WhiteCoat

Why I’m a Bad Doctor – Part I

I had three different patients infer that I was a bad doctor in one day. I’m starting to get a complex.
Oh well, at least none of them spoke in Baby Talk.

First was a patient who was 16 years old who had an aphthous ulcer (“canker sore”) in her mouth. Looks painful. Try Anbesol. Oh, the Anbesol didn’t work? Use Tincture of Benzoin to cover the ulcers and they aren’t as painful. What’s that? You need a note for missing school for the past 4 days?
“OK, what should I write as the medical reason that you weren’t able to make it to school?”
[With the eye roll] “Because I’ve been crying my eyes out in pain for 4 straight days, duh.”
“Unfortunately, I can’t write ‘crying your eyes out’ as an excuse for missing school.”
Mom and painstricken teen glanced at each other.
Then mom gathered up their things and said “Come on, honey, we’ll go to Metro Satellite Hospital and get a note. The doctors are better over there, anyway.”

Then was the mom who brought her child in after being bitten by a dog. The child had a small cut of about 1 cm on the side of his face that needed closing. The mom made it clear on several occasions that she “was studying to be a nurse.”
Before I even said “hello,” the mom said “I want him put out for this and I want a plastic surgeon to close this wound.”
“I don’t think you’ll find anyone willing to take the risk of putting your son under general anesthesia to repair a half-inch cut on his cheek. I’ll go call the plastic surgeon to see if he is available to fix it, though.”
Grandmother was in the room when I came back. I told her that the plastic surgeon was unable to come to the hospital that evening, but that he would see her son in his office in the morning and would close the wound then.
“How is he going to put him to sleep in a doctor’s office?” the mom asked.
“He isn’t,” I told her.
Grandmother chimes in “they’re just not doing these things here because they aren’t qualified.”
They left the ED and called administration to complain about me later in the day.

Finally was the man in his 70’s who had been falling … for 3 years. He had seen multiple neurologists and had been evaluated multiple times for the same symptoms. Because all doctors are dimwits who earn their money by testing and not by diagnosing, there was no official reason why the patient continued to fall. His latest round of radiation (CT scans) and laboratory testing were performed two weeks prior and showed nothing. Several doctors had recommended that he use a walker … which he refused to do. He also refused to go to a nursing home.
The patient fell again that evening, so his wife brought him in to be evaluated by me for the 27th “second opinion” of the cause of the patient’s falls.
I didn’t find anything different from the exams documented on him previously, and I didn’t see the need to engage in insanity by ordering another round of radiation and blood tests, so I told the patient and his wife that I planned to send him home.
“I want him admitted for a couple of days,” she stated matter-of-factly.
“OK, what is it that we’re going to do for him while he’s in the hospital?” I asked.
“Just watch him so he doesn’t fall.”
“You said he fell because he wasn’t using his walker. You want him admitted so the nurses can make sure he uses his walker?”
“I want him admitted anyway.”
“What’s going to happen after a ‘couple of days’ in the hospital?”
“I want him admitted.”
“If he wants to go to a nursing home, we can try to admit him to satisfy Medicare’s rules. However, you’ll have to sign a form stating you’re aware that Medicare might not pay for the hospitalization and that you will agree to pay for the stay yourself if Medicare does not do so. Or, he can stay on our extended care facility at a reduced rate if you’d like.”
She scowled at me and said “You’re not a very good doctor.”
The specter of a monetary outlay for one’s medical care had an effect on her desires, though. She took her husband back home, warning me that “he better not fall again” as the nurse wheeled the patient out to the car.

Sorry, lady.

Maybe you can form a support group with Canker Sore Girl and Gramma Dog Bite.

34 Responses to “Why I’m a Bad Doctor – Part I”

  1. ERP says:

    My blood was boiling just reading this.

  2. redrox says:

    Deeply refreshing to hear a doctor stand up to such nonsense.
    I like the cut of your jib.

