Does anyone think the PATIENT may NOT be the PROBLEM?

Some Personal Thoughts from a "Complex Patient"

Like I'm not.

Any number of things really, and what's a riot is though a provider myself for twelve years and inactive for a time but the knowledge is there I use it a lot differently to begin with.

But what's a lot more serious to me are for one that "How to "get rid of a problem patient in 10 days" is what is being taught in medical schools daily across this "developed" country.

What happened to simply paying a PR department or having an ethics of medicine and one also educated and experienced in law?

I worked in a Catholic hospital, in another Houston area hospital, as well as one in my hometown Nevada residence, two Seattle hospital and one Northern hospital clinic before I took a job selling lattes, which was a hoot.  People were a lot more friendly when I sold them coffee and dished out some home remedies in conversation over a doughnut, and I have never until recently had to scale back on what's given free.

My college education came at a heavy price. Time from my friends and family.j

Having to put an end to fun for one: a nightmare beginning for them: battling chemical dependency and learning to live tolerating most if their pain its difficult to walk out on someone who clearly has a serious drug problem and say "I am not giving you Vicodin, Percocet & any opiate or opioid drugs."

What I also was taught to remember is kicking the physical addiction is extremely difficult thing but I was allowed to and required to help them get treated if they were willing.

When not and screaming a line of cursing its a bit different. And even then I usually was able to place one final attempt to ensure if they were at risk (people get desperate) and send a CDMHP ( mental health if anything was able to get them a 72 hour hold in a detox facility.

Paperwork was usually it.

And my signature.

Less and less do I see private practices that thrive and the advent of hospital oats running patient care.

And even well insured people with complex and chronic health concerns do poorly when one provider isn't the person who runs the show.

As a "patient" myself now I'm ever more humbled with mysteries of the human body and what changing one thing in a persons medicines or self care routine can do.

To remember first to do no harm? Before taking my commencement at the Masters level I was humble and did take the Hippocratic Oath.

Removing it from a medical education creates hypocrites.

But with remembering that professional obligations to a patient existed if not ethically but a moral one I also felt obligated to do the two inches of paperwork, if it spilled into regular activity on the next shift, coffee, food,and Tylenol for the headache I felt for the screams about overtime?

It was hardly worth the fight. I parked it in a staff lounge and punched out. Why? I had to do it and no interruptions when one is no longer on the clock, it gets done faster no matter who you are if no one interrupts you.

Free food?

We used to kid each other, "A tube fed and leg bag and I can last forever"

When are any of us the Energizer Bunny?

Fact is no one lasts forever. Except God.

However I see four behaviors so frequently:

Laziness (usually over what amounts to two pages of paper and a? Signature!)

Arrogance.

Generally incompentence or being human and at least being thoroughly unable to admit you are wrong.  Or you were. If its required of one of my patients I was never "above" admitting I'd been wrong. And admitting my own fallibility.

And complacency.

Dangerous combination really.

Ghandi happens to be right, and since people are examining themselves wanting to understand why provider relationships fail?

You aren't dating folks!  :-)

Seriously if you saw the nature of family lives? Physicians, nurses are by no means exceptional in this area.

Some of the highest rates of "failed interpersonal relationships." Like shrinks or neuro and cardiac surgeons? Nurses in those areas?

Love us what it comes back to each time, but personal accountability too.

It's barely taught to kids or many adults. 

It bonded me to more patients, and for some even putting a hand on that of someone dying was never an issue, it was done and now?

It's not allowed, I guess too much of a good thing but allowing regular practice of some evaluation and sharing also helped people show you care.

The most satisfying job was actually in communities and often done by word of mouth. Church groups and Bible studies were rich ways to fulfill time with my son and daughter, but now to think back it taught them values too.

What I've seen in a brief stint considering moving my care to the University teaching hospital?

I guess I'm not in agreement when someone I love is in the building where an oral surgeon could have changed her quality of health: that I also was elsewhere or would have clearly come to help.

Getting one us a major problem if you are in a crappy category.

Take your pick:

Pain, mental?  A bad oral infection causes mostly neurological symptoms for us both.

And many with chronic health disorders?

Find another provider. I think community health offers the most rounded approach.

So many changes (a positive usually) but human fallibility is within each of us.

Doctors too and it's harder to take anyone who lacks many financial resources, and governments inviting themselves in?

Well I hated to say this?

Hardly!  Forcing something makes it no less attainable.

And I've found? Everything ends, relationships too.

If a doctor doesn't work?

Find another, burning bridges when you leave? Ill advised. Providers are human too.

So are patients, so limits are simply on both sides.

What happened? Manners, that's what.

Okay-this is strictly unplanned, but as I consider after a phone call to my own doctor, that I do very much like, I am reconsidering my "planned" course of actions.

The diagnosis of RSD and also my own separate (I feel, but really doc, what do I know?  Um, an MSN thanks......but of that-I also have worked separate non-healthcare jobs.

As also I have in a customer call center for a brief time, that I enjoyed it so much, that I actually that was volunteering at a hospital and wound up being offered an ER job as a technician-that as an  EMT, I dreaded amy next shift after a "person vs train" call, I seriously was looking for a good reason to justify quitting.  Raising a family you take those decisions seriously.

Being able to pay rent-kind of important to begin with, regardless of where you live, what you pay-folks, we may have living in public housing-it's not a life anyone signs up for but luck out, move to a small town, perhaps luck changes.  You begin to see another side to others, one you may like, and then you evaluate-one your own actions.

That I myself rarely leave my apartment-expensive to have things shipped, mine is mostly disability, yes.  But the rare occassions we go to doctors?  LOL, I am joking, of course, but the welcome help of a friend I also consider a caregiver, and that I try to help where I can as well.

I guess an idealist always one.  But I was also not raised in a barn.  Or born in one, but well, Christ was-so humble a bit.  And consideI typical

But an eventful weekend, I had contacted my docs office, left a message that I would be in touch.  But basically that I had planned to call them: money only being part of the reason, but I do live in an outlying area, but have my healthcare that is based otut of the University of Washington.

Kind of far-very for me, and previous visit the doctor had ordered bloodwork, I had forgotten to tell the doctor who had been wonderful.  It was really refreshing to actually have a doctor who remembered the basics-like listening.  Asking a few questions, a short and limited exam, but had been suppportive-that she went in to see for well-either another patient was already in, but given the short time luck on my part-God, I guess through another-but she brought my coat I had left-the hyperhydrosis kicked in-I had left it behind.  I tend to not care for sticking around any medical facility, but a needed stop added to the trip home added to the (for me it's time, I dislike not being alllowed my usual continual movement.

