my mind about all of this."

Oooooooooh, crap.

She's acting like a bitch because she's scared.

Damn, did I feel ashamed of myself. It's a classic defense mechanism, and I didn't pick up on it at all.

In my defense, as the visit continued, it was still clear that she was somewhat obnoxious at baseline, and no matter how much I tried, it was difficult to be fully sympathetic. However, I had probably over-reacted in labeling her as completely difficult.

So, lesson learned.

Thankfully, my attending still thought the patient was annoying enough, and she had a good enough medical reason to justify it, to turf the patient to urology. It takes a lot for a urogynecologist to turf a female patient to a urologist, but it was medically justified, so it will work out for all of us in the end (including the patient, who will likely get her problem diagnosed more quickly through the urologist).

My new goal: learn to deal better with arrogant patients. They're among the most difficult type of patient to deal with, as I learned during psychiatry, but I still need to try harder. I'll put it on my to-do list, along with getting my damned personal statement written.


*I had another patient today who answered, in response to the "what do you do" question, "I'm a trainer." I was stunned silent while I pondered such an unhelpful answer. Was she a dog trainer? A personal trainer? It turned out to be neither; she "trained managers." Please be helpful when you answer, people.