  3. paul says:

    man, you’re terrible. i feel sorry for your patients.

    you should clarify to the third lady though, that even though patients falling “never” happen in the hospital, that rule has not yet been extended to people’s private homes and, in fact, he might fall again at home.

    these people that demand plastic surgery on simple lacs… definitely one of my pet peeves. i say i can fix it myself, i’ve done it a thousand times, the kid doesn’t need sedation, it’s 11pm and i can’t call in a plastic surgeon to deal with something i am capable of fixing myself. i give them the option of following up in the morning. they don’t want to wait till morning. they insist on ambulance transfer to the tertiary center… which is an emtala violation since I CAN FIX IT MYSELF.

    usually i wind up telling them their 3 choices are 1) let me fix it, 2) see plastics as an outpt in the am, 3) sign out AMA, go in your own car to the big hospital, be triaged again, wait in a waiting room again, be seen by an ED doc again, get in another argument about the need for plastics, wait there for plastics to come in (assuming they’re willing), then enjoy their delayed primary closure.

    usually they let me fix it myself at that point.
    :P

  4. ndenunz says:

    Grown son accompanied his elderly mother for follow-up visit on neck muscle spasm today. This was the first time I met him and I greeted him cordially.

    He wondered whether I was going to order an MRI. I explained why I wasn’t — the problem was clearly muscular, no nerve involvement, getting better etc. He stated twice he was going to get a second opinion while I was examining and interacting with his mother. He stated it could be a nerve and it could “blow at any minute”. When I didn’t order the MRI he asked to whom I was going to refer her. When I asked him what type of Dr. he wanted her to see he said he would take care of it and walked out.

  5. hashmd says:

    I get the same in Urgent Care too.

    These are examples of why patients cannot absolutely be “customers”. They cannot get what they want when they want it because GOOD MEDICAL CARE does not warrant it; it is not safe to render the care that they want; and in case #3 it is Medicare fraud to admit them to the hospital when they do not meet Medicare criteria for admission.

    In no case you have cited are you making medical errors in judgement-our definition (but not a jury’s definition) of bad medical care. You are a “bad doctor” in their eyes because they have the sense of entitlement. Good medical care is based only on their definition of what it is and how it is delivered to them NO MATTER HOW UNREASONABLE THE REQUEST MAY BE.

    I have seen people throw tantrums in fast food restaurants because their order wasn’t ready in 1 minute from the time they ordered. Does that make the restaurant “bad”? Did that make the employee “bad”?

    Customer centered service is a goal and meeting it 100% is only a goal. Perfection is a goal but not an attainable goal.

    Meeting unreasonable demands is NOT customer service. Deflecting their attention and making them happy even when not meeting their expectations is an art only very select few are capable of performing.

    Even Disney can’t make everyone happy.

    • Emily says:

      THANK YOU!

      I am a nurse. Not only am I floored by the customer service stance that hospitals and medicare are taking, I think it is a quite dangerous idea to institute. So, medicare, you are going to refuse payment based on a patients opinion of customer service? The first quote I think of when I think of customer service and satisfaction is, “the customer is always right”. Well, in medicine that is just not true. In fact, the customer is often times wrong. That is why they come to us. Nursing school and, by leaps and bounds, medical school are held to a level of expertise and knowledge that most people either cannot achieve or have no desire to achieve. That is fine. However, it also means that going online and diagnosing yourself doesn’t make you right. Do you want just any old person who can research WebMD to treat you or care for you in the hospital? I think not. That is why you require professionals who have gone through specialized degree programs and passed nationally recognized boards to be in charge of your care. I’m not saying we are infallible, but many of our patients are. I’m not being disrespectful; I wouldn’t do my job if I didn’t love an respect my patients. I am simple speaking the truth. If you don’t like it, see if WebMD can cure you…and let me know of the outcome.

  6. TisDone says:

    To me, the last 2 examples highlight a knowledge gap – the patients all have (what seems to them) to be desired outcome that is close to reality, but not quite up to medical standards (the first one, and her daughter, are both clueless about medical priorities and are clearly beyond help).