To the degree I can.  Progression, no cure, etc.  :-)

Also it's an issue of in some cases that I feel truthfully the behavior of office staff either reflects directly at least who is in charge-no one, or a person-and found when I just had found the time after my routine in the morning, but a bit of just being kind of lazy but the RN I spoke with was short, rude, and a bit disrespectful of that experience.  I'd had some concerns, needed their fax number-I can get it online if I elect to go thed  route and fax them records.

A suggestion.  Log who you talk to-when, and a date.  One sentence if you are able, what.

If you are complex?  My guess is yes-so a note is one way to keep track-also who did ad d good deed, say thanks.

It's manners, I was taught-and likewise-had thanked the doctor for bringing my coat-but well the RN hung up-and no, it was not a lost connection-DSL has limits when you have to plug into a wall because your  system picks up no wireless signal.  Add to the "daily pains" but I chuck it on list of why movement helps.

I believe though in positive reinforcement more than a negative.  Also in giving a message, or if at a learning institution an opportunity if the see it as such-clearly the doc did she took on 2 pretty complex conditions in one patient.  An RSD'er on a feeding tube?  Okay, so if  she is half lunatic, welcome.

But well, I figured sometimes-and bugging someone if they are a thorn?  No, you let them squirm.  Play your cards right though, a lesson is in it.  Hanging up when someone does not ask yet the final 2 most important questions after telling you that grossly infected gumls, and being unable to tolerate an oral antibiotic,

Not concerned at all.  None whatsoever.  I prefer Skype and well, never plug my phone in.

Um, okay.  How is she going to get in (the RN-I called her back-getting the Call Center.  LOL, perfect.  Sent a computerized written message, told them-then explained why but by being very friendly, and understanding it was an odd request, explaining to a small degree that I was complex, but that I did not appreciate the price, but knew that she was the messenger-mentioned in brief my call center work.  Relating to the person who answers the phone, is always an important factor.  It may be a learning institution, but thus far?  Smart as far as I am concerned.

At any rate, I decided on the fax, because my price for her behavior-the patience I have from a previous experience is strictly limited.

Thus a polite note to the doctor on top of the medical records should pave the way a bit.  Waiting a few days and letting her squirm is tempting.

Making an enemy of someone however is never wise.  Teaching a bit of manners albeit indirectly well, another story.  You call at 4pm, remind "I am not tolerating an oral antibiotic" and even if it is 3 when you get sick?  The staff complains.

Then the doctor gets either upset and then what?  That right there can create a problem for some patients-you get "behavior"  a and one slip and what?  Legally they can refuse to see you.  Ever, including every doctor in the system.

But there's not really a "little person," and each person has a significant role iin keeping doors open.  They do have jobs to do.  If it is a lengthy request-in writing can be best and jotting notes while for example, when a caregiver comes to help-there's a chance and you can lose out on something that can improve.

Or you can be spinning your wheels.  If at any rate-that's a consistent problem, it's either a department-or any number of issues-down to the facility-taking a look at how they practice  medicine-a short mission-if one isn't available-then something telling you about providers may also tell you where their interests, prorities-some of that can be of help when attempting to relate to someone.

But if someone is rude, and disrespectful-if you request an antibiotic-they'll look, see perhaps why and if they
retain staff-or if someone is good otherwise, honestly?

None of them are perfect.  At times, it may be worth biting the bullet-it depends on what you put up with.

It's not hard to say, "Guys, this bothers me, how can we work together to fix the problem?"  Compromise, and sometimes you are surprised at what people can do and how they respond.

If you have people who create stress in your life, maybe distancing yourself a bit, LOL, but on a lighter note-it's not always you either.  Just know that.

What someone else does and initiates behavior wise-you have no control over.  How you respond is another story.

Just as permanent also.

Sometimes putting more into it gives you something to go on in the long run, others?  Years may seem like worth preserving-one who walks in your time of need is hardly anyone I would want to be around or work with (and for) as a provider.  Small names aren't always bad-but remember human fallibility before rising to anger-for us?  It's not worth the price in pain you will pay later.

Just some additional thoughts, thanks!

Martin Brodel says it well on Poverty

The Complexity Factor-Thoughts on obamacare, On a Personal Note

Oral surgery is one thing the UW does well-they train them.  Being a teaching case is one thing.  Allowing yourself to be operated on by a student dentist is another.  RSD is a serious illness, and it cannot not affect every part of the body.  And I believe when one new doctor begins the required research to present my case: well, I think she is already quite intelligent.  And highly compassionate.

It's a refreshing change.  A minor change in one prescription she wrote-adding dextromethorphan to the phenergan I take (aka "promethazine) for the overwhelming nausea that caused me to obtain the medical marijuana permit-to which she never so much as retained a copy for their own records, I guess those prescription monitoring programs must be very "up" on what I do with the stuff.

It's called treating the actual problem.  You keep the card even if it's legal because folks-do they label whatever you buy from the dealer?  Do you know if chemicals were used, if mold is present?  Do you know there are up to five-detectable levels in lab tested medication is one thing-different ingredients in medically grown marijuana?

It might be expensive to use dispensary medication, but I will be perfectly honest: yes, I've used both-sometimes to at least have some kind of something and during the very brief time I could not get a ride to the "weed doc" sure, I did get something, but from a fellow patient.

I know how to made a few medibles, a skill I picked up before it?  Sure.  When a doctor-naturopaths issue permits in my state, they are the most qualified to do it, the state even knows, but certainly, a pain doctor does need to refer you.

But I went to that treatment, not with my eyes closed, as many do, but with them wide open to the fact that marijuana has five active ingredients-THC, dTHC, CBD, and well, does anyone need it spelled out?  It's as unpredictable as any other drug.  Or "medication" and since marijuana is a prescription, and a C-1?  Even in Washington, which is the only state where possession is not enforced?  No, appearances are not what they seem.

Get caught with 2 pounds, you go to jail like any dealer with intent to distrubute tacked onto it in all likelihood, and well, with 24 ounces-and most pay about $200 for it, and up to $250 for one ounce?  That the clinic I renewed my certification at said basically if I want more than what the one local cop I find even tolerable?  My "pound and a half"?  Um, times 24, that would cost?  LOL, on a federal disability, I would be a moron to spend that kind of cash.  And probably would be taken to jail.  Rightfully-it's called a nearly free-dry out.

People will get addicted to anything.  And for everyone, I believe, in each of us lies something that we have a hard time with.  For some, drinking, for others, opiate narcotics, some for some reason known some say to God, to me, I think the opposite.  Only from the pit of hell could someone come up with something like methamphetamine.  My guess is in the beginning most figured something along lines of Ritalin.  I doubt they got what they bargained for.  But to get addicted to being floridly psychotic, I fail to understand the lengths people go to inject gasoline mixed with things like lighter fluid.

