Monday, April 30, 2012


We all know what happens when you make assumptions. 

And the truth is, labels are no better.  Yet as physicians we make them all the time.  The label is less about the person and more the feeling they invoke inside of you.  When you like a patient they become "friendly" or "easy".  When the relationship is more strained, they are "complicated" or just plain "crazy".

Labels not only color the interaction between doctor and patient, they also are intimately tied to clinical decision making.  We live and die by our own sword.  But occasionally we draw a faulty cover for the book we pick up to read.  The result is chaos, and poor medical care.


Allison was a difficult patient.  A striking middle aged woman, she strode into the exam room with the same confidence that she entered board meetings.  Her control over her appearance and profession, however, were in stark contrast to her personal life.

Allison was a mess.  Full of anxiety and inner loathing, she bounced from one tumultuous relationship to another.  Men and women passed in and out of her life quickly.  She was unable to maintain even the simplest bond whether platonic or otherwise.  Because of this, she spent an extraordinary amount of time in her therapist's office.

The stress and loneliness manifested itself in the form of somatic complaints.  Years ago, when we first met, it was headaches.  She later progressed to myalgias.  Her most recent issue was chronic abdominal pain.  Her labs, cat scans, and scopes were all normal.  Yet her pain was unrelieved.

My relationship with Allison had it's ups and downs.  Although she was nice enough, I couldn't help getting that sinking feeling when she showed up on my schedule.  After countless attempts to solve her problems, I often came up with the big zero.  Undoubtedly patients like Allison make physicians question their professional relevance.  There is nothing worse then striking out every time at bat.


When Allison entered my office this morning, I figured I was in store for yet another fruitless workup.  But today was different.  She walked into the room with her head held low, and a slouching posture that I had never seen before.  The confidence was gone.  As she sat down on the examining table, she lifted her head to speak.  The left side of her upper lip was swollen and her left eye was black and blue.

I stood quietly and touched her face, palpating the cheek bones and orbits for signs of fracture.  Then I sat back down on my stool, and decided not to ask any questions.  We stared at each other, and I waited for her to talk.  A few moments later she began to speak.

In a fit of anger, her latest boyfriend punched her in the face.  Allison picked herself off the floor and left his house immediately.  She then called the police.  I was saddened by her story, but glad that she had the presence of mind to protect herself in this horrible situation.  I told her that I was proud of her while being careful not to be condescending.  Allison looked up more defiantly this time.

I would never go through that shit again!

My mind caught on the word "again" as I waited for her to explain.  Apparently Allison had been removed from her home by social services as a child.  She had been a victim of abuse and neglect.  She moved from home to home as a child.  Some times her caretakers were good, other times not so much.  She was raped by the teenage son of one of her foster parents.

My mind  was spinning as she continued to tell her story.  I clicked over to the social history section of the electronic medical record and read in horror.  One lazy sentence.

Adopted, family history unknown.


Things have changed between Allison and I.  I look forward to her visits, even though I still often can't fix the emotional and physical problems that plague her.  I now recognize that  the "difficult" moniker is more appropriate for her experiences and less so for her intentions or personality.

In fact, I've found an altogether different label for Allison now:


1 comment:

Anonymous said...

Great post!
I'm a psych patient who is *hopefully* going to start med school next year, and I'd love to do general practice.
I've come across this attitude from many medical professionals that patients with psych/emotional etc difficulties are just difficult people. From my experiences, it seems that it's a sad truth that if someone is a psych patient (or has these difficulties) that at some stage in their life they were mistreated or abused in some way.
It seems such an obvious connection.

How is psych and emotional/behavioural difficulties taught in med school?
What are the throughts about treating them in primary care?