    For the scar/suturing case – the parents goal is to eliminate the chance of a life long scar on the child’s face. That by itself is not an unreasonable request.

    For the fall patient – the family is scared. There is clearly an underlying cause that has not been identified. Whether its neurologic, cardiac, or other – there has to be a cause – and they are scared. Since, in theory, any additional fall could be one that causes a significant trauma, their goal is to give the patient the best chance of being in an environment where a fall won’t happen. And since they’ve likely heard the phrase “we’re keeping him for a few days for observation” on numerous TV shows – its not an outlandish expectation.

    However in both of those cases – it seems that the patient’s family’s goals are reasonable (even if not realistic) – they just don’t know how to get there.

    So – even though there will always be thick-headed people who don’t listen, even in the face of a truly competent and caring doc, what can be done differently to help manage the understanding and knowledge gap the exists between patient expectation and provider competence?

    • TNK says:

      This is what I was talking about below. Some doctors (not all) do not listen. They hear bla blah blah but do not really engage in listening to the patients concerns.

      When I read this doctors description of what happened I thought he was pretty rude. He more or less told them… yeah so what..

      The dog case, I immediately thought.. maybe the kid is going to get really worked up and needs to be calmed down. He just got bit by a dog, which was traumatizing enough. Maybe knocking him out is not the answer, but offering something safer to “chill him out” would have been appropriate. My daughter punches and kicks people when they come near her with needles, and she is 12. I might say something to a doctor or nurse about getting her calmed down with something before attempting such a task.

      The falling patient. It sounds like he has been through a lot of visits with no answers. I’m sure the wife is concerned (as well as the man). If they have been to several doctors is it possible that each has done some preliminary hunting but not really indepth analysis of what is REALLY going on. People don’t just fall over and over again for no reason.

      • Barbara says:

        My fathers doctor kept saying the same thing this doctor was saying so after multiple doctor appointments with him saying he was just getting old (He was 66!) we went to another doctor and guess what, he has parkinsons disease!

  7. Tom B. says:

    Next time I get the desire to go to medical school, I’d read your blog again.

  8. ladyk73 says:

    I feel bad for the kid who got bit….Crap….now the kid will have two potentially painful events on TWO days!!!

    Anyways,

    The only patient (and family) who was not a 100% sweety was a guy who was in a lot of pain. He was getting annoyed try to communicate with a trach to his frazzled girl friend, all while his IV started to beep. I told the nurse about the IV, got the g/f to calm down, told the doc he wanted meds to sleep….

    and most important…..I got him to smile though!

    Today was a good day….

  9. These types of cases are irritating for a couple reasons:
    1) Unhappy patients tend to be the ones who sue.
    2) Unhappy patients are the ones who complain to hospital administration. A good, established physician will not have much problem with this. New ones will be called down to the pricipal’s office for a talk.

    You take the good with the bad. I guess that’s one reason we are paid the big bucks.

    -Steve
    (I’m a hospitalist)

  10. Rogue Medic says:

    One of the nice things about EMS is that we can usually pass the buck, when we encounter these I want it and I want it now! people.

    Veruca Salt: Daddy, I want a boat like this. A beautiful paddle boat is what I want.

    Grandpa Joe: [to Charlie] What she wants is a good kick in the pants!

    We need a well done study to show that a good kick in the pants is the best treatment for them.

  11. EPMD says:

    Once had a an old (competent and healthy) lady who fell at home. Family wanted her admitted because, “she could fall again, her house is a MESS! She’s not taking care of herself”

    She was clean and well groomed on arrival, no fracture on X Rays, she was ambulatory and wanted to go home. Family wanted her admitted and were furious at me. “She just told us she ate A WHOLE BAG OF CANDY at home! Clearly she isn’t taking care of herself!!!”

    Told the family we didn’t admit patients for eating candy. If we did, we’d admit everyone. And I wasn’t going to KIDNAP this competent lady by forcing her to stay against her will.