My first day as an Emergency Medical Technician, age 19, I walked into the ER, passed a "Anti-meth" poster, but in those days they did not hang the booking photos of someone who wrecked havoc on their bodies but they put up the actual ingredients-to some you would thing gas, cold meds, and Good Heavens, just about any ingredient.

I congratulated the Nurse Manager.  "Good job, you are handing them a recipe."  It was taken down immediately.  That today I likely would be ignored?

Or laughed at for being a "weed smoker" and told that I am killing brain cells.  Um, preserving them actually because having taken medications from "modern medicine" I have been able to safely say?  "Weed" as some call it, hemp, etc, is one of the most difficult to manage if you know nothing going into it, save what the dispensary elects to share.  Which unless you go high end?

You wind up with something that may not be what you need.  I listened at first to them.  Unfortunately it was someone in it for the wrong reasons.  That I was also left sitting out in my home-and acquired a hospital visit, and by ambulance because I couldn't pick myself up off the bathroom floor, was as swollen as they come?

And nothing was being tested-meds were never labeled, I finally noticed-another dispensary?  You bet after the way local hospitals have begun treating patients.  Formerly?  You had no ride home, they at least would give you a cab voucher, and send you home safely provided the patients had one.

More than once as an ER nurse, I did pony up-at times, up to $20 or $30 once, to get a patient home-or at least to a shelter.

Any given time I leave a hospital ER, patients are sleeping off a Diladud, Morphine, or whatever medicines they are screwed up on as what would even five years ago have been considered irresponsible both by nursing staff and by the ED physician prescibing those drugs-now?  The least path of resistance is being taken, and patients are paying a heavy price.  A very heavy one.

Myself?  God, if I wrote in this blog even a fraction of the abusive behavior?  When a patient who is normally bed-or at least wheelchair bound in three years of "treatment" following a surgery that the orthopedist if he had checked my history-his only question being why I hadn't returned to his former medical school friend?  The guy may have saved my knee, but had they been close, he would know his friend had passed away of pancreatic cancer-or I would have returned.  But coming to learn that not only that, but that he'd suspected that I had developed this after the second of three surgeries to give a 17 year old mother a way to continue walking-he also advised no further knee surgeries-despite several office visits, I wasn't given the information I had to make the right decisions for myself.  The knee problem, yes, was corrected, and until 2 years ago, I was able to walk well-to some degree I can, with a crutch is mostly best, but I hate the crutches-would I prefer a cart?  Likely.

But why bring the medical marijuana up?  Because I believe firmly that it saved my life.  To a degree, set me free of the worry that was continually on my mind-that I may have an ache in my jaw, but that only one full dose of a pain medicine only now-nearly eight hours later, almost ten?  That I get anything now, I can barely function and that even entering the atrophic stage?  I manage, yes, on some amount of pain medication, and sure, it's scheduled.

Stage four doesn't exist?  I assure you it is alive and well-that I can name not just one, but at least 2-3 patients like myself who are wrongly labeled Stage 3.

No cure, but Stage 4 is suddenly gone from advances in modern pain management?  This disease has affected my gut, my lungs, my central nervious system, circulation in my feet are now compromised the muscle spasms I get are severe enough when not with the right meds-not always weed guys-I do avail myself of modern pain managment too.

What if I told you patients on a medical permit studies clearly show we have lower doses of any of us that are on opiate therapy.


Standard of care?

That a man now lies hospitalized but not at the local hospital where a female security guard assaulted him, that in my mind is a sin.  Not of his own-though the (then discharged patient, much like me, was a wheelchair bound patient-and being as was I, though slowly, and not to their liking, but what I saw stopped me in my tracks.  It was a level of sick behavior that keeps in fear of ever going back.

That I've already placed a call to my new primary care doctor with a message that I am calling and via Skype, but because I have no (the actual phone, service I have, it is called paying a bill-contrary to what many in my own family choose to believe, they know exactly where they stand, and well, I believe I understand better than ever now why so many views of this blog have been in place, and I am guessing it's the total breakdown of the doctor-patient relationship, disallusionment with what doctors formerly provided.

Marry Poppins said it, "A teaspoon full of sugar helps the medicine go down."

When a doc used to spend more than five minutes in the room, and now a medical assistant with less than ten months of training is now fuklfilling a role that fifteen years ago would have been at least supervised by an RN who would be easily accessible?  I think that much of that is part of it.

Other things also are things I find terribly disturbing as a former ARNP-level training.  That a friend's child-though 37 at the time, a parent is a parent-and it for 98% of us, anyhow-never stops-even if your child dies, you think of them constantly, you miss them with every fiber of your being.  Whether you were to be destined to keep, raise, and well, in my own case, hopefully walk her down the isle-you were a parent for life.  That my own flesh and blood has never laid eyes on his own grandson.

Is reflected by his own behavior.  That he does not remember the night his granddaughter was born?  Or the day she left this earth to be with Christ, the Savior?  To me is a great tragedy.

But one thing I can think of no greater tragedy and that is one of a wasted life.  And after a life of nothing but the suffering of others, confined to my own home because of my own physical limitations?

I almost consider it a reprieve-sure, and the thing about the pain improving with the atrophic stage?

It is a load of boloney-I'd say worse, but I made a goal of my own.

Watching my own moth-at times, and largely of stress, I can cuss with the best-but truthfully little is said with talk like that.  Verbally.

I think when it's a teenager and it's every other word?  It used to be called showing off, preening-and well, probably looking for some acceptance.  And quite frankly that the f-word is the choice in most cases, shows of little creativity in my own learned opinion.

Well, work in an ER, on an ambulance-you will hear a lot.  Work in a nursing home, you will hear far more, but there, you grow a very deaf ear.  Because mostly it is a response after many have a stroke, and they often don't have the ability to say more than perhaps maybe 3-4 words, and that is normally after a good deal of therapies, and so forth.

What is tragic of all the changes in healthcare?  That most of the abusiveness I see as a patient but remembering always the job of the providers, is that there is little compassion on the parts of providers.  When docs used to take a patient's word.  Now they treat old medical records.

Great, we used to use a medical file from previous providers, not to judge, or even gauge what a patient was like-that was done upon meeting the person.  I was also taught that you asked them what they preferred to be addressed as-and that was what it was called-be it their given name-or something like "Shorty."  It's what gives you a connection.

