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the problem patient

Yes, the dreaded problem patient.  They come in all shapes and forms but they are the bane of every health care worker’s existence.  I used to think that it was only the bane my (the intern’s) existence but thinking about it now it’s probably worse for a lot more people. 

Most of you know what I’m talking about when I say “problem patient” and most of us have been a problem patient at one time or another (probably more frequently for those of us in health care).  As I said, there are many flavors of the problem patient so it is hard to define, but you know one when you see one. 

  • If the patient is admitted to the hospital without any medical indication for inpatient care because he/she knows an attending, you might have a problem patient on your hands.
  • If you get 5 pages over the course of 4 hours just regarding the patient’s request for you to change the pain medication dose from 4 to 6 to 4 to 6 to 4-6, you might have a problem patient on your hands.
  • If the patient writes down the name of every doctor who comes into the room, you might have a problem patient on your hands. 
  • If the patient wants to have the doctor confirm in person every order he has placed (note: not explain, just confirm that he ordered it), then you might have a problem patient on your hands.
  • If the patient has nausea and dry heaving without vomiting every time he/she is told that they can be discharged today and then goes on to have a full dinner when he/she is told they can stay for tonight, you might have a problem patient on your hands. 
  • If the patient says, I’m not leaving until I’m back to 100% my normal self even if it takes 6 months, you may have a problem patient on your hands.
  • If the attending is yelling at the patient, then you might have a problem patient on your hands.
  • If the patient tells you that he/she is deciding which oral pain medication he/she will have you switch him/her to, then you might have a problem patient on your hands.
  • If the patient tells you that it is ridiculous to be discharged from the hospital at 4pm in the afternoon, you might have a problem patient on your hands. 
  • If the nurse–the freakin’ nurse!!!–is fed up with the patient and prefaces every phone call with “I’m sorry to be calling again”, then you DEFINITELY have a problem patient on your hands.  (this one has 100% specificity)

Again, these are just some signs.  They are not 100% sensitive or specific (except for that last one) but they can be indicative.  Moreover, this list is not nearly comprehensive but I think you get the point.

What are the common denominators here?  1) the desire to not leave the hospital despite being medically cleared and 2) the desire to micromanage health care. 

On some level, I can understand both of these underlying issues.  Before I knew more about how nasty hospitals are, when I was sick, I’d want to be in the hospital and when I had surgery I wanted to stay there until I was all better.  What people I think fail to realize sometimes is that hospitals are just filthy places.  And that’s understandable in my opinion since hospitals are where SICK people go.  And not sick–my belly is ow-y sick, but I’m talking more like I have C. Diff colitis and blowing diarrhea all over the place sick or I have disseminated MRSA septicemia sick.  We can discuss the role of the health care providers in spreading the nastiness another time but no matter how it is spread around, hospitals are not clean places.  Sometimes I sort of feel like the guy who works at burger king and knows what goes on behind the counter so he can never bring himself to eat there ever again.  So the end result of people who don’t want to leave the hospital is inevitably a nosocomial infection.  I’ve seen it happen and it kills me every time.  A patient delays leaving, delays leaving and just when it is about to happen, comes down with a nasty infection.  It kills me.

Some of you cynics may have the thought that my main reason for getting on patients who want to stay longer than necessary is out my desire to have less patients to deal with.   This is not correct.  In fact, the opposite is true.  Patients who stay beyond the necessary amount of time typically have the fewest real or pressing problems to deal with because they are healthier than most other patients.  On days when you are getting 3 pages at the same time: #1- patient x having acute change in mental status, #2- patient y having fever of 105 and #3- patient z wants to talk to MD about his/her lab values from this AM, it is really easy how to triage at least one of those pages.  And, with a limited number of beds, filling them up with patients who could have been home, means less work for me.  It’s the senior residents and attendings I feel bad for.  They have to figure out ways of getting these peoples home because when the patient gets pissed at me for telling him/her that it’s time to go home, it’s then the higher-ups’ job to step in and convince the patient.  And, it’s the higher-ups who spend the mornings determining these patients’ plans. 

The other aspect of the problem patient is the desire to micromanage their health care.  Medicine is based on the principle of maintaining hte patient’s autonomy.  That is, we inform the patient and the patient makes the choice.  And that continues to be true but when patients abandon trust in the physician’s expertise/knowledge and exercise this autonomy to the level of small details, it can become a logistical nightmare.  It would be ideal that I could explain to every patient why they are on drug x vs. y for each and every problem but there just isn’t enough time.   I try my best–but for some routine things, like pain medications, it’s impossible, or at least it’ll take some time.  I have no problems meeting patient’s requests for things that are not dangerous but it can be brutal on busy days.  I made all of the changes requested by the patient who wanted dosing on his/her pain medication changed from 4 to 6 to 4 to 6 to 4-6.   The other patient, however, who no longer wanted to take his/her antibiotics because he/she didn’t feel like it anymore, on the otherhand, I had to take a good hour of time to explain why this was not a possibility.   I mean it’s all good of course and I’m happy to do it but when it’s just me dealing with the entire floor and everything from the emergencies to admits to discharges, this kind of stuff can really slow the pace of the day. 

Unfortunately, there’s no solution to any of this.  I’d tell patient’s to trust their doctors more often but then there are enough dumbass doctors out there that it’s probably worth it for patients to have a healthy degree of skepticism and to ask questions.  I guess the only thing to impress on people is that the hospital is not where you want to be–it’s nasty–where sick people go.  With that one point understood, I guess we the residents will just have to keep on keepin’ on.

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One Response to “the problem patient”

  1. 1
    Andrew:

    Mud’, I laughed out loud at bullet point 6. It’s truly amazing – and kind of depressing – the extent that people let their life and personal dignity degenerate… to a low point of wanting to just stay in bed, watch TV and have someone essentially feed them and change their diaper (like a baby) indefinitely.

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