    KIDNAP didn’t even register with them. They couldn’t understand why I wouldn’t keep her against her will. People are unbelievable.

    • TNK says:

      Ok, not to be rude.. but some people with serious mental health issues can present and cover up their issues. Maybe the family was concerned that this lady 99.9% of the time is not taking care of herself (living in deplorable conditions, not washing, etc.). Something you as a physician wouldn’t pick up on in a 15 minute office visit.

  12. toni says:

    This month I had about four nights when ALL my patients were nice! It was odd and I kept waiting for the BOMB to drop. When a call light went off I busted a move to get up and answer it with a smile. It’s amazing what a few words of thanks and appreciation of care received can do for an RN/MD. Chin up and try and remember the nice ones. I loved the pet peeve about the baby talk. I work with a nurse that would make you lose your mind. She baby talks all her patients and has ridiculous nicknames for them. I think of gouging my eardrums out when I hear her.

  13. Andy says:

    Speaking of “customer service”… The fundamental problem with American medical care is that the patient is NOT the customer, because the customer is the one who pays the bill. If everybody had a high-deductable health insurance policy, paid for by themselves rather than an employer, these “I want an MRI, plastic surgeon, admission, etc.” demands would largely disappear. We would all be better off, including patients, if people were forced to balance what they wanted against what they themselves were willing to pay (assissted by learned advice from a physician).

  14. Chrys says:

    People don’t seem to understand the risks associated with putting a child under sedation. There is no history to tell you how they will react, and it isn’t just tucking them in for a nap until it’s over.

    Years ago I worked for a practice, and colleagues of ours lost a young 17yrs.old during a routine impacted wisdom teeth extraction. It was devastating to all involved. I can’t imagine going in and demanding something like this.

  15. William the Coroner says:

    Remember, though, Toni, it’s the nice ones that have the highly aggressive malignancies and ruptured aortas. The real bastards keep going and going and going…

  16. MLP says:

    Interesting array of patient encounters. These are the types of visits that test the communication skills of the provider. It certainly sounds as if the patients are being unreasonable though. Keep up the good work doctor!

    MLP

  17. [...] school or admitting a patient to the hospital for walker training and observation, this doctor won no brownie points with his [...]

  18. joey says:

    Your post is a real world demonstration of the cost and risk shifting game that our healthcare system has produced. When people have no responsibility for anything but their co-payment, they have no need to care about what is right, or what is necessary. Between pharma advertising and the concept that medicine is a ‘service business’ we will always be ‘bad doctors’ if we don’t do what our customers want us to do. Just wait till the government gives the millions of uninsured people coverage- the doctors who use their brains to treat people will be bludgeoned into either submission or retirement, and those who only use their referral or prescription pads to move the problem somewhere else will flourish.

  19. Steve says:

    Did you check the old duffers ETOH level? I would hazard a guess that somebody that refuses to use a simple walker, because he is an ornery old coot, is also somebody that imbibes on the sly.

    Steve
    Not a hospitalist, just an onc nurse.

  20. Chris says:

    No medical background here, just enjoy reading your blog. I’m the mom of a 6 year old daughter, and the last thing I would want is my daughter put under anesthesia unless absolutely necessary – and calling a plastic surgeon? For what?? A tiny laceration that might leave a teensy mark/scar? If I have a bad sore throat, I go to my doc or the local doc-in-a-box, get a culture, and if it’s not strep (which I’m prone to), thanks, I’m outta here – no antibiotics needed, it’s a virus, and it’ll go away by itself. No one wants to just say “hey, it’s a bad cold, it’ll go away in a week or so” anymore…….sigh. OK, rant over. :-)

  21. TNK says:

    I think the doctor has to remember, that he or she is seeing the same thing over and over. To them these things may be trivial but to someone who experiences it once as an event, its a big deal.

    I know a LOT of people who have problems and feel blown off by a doctor. Doctors who often do not dig deep into the root cause of problems.