And I am of the belief that one needs to exist on some level-or you are the last person who ought to be making decisions for someone even medically without knowing-do they have religious beliefs, personal ones (I myself do) and what were they?  It was always part of my own assessment as a nurse even to ask questions of sort of if it was to know a bit about someone.

That for example a quick trip into a local ER was about as disasterous as it gets-that sitting in a lobby trying to message someone-not knowing that another had a prolonged emergency of her own, that it was never able to have gotten a message to me, that possibly if need be-I may have to find some other route of transportation.  That a good friend is also in need of a-well, a friend, and some prayers.

Which of course, will be forthcoming, and are.

But when your teeth are in the shape my own are-great dentition does not run in my family-that the men in my family do fare better, is also a clue thy at OP runs in my family and why mostly I use my chair-it is known as prevention.

And is it practiced?  Hardly.  If you can "pony up and pay up." And that almost every pain clinic for example, save ones associated for hospitals are allowed, and almost all do?  Ask for?

Just to secure an appointment.

It was that part I have a problem with.  Not anything associated with peeing in a cup, whether opiates are given I can and always was able to tell them exactly what they were going to find.

But that I use my medical card to keep off them to the degree that I can.  When your back also resembles what my own does-a spinal curvature went undiagnosed as did EDS III-but as well, probably one other type, that the same condition is related to my low blood pressure, orthostatic nonetheless-stand up fast?

Right.

But any of the "private clinics" that one may seek treatment at, you will be billed $600 to the card for not showing up.  Or a hundred bucks goes to collection-and they don't wait.  If your insurance was not taken, and you even went and showed?  You either paid six hundred, and one kind friend offered to, and I told him to put his money away that no idiot doctor in their right mind deserves that kind of money-five years ago even-for an initial consult and he could burn for that kind of cash.

Little did I realize the irony of my own statement.  See, there was a person in my life aware completely of the diagnosis in 1990 that probably dated back to the 1983 traumatic brain injury I took-the extent leaves a plate in my head-no, hardly do I set anything off unless a body scan is done: the plate is small.  Back then-oh brother-Burr holes in the middle of an ICU was what saved my life.

NOW?  Ha, you get what is known as a "bolt" and had time permitted, they likely would have used the type that goes deep into the center of the brain, through brain tissue?  Into the ventricles.  It gives yes, the most accurate reading, and since others are developed for the less serious ones-but I garauntee you if one is used at all?  You are very critically ill, and well, comatose usually be it in a barbituate coma as I had been at least initially-worried the doctors when wakey wakey did not happen right away.

Kids, however, always have a mind of their own.  And their bodies are not that of miniature adults.  And is why they ought not be treated as such.  Specialization is one thing.  Referral to one for a bladder infection as a friend's mother once was-I only could roll my eyes.  Do I know the feeling?

But what I also learned in nursing was that you don't treat fully grown adults as a child.  You at least assume that they can read.  Or if you are aware they can't it still doesn't mean that they are as some now jokingly refer to me, "drain bamaged" and amongst friends, I know the joke is on me, and learned long ago that the ones using the term recognize my history-that I have temporal lobe epilepsy and psychomotor seizures are highly unpredictable, and some you cannot tell they are having them, bot one thing they aren't is a behavioral issue.

But I have always believed, to return to the topic at hand, in pain contracts, that when my new neurologist-who quickly lost interest in treating me upon learning the actual complexity that gastroparesis also accompanies this "new patient?"  They failed to continue returning my calls once he felt that my "pain management" was fine because one of his referrals panned out?

Yeah, the doc he referred me to is very human.  I say this dryly with a reason.  He's not got great ratings, few pain docs really do-some of the work is incredibly hard, people are physically and mentally in a lot of pain when living with something like RSD, and I never think that they really understand the necessity of controlling anxiety.

It is a normal response, folks, to a severe level of pain.

But one thing that appears frequently in RSD literature that I find myself at odds with.  The McGill Pain Index.  I find any number rating offensive in a way.  I also as a provider find it a very poor representation of the real level of pain someone is in.

You leave out anxiety, the fear of not always knowing why, the frustration of a potentially failing relationship with a provider, not knowing if this one is going to work, that your pain that has you hunched over watching the clock?  Does it ever resemble something like this?

How long have you been waiting, that the pain seems interminable, like it's going to go on forever?

That it was all they ever did, that I frequently offered my previous provider that I was happy to sign one-that neither he nor the last pain management doc-was in fact, not at first even in PM?  That he basically began his twisted game of taking me apart diagnostically and without my knowledge?

That in six years, he never actually did a single one, had me sign a pain contract, which nowadays is pretty much standard, that one outside consult before him, had resulted with me being put on the one drug I hate more than any other, that I have had myself taken off of it (methadone, to be frank-I hate the side effects, it rots teeth, with crummy genetics in that department as well, and pointing out to the provider that I had no dental, could not afford it, and he spends the better half of twenty minutes arguing with me over it?  And despite the fact that I spend the better part of half my personal income attempting to help relieve my pain in some way--be it distraction, be it pain relief-or the medical marijuana that has decreased my overall swelling so that when it happens, there are not the huge fluctuations in weight I formerly had?

That in stopping a good deal of the pain meds, starting with the methadone?  It does nothing for RSD, and I think that there's one simple way to tell the difference between

That I took the puny dose, got no benefit-that genetic testing on a family member took place during that time, that it was paid for out of his pocket-with an upcoming surgery not just for me, but also for him, and his being even more extensive, and equally necessary, so we both thought.  Mine I obviously regret.

But in the 3 years since, I can assure you that Stage Four?

Is alive and well.  Mine is a result of poor and further deteriorating healthcare availability resulting in my own decision to move all of it to a neighboring county and access the area's teaching hospital.  That at this point, I would not set foot-or wheel-into a single medical facility in this county at this point, critically ill?  Transport me by helicopter to the trauma center then folks, because as long as I am upset enough by what I saw today-I elect not to share the depravity of a female security guard with a boundary problem and probably a few mental ones-that when I worked ED fifteen years ago, that she by the employer I worked for in Eastern Washington-none of them really in the three jobs over seven years (everyone needs change, I certainly did), and that what drove me out of nursing, and with a friend in 2006, we mailed our licenses as providers back to the Board of Nursing with letters we co-wrote telling them the reasons.

It's called lab testing.  From the proper folks, not only is the medication for me, more effective, but their staff has their own background.  And listening to what they say?

Has always proved to be a good plan.

And honestly it's nice to think clearly, not be loaded up on a lot of medicines that many take to offset how tired-or that tremor that some meds give people?  I may have some atrophy in my hands despite the constant activity I keep going from waking up to falling asleep-but it also helps as progression has I feel beel slowed some, so with CNS disorders, you are affecting the entire body-by definitaion I think.

