Doing the best for a difficult patient


Sometimes it’s almost a test
The inappropriate narcotic request
If it’s bad that I judge
I just will not budge
For the patient I’ll do what is best

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

Confidentiality limits what I can say about my patients, and what I write here may or may not relate to a particular patient or a composite of patients.
Our country has a major problem with prescription narcotics or opiates, painkillers with significant feel-good potential. I find them useful in terminal conditions with long term pain, like cancer, and in short term conditions like kidney stones, fractures, and burns. When I get to a new location, patients frequently flock to me to see if I’ll generously dole out the prescriptions. The word leaks into the drug-abusing community very early that those who seek from me come away disappointed.
I worked the patient in on request from an ancillary service, on short notice so as get the patient to the scheduled commercial flight in time.
Most of what a doctor knows comes from what the patient says, physical exam, lab, and x-ray account for less than 10% of medical decision making. This particular patient couldn’t come up with a straight story.
After twenty minutes of rambling, I made the Time Out signal and said, “Do you know that you interrupted me every time I tried to ask a question?”
No, the patient hadn’t realized it. And I had made clear that I would not prescribe the narcotics so stridently demanded.
After all, if the patient had asked for anything else inappropriate and dangerous, say, plutonium or a whole vial of Botox, I wouldn’t prescribe it, either.
The doctor always wants to know these things about the pain: context, quality, intensity, location, duration, modifying factors, and timing pattern. In short order, I figured out the patient really couldn’t answer the questions. So I would have to guess, and my best efforts would have to be at the veterinary level. I proposed an x-ray.
The patient emphasized the request for pain pills and needed to get to the airport. And wouldn’t I please call the airline and have them hold the plane?
I could have someone do that, I said, and I can do a lot of things for chronic pain, and I really like normalizing a restorative sleep pattern.
The patient didn’t want the sleeping pills but the pain pills, but then let slip the 23 pound weight loss, that had occurred but she couldn’t recall the time interval.
I knew right then the patient couldn’t make the plane. And I said so, noting the slack flesh and wrinkled facial skin.
I have to work harder for some patients than for others; I find those who require more intelligence or persistence. My job is always to do the best thing for the patient, no matter how difficult, demanding, or inappropriate.
I ordered the x-ray, blood count, chemistry panel, sedimentation rate, and thyroid/diabetes/B12 and folate tests. Then I started slogging through old records.

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