    I had a thyroid problem, but my TSH kept coming back normal. I kept telling the doctors that I wasn’t feeling well. They continually told me it was “in my head”. AFter going to my gyno about female problems (which my doctor blew off as “normal” women complaining”), she did some blood work beyond “TSH” and found that I had several issues going on (thyroid and hormonal imbalance).

    So.. while patients can be horrible, so can doctors. I think a lot patients today get average service, some worse than average, but a good doctor that provides excellent service is hard to find.

  22. pjameson says:

    Your poor attitude toward patients if surely resulting in them receiving less than good care. I get angered every time I hear docs and nurses complain about a “faker” or someone “whining” and subsequently dragging their feet. Especially when results come back to show the patient has a legit issue and they then just shrug their shoulders. If your kids were the patient you would be worse than anyone you described above for sure.

  23. TODK says:

    Your response in all three situations was adequate. Better than most I would say. However, I would suggest that you learn to base the tone and wording of your response according to the level of intelligence of the person are dealing with. You responded to each of the three patients and or their family member, as if they were highly educated medical doctors. Since their IQs may have been average or below, they considered you to be arrogant and uncaring, even though your response were direct an accurate.

  24. Laughioff says:

    Being a Doctor in general is very trying at times. Its long hours and you encounter, at times, difficult patients and family members. I find your blog to be a good example of how ridiculous people can be. The first case sound like she may have wanted pain medcation, or not. At the same time, who could blame her, 4 days in pain is not a fun thing, trust me, its not. The second case is a joke. Yes, while the little boy is shakend up, sedative probably should be administered to calm hi down. To have him putuder General Anesthesia is insane. There is always a risk with GA And all over a 1cm cut, insane. To request a plastic surgeon is outageous too, if the mom and grandmom thought this doctor was bad, wait until they meet the plastic surgeon. If that plastic surgeon came down an seen the 1cm cut he would not be happy. He/she would probably turn around and say, are you kidding me, this is a waste of my time. The third case, unfortunately, all the poor man’s tests have been normal, and no one seems to id a explaination, I think using a walker is a good idea, becauase if he had another episode, te walker will provide him with support. However, medicare does require ligeitiment reason for a hospital admition, a docot just can’t say, oh ok, you wanted your loved one admitted, ok sure, no problem. There is a protocol that must be filed. Just like is a patient has insurance and they wanted to leave the hospital after say being there for 2 weeks, and they sign out AMA, which I strongly suggest you don’t, your insurance company now is not required to pay for your hospital stay, which mens yo will get the bill. Your insurance campany doesn’t not have to pay for your admition if there isn’t a legitment reason. USA offers wonderful healthcare, not I am all for a healthcare reform. I don’t know you, but from your blog, I don’t think you are a bad doctor. The patients and family probably didn’t like your staight forward answers and questions, they probably wanted you to baby them. Everyone always wantsto blame the doctors. The problem is is that when it comes to healthcare no one wants to hear mistakes, and in reality, humans are not perfect, and doctors are human. Everyone is so quick to point the finger at the dctors. They want to complain about little things, a 1cm cut, a mouth sore. I am not trying to gain pitty, but you don’t know what bad is. I had a lap chole in 2007 and I am still sick from it I have had 16 surgries in 2 1/2 years, the most recent being the end of Jan.2010, and I now, no longer have a belly button. And I don’t complain. Yeah, do I sometimes get upset that I am 25 and have had to put to my life on hold, with school and work, especially when I see my friends gradating college, getting married, having kids, yeah. Talk about needing a plastic surgeon, I am going to need abdominal reconstruction, and someone is radical over a 1cm cut. you don’t know anything. When I would go to doctors, I would sit in the waiting room and I could always tell who did’t have any medical experience because they would be the ones freaking out and yelling at te staff. Someone people just don’t have any class. They want what hey want right now. And as for the doctors being “bad”. Like I stated before, I have been sick since 2007, and I had to go to the ER numerous times. And I would most of the time be sent home because the ct scans would be normal, but I was still in so much pain. Well I use to work at the hospital where I would go to the ER and where I had surgery. And I know if it is seen that you have had frequent ER visits it is assumed you are “drug seeking” but I wasn’t, and on one occassion, I was in so much pain, my friend took me to the ER. I waited 3 hrs in the waiting room and when I got back there i was given a GI cocktail and told, we are not good at the chronic pain stuff but the life threatening stuff they are really good, gave me a shot of toradol and discharged me home, not lab work no nothing. Healthcare, in the USA is wonderful!! Not!!