In trauma, the brain shutting down or the brain stem herniation that began I later learned, that necessitated a neurosurgeon taking a huge risk in the 1983 brain injury I wound up with: and in the middle of the PICU on an 8 year old?  Saved my life.  That it was at the very same training hospital that I had been born across town at the University Hospital that took me straight to the NICU?

Sure, I was a preemie myself, but not by much, at 34 weeks, these days-it's not uncommon for them to set a weight goal after the first day and usually it's 4-5 pounds.  Raising kids who were both preemies but only one as my own?  Making sacrifices of my own to get an education no matter what but that as I did, I also was working, and at the same time-learning.

But that prevention was the best route, and that most surgeons then thought nothing of reaching up and grabbing your galbladder to prevent you from needing surgery even.  That surgeons would wait for what seemed like forever before operating and now you are on the table before you know what's happened, it's over?  It's not always such a great thing.

That lengthy recoveries I have had-hospital stay-wise, I have had nothing under 5 days even in the last 2 years, but that the care is non-existant and in the region I live in short-stays are so common, that it may as well all be outpatient?

That a basic level of care was expected of me as an RN as well-that if a MA even presented themselves as a nurse, which often was a frequent error, a huge difference exists no matter what the situation is.  Ten months, maybe, but many years working also can provide one, if they make notes, I guess-whether a mental or written, being visual-it's why entries are commonly set with a thought.  That prevention used to be the name of the game, so to speak.  That my Part C carrier had a wonderful online health-related program where you earned points for recording things like physical activity-and operating yes, on a certain level of honesty on the part of the recipient, it was limited to once a year.

What a great goal though.  And teaching people that yes-keeping track is important too.  That their physicans could be provided with daily notes-reflecting how you felt overall.

Not only keeping track of pain levels, for example.  I have seen myself get hyper-focused.  With such major complications-the reason people have become chronically ill-probably lack of prevention.  The program was shut down for Medicare recipients-guidelines prevent them from giving anything.  But that they took a penalty for having it?

I know it made a difference, but now having changed the cooking, the way I even see food?  We
Infections, skin breakdown, sores, swelling, folks, this kind of complexity I admittedly had no business fooling around.  And seeing a  pain doc who was in over his head.  Very.  And had an ARNP who clearly did not know what boundaries are.ri


When you are in need of what they have, and you are unable to beat the system?  For further understanding, see a page I have established, mostly to keep what is personal shared with friends so their concern can be addressed, and they too can comment if they wish to.

You join it.  A teaching hospital ensures that a faculty doctor will likely rubber stamp the RSD since the effects on the lower body are clear, some in my hands but so long as I can type, silent I won't be

And obamacare?  I guess this page speaks to the sad fact that if you are on public assistance, few places are in existance that you will get proper care.  I recommend reading my blog-but answers are one thing I doion't have.

Save to say that you really need expertise-does saying you are an expert in RSD/CRPS make you one?  Not ever.  Taking the Hippocratic Oath out of a medical education has always been as much of a mistake as allowing a computer in the exam room.

It is a barrier of another kind.  But there is more.


It's been my own journey mostly.

And also on a more personal note, what has lead me to more carefully examine why the doctor-patient relationship can fail.

My own experience is:

• Loss of trust, on both parts-some providers, especially in pain management sometimes have to givve bad news, and some do not take it well, and at times if you see healthcare not as getting basic needs met, but as also being allowed to ask for help?  The relationship is already in peril, and looking elsewhere well, I would advise it.
• Lack of knowledge really?  On both parts
• Inaccurate information conveyed to a provider by a third party-and in spite of HIPAA, when it's those  closest to you-a provider can either ask you for the truth-or continue living a lie.  Sometimes it's easier as we all know to believe the worst about a person than to find out the system has repeatedly failed your patient.
• Lack of compassion
• Taking the Hippocratic Oath out of the Medical Education.  I think it creates more hypocrisy.
• Doctors practicing medicine from what is basically a cheap or free download to an Ipad, Blackberry, iPhone, or Android device.  I cannot myself think of a worse thing to bring into an exam room.  That they have a very highly developed camera on them, that despite that no pictures are taken that I am aware of the thought that it would be easy to get shots-but that likely some probably are gives me a sick feeling.
• That medical students have been given courses on basically how to "get rid of" what they consider a problem.  A friend of mine has just finished-or is still yet finishing, but at 62, she has earned a right to slow down some, and basically an opthamologist refused to take her on as a patient despite a family member who has a position in the medical community of her city, and he told her that despite the fact she has excellent insurance, "too many problems,"  as the reason she was given for her own denial of care.
• That medicines in order to be prescribed require now that you are seen every 30 days, and in a catastrophic illness, be it RSD, be it anything from lupus to cancer-that the medical community has banded with the goverrnment?
• Micromanagment of healthcare
• Prescription drug abuse-and largely patients are not the only ones.  Ever watch the program "House"?
• Forgetting that use of prescription medication by some patients is taken seriously-but that many with chronic pain, well, we are denied medications at times for our own protection-you do need them to work when well-you reach that "point" and the unknown of not knowing when it is-kind of demands that one is using them with a great deal of caution.
• denial
• Abuse of the system of healthcare to meet some other kind of need.  This would be in some cases of very serious illnesses of other kinds.
• Mental health disorders-this is a crucial area to be honest about-having a mental health diagnosis does not necessarily make a person "crazy."  I would be surprised, if not concerned, if a period of adjustment had not taken place when the latest and most recent insanity in my own life has taken place.  And having simply stated, members of my own family who refuse to admit even that a period of depression, a degree of memory problems as a person ages-and that in PTSD?  Some issues are to be brought to light by the patient.  Well meaning or not, scratching at a wound, albeit an old one is well, not always helpful and can make matters worse-getting permission is generally a good idea.  People will discuss matters on their own eventually that they feel is causing a problem-pushing what another thinks can be a sick level of creulty that I wish upon no one.

In the era of 1910-1920, in England, the British government attempted to get into how medicines were prescribed, regulate, schedule them into an oblivion and create in large part the mess with prescription drug abuse-and basically invite themselves into the exam room.  The British Medical Association did then what the AMA lacked the spine for IMO, that I feel is in part really that the BMA told their own government to basically fly a kite?

Speaks to why the obamacare mess, and in part is responsible for my own difficulties retaining care, however, that recently moving my care in one final fell swoop to the local teaching hospital has helped immensely.

