On Choosing One’s Patients

On Choosing One’s Patients

Friedman, Joseph H

A resident sat in with me while I was seeing a patient I’ve known a few months. The patient has an intractable headache and a constant need for narcotics. The resident commented to me later that I had looked “annoyed” during our session. I use the term “session” ambiguously, knowing that the term is used typically for seeing a therapist. One has a “doctors appointment” with a neurologist. But, of course, patients with chronic pain require a sympathetic ear, more than clinical acumen and science. Yes the patient upset me. She bothers me because I know her problem is not physiologic but she won’t believe there’s an emotional etiology.

My problem, though, is me, not her. Looking “aggravated,” “annoyed,” “pained” or however else I may have been described, was not fair to the patient, punishing her for complaining about the very problem for which she was seeking my help. It was bad doctoring. Unfortunately, while I can take forever with my slow-moving Parkinson patients, I have, in truth, limited patience for people with the more common intractable disorders that generally make up the bulk of a neurologist’s practice: headache, dizziness, back and neck pain. Clearly, I cannot do a very good job then. On the other hand, although I do specialize in one narrow area of neurology, I continue to think of myself also as a general neurologist and welcome “challenging” cases, patients who have escaped diagnosis for any number of reasons. In addition, these problems may include pain syndromes, although not usually. Chronic pain and chronic dizziness syndromes are different from the acute disorders and always involve emotional issues. Interestingly, conversion disorders are a psychological challenge I find interesting. I called the patient and apologized if I seemed annoyed. One problem solved. I’m less angry with myself, but here is the question. Should I refuse to see headache, back-pain and dizzy patients? Should I be like the orthopedist who sees only “shoulders” or “hips” or “spine,” turning everyone else away? “Dr. Friedman doesn’t see headache patients because he’s not skilled in that area.” “But I want to see him. He’s listed in Rhode Island Magazine. I’ve seen five other doctors. I’m sure he’ll help me.” Of course, I won’t, so, perhaps my secretary should say, “No, he won’t. He told me to tell you.”

Miss Lonelyhearts is a short, depressing novel, written in the 1930s about a newspaper columnist who, on a lark, takes over a daily advice column, of the Ann Landers genre. Except these letters are not about what to do if your daughter’s father-in-law belches at the dinner table. These letters deal with the depths of human pain and suffering. The columnist becomes overwhelmed with the tide of human misery. How should we deal with the patient with constant headache who cannot pay her bills, whose children are doing drugs, getting into trouble, who is raising the teenage daughter’s two children, etc etc? Antidepressants won’t touch this; she needs a new life. Am I, the skilled neurologist, too busy to sympathize? Annoyed that a primary care physician would “waste” my time, thinking I could help, or relieve his responsibility to the patient knowing that he’s going all out, even referring to the specialists?

When I can, I try to teach the medical residents how best to use their neurology consultants, how to avoid useless consults, but I owe it to the patient whom I actually see to be as sympathetic as possible, to try just as hard to help as I would a case of some rare disorder, whose diagnosis or treatment will burnish my reputation and make me famous. I do not know whether it’s the uselessness and inadequacy, the fact that both the patient and I could have put the time to better use, or the challenge I will have explaining to the patient that although there is pain, there is no threatening medical problem. No aneurysm, tumor, stroke or inflammations, just pain, physical and emotional; and you can’t treat the former without grappling with the latter. “You mean it’s all in my head?”

The better doctors among us are priests, but, alas, few of us are saints. I haven’t solved the question in 20 years. As I know less and less about more and more, it may be taking care of itself. Perhaps it is the coward’s way out.

Joseph H. Friedman, MD

Copyright Rhode Island Medical Society Mar 2003

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