  25. a doc and a mom says:

    I think this whole needing a note for school day absence thing is absurd, and places families and physicians in adversarial positions.

    I missed a day of work last week for gastroenteritis with vomiting. It passed in 24 hours and I didn’t go to any doctor, of course.

    It’s paradoxical and oppressive to expect me to take more time off of work to overbook into a busy doctor’s schedule to get a note ‘excusing’ me for my absence.

    Parents can decide when it benefits their children to miss a day of school. And quite frankly, the reason might have nothing whatsoever to do with their physical health in any case.

  26. Rissa says:

    Not a doc…I do the mental health.

    In response to all the OPs who suggest that this doc was “rude” or otherwise inconsiderate:
    Gads of Americans are turning into pansies. We go to the doctor for ANYthing.
    P: “Uh, hey doc, it hurts when I punch myself here.”
    D: “Then don’t punch yourself.”
    P: “What? You aren’t going to do any tests? I could be dyin’ here!”

    I’m sorry, but I just don’t see how coddling an impatient patient does the patient one lick of good. It teaches them that EVERYTHING is worth of a doctor’s visit and that EVERYTHING needs medical treatment to resolve.

    Which is B.S.

  27. Pat Whitmore says:

    I don’t think doctors today are as concerned about their patients’ health as they once were. It could be that they are required to do more paperwork for the insurance companies who pay them, and they spend a proportionately larger amount of time on that paperwork. Also, I don’t think they are as honest and straight forward as they once were. I’m sure it is difficult to give bad news to a patient, but there comes a time when you have to step up to the plate. If you’re a wimp, you shouldn’t be a doctor. Becoming a good doctor takes more than financial resources, and the ability to pass tests and get through school; many people can do those things. A good doctor is one who can respect the patient, empathize with a given patient, and put themselves in the patient’s shoes. A doctor who hides from his or her responsibilities is not a doctor at all and should, perhaps, considering leaving the field.

  28. CJ Gross says:

    Yeah, I’d have to agree. You are a bad doctor. perhaps consider a job where you don’t have to deal with people because you are obviously very unskilled in that department. It is a shame that people like you are in the medical field at all. Do you remember taking the Hippocratic Oath . . . try to remember what it says. Try to remember why you are a doctor in the first place. It’s not to pretend that you are God. It’s not to look down on others. You are a truly unfortunate soul. Give your patients a break, get out of the field immediately. As a doctor, you should strive to have every patient say that you are exemplary. The fact that you sarcastically call yourself a bad doctor really says it all. Poor poor you.

    • james says:

      CJ Gross – you have clearly no idea of the daily stresses or demans placed on doctors, nurses, physiotherapist and the many others involved in patient care.
      On a daily basis, doctors are dealing with very unwell patients, and have to make life/death decisions, they work long & often thankless hours, and on top of that have to deal with very demanding, unpleasant people who feel entitled to be rude, aggressive and nasty because they do not feel the ‘right test’ has been done or they don’t like that recommended course of treatment.
      CJ – you obviously don’t work in a job that exposes you to high numbers of people on a daily basis and have little understanding of what these medical staff face.

  29. 3rd case of falls says:

    Had the patient been screened for cognative dysfunction, and what cognative assessment test was used? Results? Also, was there any possiblity of medication (by combination or confusion) contributing to the repeated falls?

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