And that a second year resident listened so incredibly well.  That I left my jacket in the exam room, and she saw it, and caught me at the elevator and gave it back-I looked at my caregiveer, and said, "The last place I was at, it would have been thrown in the lost and found and I either would be buying a new one, or I would be out of luck without a lot of trouble"

That it happens daily and to people like myself who can ill-afford a new coat at the drop because of what amounts to laziness?  And that complacency is really at the center of what I believe to be the core of what lies in the center of events that I feel have taken place for a reason.

People don't like huge changes.  It happens to hurt-and growing pains are no exception.

That the oral surgery I desperately need now?  It may finally be within grasp.  And a simple matter of asking for a referral.  I consider myself very fortunately that I found a GI doctor willing to tell me to wise up and do what I have.  When a system has told you to fly a kite?  You record the call, store it if you have to-but keep it for when it rains.

And I live in the Pacific Northwest?

When you cannot beat the system, you join it.

It may not be much, and an old photo-the building has been remodeled and updated.

Education is well funded.  And being a teaching case?  Well, it has it's perks.  You get to talk and well, it's sort of in a way: required that they listen.

You teach them to keep listening-I have much to say to them.  I hope they do-because their sister hospital-one they own and care about the reputation of?  Turned me away on oral surgery 3 times.

ME?

Complexity factor.

And never quit.

A Problem Patient-Who's Problem is it?

Oh, is that a loaded question.
s
I guess it would be a matter of who perceives the problem, who is responding to it, how, with what expectations?  And who is responding and how?


But when I am told that I have no choices in my healthcare, and that I am now required to pay $200 in transportation costs (as the ER is too cheap anymore basically and seem to be of the opinion of their patients that we "plan" for when for example, I got a bit of hypotension, my blood pressure was always of the lower end of normal.

When I am in very severe pain, I typically have an initial spike?  But then it drops and fast.  Body temperature is the same.

I can think of one time that I got an actual temperature over 102.

I was in the intensive care unit.  On a ventilator and septic.  And I found my way off after ten days.  By the end of that, I was on TPN and in for a long haul of a 10 week hospital stay-or give or take.  The bill?  Over $3M.  Over ten years ago.

But someone hung something on my page.  And I guess I had to re-evaluate a bit.

One is I am not ever going to support that medical schoools put doctors through required coursework on "How to Manage and Discharge" the "Problem Patient."

That multiple diagnoses are one factor that is what tabs me a problem before I walk in the door.

When I have seen no healthcare providers basically in nine months, and that clinic, how on earth is one a problem before they walk in the door?

I would say in that case the doctor is the one with the problem for agreeing to complete the course.  Make your own mind up if you elect to cause one.  But in all honesty it's why I hate the McGill Pain Index.

I think it's wrong.

Because mostly I feel that human beings cause more suffering than any physical cause or disorder. And no pain is greater than the loss of a child, in my own opinion.

And that no tragedy is greater than a wasted life.
 t
But I also hold tremendous value for human life, in the long run, and now that I am focused on my own for the first time, I am not doing so great in the "body" department.  But what read on the photo was what strikes me the most.

I think taking the Hippocratic Oath out of the medical education was the stupidest thing they have yet to do.  Thirty-six hour shifts, is one thing.  So is working almost more hours per week than what is contained in one week-however, I think that in some ways?

It has created truckload of hippocrites.  Not taking the Oath.

And how hard is it?  What happened to road testing a patient, making sure they can have their medicines, that they can hold them down?  We used to admit patients when that last part was even of question.  Diagnosis and treatment, and eventually they were usually discharged quickly.

And did not return three days later again to spend thousands of dollars for what amounts to a fifty dollar at best-bag of IV solution.

Meds?  Like the six people so screwed up they were crashed in the lobby sleeping sounder than a newborn.

Right, scratch that one, but folks, when it comes to them not being willing to give you more than a bus ticket?  Congrats.  It is a Friday night at 2am.  And in outlying areas?

No bus service on weekends, and I am not able to exactly ride a bus now, am I?

So what happens?

But her photo read, more or less:

"Don't look at me for what I can't do/disability.  What is it that I can, is what matters" and that was essentially the long and short of it.

Any person who refuses to see you for simply being a human being, with limits, as much as anyone else has them, and somehow expects you to be 100% on each visit, have every bit as much forgotten your own humanity.

As they have their own.

My food may be different for example.


It makes one no less deserving of being able to get it and it need not be a fight.  And when it becomes one of having it available, and at least a willing doc, and no supper to do TPN, then well, I would always prefer my gut do the actual work.

But for people to see you like you are deserving of being spoken to like you are a small-and perhaps delayed-child, and frankly that they are not even aware of that I hold what is 2 quarters short of a higher degree?  Well, I didn't sign up for this either.  And if life is hard enough and, you take it as an opportunity to accept what challenges God sets in front of you and become a better person for it?

How that would for example, take what my best friend has accomplished in one year-let alone 3, and as both of us have progressed, but together, we each have developed new talents, grown as people, and well-given back to modern medicine labels that well, few overcome.

What they are, remains unimportant, your doctor?  I'm afraid that with the few choices we have, as unattractive as being in a public system, but one at a teaching hospital?

I guess some memories that show some willingness to fade, that you get put throu
gh a couple more paces?

Anonymity and safeguards lie in it as well.  And when it's not going there for something like every day healthcare management for the average individual?

With a disorder as serious, as complex as RSD?

I guess I do feel the protection of my "number" as a bit of a safety-but that my physician, though not experienced, is not exactly a total fool or I would for one, be unlikely to see them again, but required to know what I have.  And documented responses to treatment (nerve blocks mainly) are sitting painfully clearly telling her that in this case, their own pain clinic would likely result in more.


And referred me out, but also to neurology.  Good.  Study the central nervous system.

Not everyone is up for multiple procedures-save a j-tube, perhaps, and well, given that is a poke in the stomach for me, as I understand it, but nevertheless, I also know that there's some oral surgeons on staff, and both myself and another it turns out would benefit from the services of the local teaching hospital.  However many visits it takes?

They aren't going to have their records tainted either-they don't even want the files over the past 2-3 years, and Thank God!

A Picture is Worth a Thousand Words-Docs, Your Patients are Talking to You.

When this came down the "News Feed" and being a medical patient, I remember thinking, "Shoot, folks, go to a naturopath-great folks, and well, shoot, I have the opportunity to take up going to the Bastyr School of Natural Medicine, who's amazing philosophy has turned Washington?

Green.

And cranked out wonderful docs who's compassion and truly historic philosophy has given me a normal desire to eat quality food over garbage, to get top shelf Medical grade Marijuana as opposed to taking my chances.  This body has been through basically a war folks.

