When patients drive the doc to distraction // Every physician dreads certain clients

Kathleen Weaver, M.D., knows what it's like to have a patient getreally mad. While working as a resident at Oregon Health SciencesUniversity 20 years ago, she tried to block a woman who had startedto bolt from her office.

"I felt that it was important to make sure she got theappropriate care, and I thought that if I stood in the way she wouldcalm down," Weaver says.

But the patient grabbed a radio and threw it at Weaver, hittingher in the face. The doctor wound up receiving medical attentionherself for minor injuries.

The lesson she learned? "I don't make any attempt to stop apatient from leaving if they want to. As far as I'm concerned, Igive them the best medical attention I can, but if they areimpossible to deal with, I just don't deal with them."

Problem patients. The words can send shivers down the spine ofeven the most congenial and mellow physician. Whether it's a patientwho talks too much, can't seem to follow instructions, never feelswell but has no identifiable problem or just smells bad, everyphysician encounters them.

"It's a very personal thing. Some doctors do very well withcertain types of problem patients, while others frustrate them," saysBlair Brooks, M.D., an internist who is an assistant professor ofmedicine at Dartmouth-Hitchcock Medical Center in Hanover, N.H.

Brooks has studied patient-physician relations. While at DukeUniversity he was part of a combined medical-psychiatric unit, fundedby the National Foundation for Medical Education, that sought ways toidentify problems and improve interaction.

"Unfortunately, in most instances, there are no firm rules," hesays.

Weaver knows that all too well. As an internist with a privatepractice and an affiliation with St. Vincent Hospital in Portland,Ore., she sees her share of problem patients. "I just plan onspending extra time with them. I don't get angry because they aredifficult - that really doesn't help solve the problem. I alwaysfeel I have failed if I allow myself to become angry." she says.

That's not to say that she doesn't get annoyed. For example,one elderly woman who came in with one ailment after another overseveral months never seemed to get better. While the patient hadproblems, none was life-threatening.

"Finally, I helped her get a volunteer job at the hospital, andbecause she wasn't focusing so much on her aches and pains, she beganrequiring considerably less attention. She began visiting the officeonce every three months, which is far more appropriate. . . . It isnot uncommon to see someone because of social problems rather thanmedical problems," Weaver says.

But even when patients display signs of hypochondria, it may bewise to pay attention. Says Lydia Moore, M.D., a family physicianaffiliated with Bethany Medical Center in Kansas City, Kan.: "I neverlook at it as though there is no good reason why they are coming tosee me. Usually, there's some psychological overlay."

Indeed, one former patient who suffered from headaches,stomachaches, vaginal problems, pelvic pain and anxiety attacksfinally went to counseling as a result of Moore's continued prodding.She discovered that she had been sexually abused as a child. "Almostimmediately, the symptoms stopped, and she became a very goodpatient, instead of someone I viewed as an aggravation," Moore says.

Patients with a psychological need to be ill may becomecombative and antagonistic.

"Unfortunately, there are patients who I know will be a problemfrom the moment they walk in," Weaver says. "Usually, it's the oneswho have been to 10 other doctors and nobody has told them what theywant to hear. It is not uncommon for these people to view you asterrific - until you tell them the same thing they've heard fromother doctors. Then they get mad at you."

Overly demanding and rude patients are a bane to manyphysicians. So are overly chatty ones. "Talkative patients are acommon problem," says Edward Kimbrough, M.D., an orthopedic surgeonat Richland Memorial Hospital in Columbia, S.C. "Some of them can goon all day. Sometimes, you just have to cut them off and get on withyour business."

More disturbing than anxious patients are noncompliant ones,says Evangeline Archer, M.D., director of mammography services atHerrman Breast Center in Houston. "It is very sad and frustrating when you see someone die or becomeworse unnecessarily. It leaves you feeling a deep sense ofinadequacy," she said.

A couple of years ago she diagnosed severe breast cancer in awoman in her 30s and suggested a strategy to attack the disease. Thewoman had a different idea, however. "She decided that she was goingto go home and `surrender to God's will.' Although her case wouldhave been difficult, she had a very realistic chance of surviving.It was difficult to deal with."

Kimbrough regularly sees patients who worsen their orthopedicproblems by not losing weight and exercising. "They put more stresson their joints, and then they complain about it."

Among the most difficult patients are drug and alcohol abusers."They are difficult for any health care provider to deal with," saysGerald Burke, M.D., chairman of medicine at Cook County Hospital inChicago.

Drug users are extremely manipulative, says Moore. "Some ofthem come up with the most incredible stories I've ever heard. I'vehad people tell me, `The cat knocked the pill bottles into thetoilet,' or `I just dropped them behind the sofa and I can't get themout.' . . . They always have an excuse or justification no matterwhat you suggest. In the end, it's just a matter of being aspersistent as they are and not giving in to what they want."

The most trivial, but nonetheless off-putting, patient problemmay be body odor. Moore often treats indigent patients. "Some ofthe patients are amazingly grubby," she says. "Sometimes it seems asthough it has been a month since their last bath. I have to hold mybreath and spray the room after they leave."

Are physicians bound to tolerate any and all patients?Virtually all those interviewed answered with a resounding, "No."

Moore has "fired" two patients - one for swearing at her staffand another for being impossible to work with. Brooks once had todump a patient - "Whatever I did it wasn't enough. Finally, I toldher it would be best if she'd find another doctor. She bouncedthrough four others before coming back. In the end, I had to lowermy expectations of what I could do for her." (c) 1992, Samuel Greengard