Friday, November 7, 2008

Guest Post: You're Fired!

Today a patient returned to my office for followup of my treatment of her spinal problems. She has back pain that clearly will not do well with surgery, so I’ve been trying to treat her with other modalities. She has been through PT, medications, and (most recently) 2 epidural injections. I do most of my own patients’ injections and did both of hers, spaced several months apart. She’s not a candidate for surgery, but I’m trying to help her.

At her first visit, I spent 45 minutes with her, evaluating and discussing her problem, showing her the MRI films, explaining what the options were. We discussed her anxiety and depression and talked about how that fed into her chronic pain. She did well with one injection, and seemed fine at that 20 minute followup visit. Now she returns after the second injection:

“Why didn’t you make me numb for this shot like you did the first time?” Tears. “It hurt so bad!” Tears. “Why did you let me be so anxious in the recovery room?” Angry stare. “I have some QUESTIONS.”

Now, I do the same protocol with every injection, including IV Versed for sedation. I know I did nothing different the second time, but no matter what I say, she gets more upset. Finally, after accusing me of telling her at her first visit that she needed surgery, and now telling her something different, she announces, “You and I are done, then.” I offer to refer her to another physician, and she snaps, “My own doctor can find me plenty of doctors who will care more!”


As a professional, I’ve been here before, and I know not every patient is going to get along with me. It’s her choice, and I’m fine with that. My brain tells me I shouldn’t let it bother me and that this patient has issues I’m not going to be able to solve anyway. *You can’t make everybody happy all the time.* I can’t even make the fixable problems better 100% of the time. The studies confirm that.

My heart tells me that I went into neurosurgery to fix people’s problems, and I should be able to help every patient I see. Because I do care so much about every patient and because I try so hard, every patient should understand that and be happy and grateful. If a patient doesn’t get better or doesn’t like me, that’s my fault. I’ve done something wrong or not done enough, been supportive enough.

No matter how much my brain tells my heart to shut up and be realistic, I can’t reason it away. This will bother me for days. It always does. The 29 patients I saw back today doing great, who’ve thanked me for my help, don’t make this better. I love the successes, but I wish the failures wouldn’t hurt so much.

gcs 15 is a 39 year old full-time neurosurgeon in private practice in a beautiful Southern state. She has a 10 year old son who plays travel soccer and ice hockey. Her wonderful, Type B husband is a primary care MD who quit medicine to be a college professor and loves teaching premed students. She adores her job but hates the politics involved in the practice of medicine. She's always struggling to find ways to get more hours in the day.


  1. It hurts my feelings too.

    Even when I get records request for a different doctor in the same town, it can be hard not to take it personally.

  2. This is something that I feel I'm already struggling with as a medical student. I'm a great student, but when it came to "the clinical years" I came to realize that other people's (ie, attendings) evaluation of me hit me deeply, and that much of my self-worth was wrapped up in another person's impression of me. Now that I'll be starting residency this coming July, I've taken pause a few times, thinking, "Am I going to be in the same miserable spot--feeling that my self-worth is going to be coming from my patients' evaluations of me as a doctor?" I don't think I'll figure this out anytime soon, but I know it's oxymoronic for me to say that my self-worth comes from other's opinions, but that's what I feel. To get into medicine and do well, I think our entire lives are spent feeding on results of performance-based markers, and it sets us up to require external validation, unfortunately.

  3. By serendipity I've watched a couple of my tougher parents interact with other people in my community. They treat other people the same way they treat you - poorly. This has taught me that while it feels very personal when a patient or parent puts me on the defensive, maybe it's more about how this person deals with the world than it is about me. This is not to say that I write off all difficult encounters with parents and patients - it's strictly case by case & they're all opportunities to work on my skills as a compassionate physician and human.
    I, too, dwell on the one visit that soured my day instead of the other 29 kids who hugged me, fluffed me, and made my job worth getting up in the morning. Still trying to figure out why that is...
    Nice post!

  4. My self worth is entirely based on other people. I know thats not right, but it is. I don't like who I am and have been trying to change for years. I'm cynical and judgemental and very pessimistic..... I don't think I've done this to any of my doctors. I have been really frustrated with them.... I guess I did change my dentist as he was the reason I needed braces (didn't pull a tooth that wouldn't fall out, the other came in above it)... but thats really all. I want heath care workers who care about me. When I had severe depression I changed counselors a lot. I wanted someone that if I missed an appointment, they would call to make sure I was ok. I don't expect that from doctors, but when a counselor has a patient that is potentially suicidal and they just stop coming and you don't hear from them in 3 months, don't send a letter to the parents saying you will close the file. Don't you wonder what happened to them? My counselor now is through my school and she is amazing! If I forget about our appointment, she calls or emails unless we run into each other in the hall. I haven't tried to miss appointments but my memory sucks.... So... i guess I'm more willing to change counselors than doctors. I have having to recap my health history too. I have had the same doctor for about 15 years, driving 3 hours one way to see him.... anyways.... Try not to let this person bother you. She is looking for a quick fix because she is tired of the pain. Nice as that would be, I don't think there is one yet.... Maybe gcs 15 could help me with my migraines! I've tried just about everything.... any suggestions?!?!? :-)... sorry its so long....

  5. No matter how much you care, no matter how hard you try, there's a "10%" rule. That is, about 10% of your patients will cause all your grief. Skip appointments, page you late at night for a routine matter, accuse you of not diagnosing/overdiagnosing/wrong treatment/not enough treatment/too much treatment/following what they read on the Internet, abuse your staff. What's worse, it's often those you go out of your way to help. My group has a motto that "every favor will come back to bite you in the ..." I recently tried to help a Medicare patient with her bill by dissecting out some things that I know Medicare will pay for out of her total preventive visit bill that Medicare doesn't cover. End result - she threatened to report me for Medicare fraud for double billing! Don't take it personally. (You can get passive-aggressive instead. I wrote to patient that I would be happy to submit everything, all proper, to Medicare, and thus she will get no reimbursement.

  6. Just be thankful she didn't sue. That's the ultimate rejection.

  7. Nice post. It stings, no matter how much your brain tells you you can't please everybody.

  8. The chronic pain patients can be very difficult. Pain makes people act really badly, and the psychiatric milieu in which the pain often occurs makes it even worse. She probably needs a psychiatrist as well as a pain management specialist to help her cope with this. This is NOT your fault, though I can see why it bothers you.

  9. Congratulations for having less angry patients in your practice! And having less liability for someone who is much more likely tro go after you, just because of her persona. I went out of my way to help new ovarian cancer patient I diagnosed (she was sent to me by her GYN !!!) She called a few months later accusing me of not doing enough and missing her diagnosis (radilogist first wrote on the report she had colon mass, than corrected it to be ovarian masss). She saw onc, GI within 2 days after CT report became available - exception in my community where there is 2 months wait to see a specialist. She raved about her bill for the visit where I broke cancer news, and stated on one pager letter why she is not going to pay it. Thank God, I was able to put issue at rest by calling her and withstanding more abuse on the phone. I apologized for everything I have not done, and had a sigh of relief when she finally acknoledged that she had superior care, despite her personal perception.

    Be happy when they leave, the come back at you and bite you more if they stay...


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