Since just the last 10 years-forget the twelve beffore that!

So I am kicking back and paying heed, drinking as much Ensure Phus as I can tolerate.  I listen to modern medicine, some of that we all need.  And moving my healthcare to the University of Washington.

I want a doctor who has the resources-and will be forced if need be by her faculty to actually know what RSD is, stands for, and what it means in terms of what I need.

She paid attention, and was very cool.  Another friend actually saw the same doc later on that day?

She said it was a fast appointment and a truckloaod of referrals she will enjoy deducting from her rent.

Yeah, and the docs think we have the problem when this is regularly showing up in my feed?

Some Initial Tools for Those Who are Having Difficulty with their Physician-Trying to Work it Out

Okay, let's assume for a moment-or if in fact, you believe you may have some connection issues with a physician, and wish to work it out, and to do so, tools are helpful.

Just as medicines, in my view, are merely tools in which to help one feel well enough to accomplish a task.  For some, it's being able to work, run a business, or for someone like myself, being able to wash my own hair with no help-not being able to raise my hands over my head-kind of funny, but in a sad way, not particularly.

But some people-in a "human" state, guys-the docs are human too-and are going to make mistakes.  As I guess a case of walking medical malpractice-for a few years, sure.  Now, I think going to a teaching hospital for some, like myself-as RSD not being the only diagnosis I have, I returned to the teaching hospital where I was born, it oddly turns out, as I feel like Texas being my home, a move at this point isn't fiscally possible, and takes me thousands of miles from the ones I love.

I also and out of character, allowed the vulnerability to be visible, and well-very obvious to a smart woman doc, a 2nd year resident, and well, that can be wise-as she is well supervised, but she also had been aware and very much cognizant of what RSD is, and that's the first since returning to the area I now live in.

Finding some factual information about them on a personal level-it shows they are human-and knowledge of what the doctor is interested in professionally, how the subscribe to some work ethic is usually there, a facy photo in all likelihood-will tell you a little bit about them.

Having a doctor who is "just like a good friend" is inapproprite, ill-advised, and un-wise.  Having had a physician cross the line and attempt a friendship-kind of relationship-his behavior was unprofessional to say the least.  But it does happen.  And he now has been reported to this state-as well as the one he also returned to in order to work a hospital job "to pay my student loans" after being given a song and dance about "falling standards" the things I learned in the ensuing months it was a path of self-destruction on his own part, one he desperately tried to cover up-and well, it shows that they also can be well, sick, I guess is a good way to put it.  So understanding even a well-regarded, well-educated doctor can screw up.

And a neurologist can also be unaware of what RSD is as well, so when brought to that, I can also advise using some of the skills listed below.

It's called "Sixteen Rules to Conflict Resolution." but I am going to also add my own comments in red to bring it to a more applicable level, to the doctor/nurse patient relationship.  And that is what it's supposed to be.  Not a friendship.

But anyhow, of note the link posted, since those designing this deserve the due credit.  And anyhow, it can also be re-applied to some level of personal relationships-

16 Rules for Conflict Resolution (Fighting Fair)
.
Negotiate from the Adult position.
Childish behavior is of no position in any relationship that is with a professional healthcare provider.  By that, I refer to the following:

• swearing-if accidental, self-correct as quickly as possible, and even if you cannot stand them by this point?  It's advisable to apologize for a slip on language-as for me, I say a prayer and ask for forgiveness, and if need be, from anyone offended by that.  As for myself, life takes me down a winding journey-and around a group of friends locally, I know a couple people who work in law enforcement, one of my parents served in the military-and some find that language used can be a bit strong--but for me, the worst of what I heard came from working in the Emergency Room, and oddly, nursing homes--sometimes, with some, even the elderly who can be affected by a stroke and left only able to say a few words, and sometimes what you hear would be extremely offensive.
• Words are tools too.  Use carefully chosen ones, especially if the physician comes up and says, "Well, perhaps we are not the right doctor(s) and patient team-" or something along those lines.  
• And sometimes, admitting your own vulnerability can also be an advantage.  Being "human" I guess I find it not such a bad thing.  Allowing a degree of it, when visiting the teaching hospital I now get my own care at, I did just that, and the doctor listened quietly, as some of what I had to say is very disturbing information to absorb for anyone, I did end the appointment on a lighter note-and in kind, she responded by agreeing that the record-getting would be kept to a minimum.  To keep clean what ought to be, nothing I am uncomfortable with-in terms of records, will be entered into my file, unless I agree to it after reading first.  It was her way of establishing trust.  
• If it ever becomes a trust issue?  I'd begin searching out other options.  For example, the degree of debilitation from the RSD as the progression sped it up after the 3 years of past since that surgery I guess I wish I had not pursued.  Given that there was only 2 qualified doctors to do it, it should have been a clue.  But admitting mistakes can also be a generally good idea.  But sometimes, when we make them, there's consequences, and I guess that's generally a good thing. 

Avoid ultimatums.

• Personally, I find them patronizing and well, they remind me of people I'd prefer not to be around, but sometimes one does have to make their wishes known?  But boundaries from the beginning are generally a great idea.  And on both parts.
• Finding a middle ground to which you can meet on can help.

On a personal note, I got a letter that was "I hereby direct you to...." from a doctor once, and I remember thinking: "I am not in first grade, buddy, care to speak to me like an adult and well-I was a bit angry about it, but realized well, it's one way to make your wishes known.  I would have preferred they speak to me and say "Could you please not/or do ____________?" would have been favored on my part.

In nursing school, we were taught a theory course and a clinical training in the varying major specialty areas, and "medical-surgical nursing" was the notoriously big and difficult course.  Pain, cardiac, kidney, etc, was gone over in theory, and we were rotated through the major areas of the hospital. And learned tremendously from them.  What we learned and the school emphasized, was a non-paternalistic approach.

In teaching the patient about their diagnosis, treatment, and then follow-up, to not paternalize meant that "Don't assume that they don't know," but approach on an age-and equal level of intelligence-and talking to people as if they are in grade school, and well, the doctor sending the letter with was was basically an ultimatum if you choose to see it that way-what it was over?  So stupid that I was surprised they used the postage.  What I did not know?  In all likelihood, I was being labeled a "difficult patient" and the chances in all likelihood?  Was because some serious mistakes, very poor care had been provided, and multiple times, i attempted to repair the damaged relationship with the medical group from a larger area hospital, it was a series of bad experiences, but largely due to their own lack of knowledge on RSD, and that when mistakes are made, and the hospital and other docs involved in your care spot any legal history, or that they potentially may be held liable?

Don't expect much.
If one loses, both lose.  Enough said.

Say what you really mean (not generalities)!

Avoid accusations and attacks.
It is a surefire way to end the relationship.  If you feel that you must confront them on an issue, then perhaps it's a good idea to go over, but it gets more complex than that-so it will be covered later.  I may not be an expert-but some bad experiences, I am choosing to see as learning experiences.

I pray they help others.

State your wishes and requests clearly and directly.

Never use sex to smooth over a disagreement.  Okay-save that for the marriage, in my own opinion.

Repeat the message you think you received.

This shows you are listening.

Refuse to fight dirty (name-calling, threatening, etc.).

Resist giving the silent treatment.
Ill-advised, should you need something.

Focus on the issue and focus on the present.
Be cognizant that when in a busy medical office, they are not going to have the time unfortunately to resolve whatever conflict in one setting, or even one sit-down discussion.  The patient loads are in the rise, and it truly is something that is, as one friend puts it, in regards to getting "stuck on what was, or what might be" (past or future), he put it in a pretty comical way: "You have one foot in yesterday, one in tomorrow, and you are (sic) pissing on today."  A direct quote, a bit gross, but in some way I pretty much agree.

Focusing on what was.  Or contemplating tomorrow?  Worrying?  And doing so at 2am?  Why lose sleep?  I get cranky without it...
Call " Time out " and " foul "

If need be, take a break if you can, wait, and go back when the dust settles.

Use humor and comic relief.

One of my favorites!  When I chose a PCP at the University Hospital, it was positive to allow the vulnerability-not for sympathy, but more that I had a lot of information to get out, and a short time to do it-but she did have well, a good amount of poise-and that helps (and is also why when docs get to a level of boundary violations-and I do plan to cover more at another time, as some research on my part and note-taking.  But at the end of my appointment, I was more relaxed.

Her also showing an interest and also simply listening with no judgements?

Smartest thing she did.  And composed her note with asking my input?  Never happened before.

Always go for closure.
It's normal to have to move on at times.

Adding the one of my own since I believe this is how people feel when it happens, reserve judgement, and preferrably for God, in my life, but what I mean is, "incompetant doctor" or "obnoxious a**, S***head?  Well, it's one way to self-destruct a relationship.  And things that may be a bit childish to mention?  If it progresses to a shouting match, and think I haven't seen that turn out bad for some?

Sometimes-also-making a simple apology can repair a lot of damage.

Notes on Patterns

After reviewing more but in summary and really in part from both personal or professional, most docs use amongst mostly the things in literature that point in this direction for what "criteria" that most use, and the first is one that I have difficulty, another friend yesterday told me after moving, and attempting for example to simply find a opthamologist, as she too, has a history like my own, and her comment, "They are getting lazy, and he said 'too many problems' and that basically he did not want to deal with me because I have too many problems-almost like they don't even want to be doctors anymore."

Well, similar experience, but I won't pretend I want to know (or in reality and in truth, I simply decided at this point, I simply don't care anymore.

But to note, any of the following will certainly in review of literature or of experience, and sad as it is, I haven't seen much to the contrary:

• complicated history
• substance abuse (sometimes they will sandwich a person with problems related to chronic pain and in my own opinion rather unfairly-into this category because it I guess seems easier than sorting out what could easily be a physical cause for example)
• Someone who has been very sick, and by that I mean, has either been critically ill, and is in a weakened state, is recovering, and finding life has just gotten so much more complicated, and they are tired, and in part, wish people to leave them to recover, and rest, but the micromanagement of healthcare requires multiple visits with multiple specialists  a group largely speaking, a lot of docs resent their personal time being "infringed upon" and have in sone used threats of humiliation (in my own experience, one dentist-yes, he was fired, but more for lack of any honesty or competency, but after it was too late for my own dentist in a new city to do anything to fix what had been so thoroughly decimmated by someone who failed to read literature that was handed to him)
• in similar regard, to add, anyone with multiple diagnoses that are complex in nature, God help us all, is going to have a hard time finding care as much as anyone with an actual history of substance abuse as well.  
• Mental health disorders-bipolar disorder (can be quickly made into a personality disorder, and a huge difference exists-someone with actual personality issues takes many years, multiple visits, and much observation by one set of providers to diagnose as such-but makes it almost impossible if this is in addition to a history medically that is complex, that has a history even of depression-and that's a very normal response to the final (though this is not an exhaustive list by any means)
• anyone who simply may have trust problems, or is simply angry with whatever issues-life can just tick anyone off at some point, but I mean people who are seemingly angry for whatever reason all the time, and allows it to bleed into a physician relationship-be it accidental or otherwise-will certainly find it hard to get care-but this isn't even exhaustive to someone with a mental health problem, though many would easily gain a diagnosis by having a problem, for example after dealing simply with some who have had what simply could be described as a few bad experiences and is trying to trust in a system that isn't the same.  I know my own issues not as much with anger with physicians as a group, but many I have found difficult personally to trust, and when uncertain where to place it, one can find it difficult to find care when simply having had a bad experience-or in my case, a series of them), it can help to return to what is familiar, but a new physician who may learn of bad experiences, of how complicated your history has become: legally and ethically now, there is nothing requiring most physicians to retain you as a patient, or even accept you as one.
• interference by a third party-be it "friend" or family members can irreperably damage the ability to seek care.
• Actually having a substance abuse-but combine it with complex physical problems, and a mental health diagnosis-even in history can certainly make it exceptionally difficult.
• Having a rare diagnosis, in which a doctor has to research what is wrong, even within their own specialty, it's quite frustrating.
• Those with problems with memory who for reasons of age, or for example, in my own case, disorganization caused by ADHD can lead to trouble even-as my attention span has it hard for me to get ducks in a row enough to get a list even together with everything that is necessary before calling a doctor's office-multiple calls in a short period is as toxic as they say to the doctor-patient relationship that finds a person in trouble.
• "Multiple complaints of pain." As is commonly stated, "with or without a cause."  Um, folks, if this is pointing out the obvious, have they agreed on one in my own disorder (RSD)?  I mean, categories is one thing, but even Type one is partially more honest in that an "event" triggers this disorder, but why is one thing I can't say I see anyone agreeing on a conclusion.  this could lead to further discussion, but for reasons of length, stopping here seems to be best, and saving the discussion for another time.

And many times, even when it's recognized that you have a complex set of issues, for example the immense fatigue within my own disorder: RSD being my primary diagnosis, I also have a huge set of gut issues, and it gets very hard at times to even keep medications in, sometimes requiring a different route, for example, my estrogen is in patches for this reason, as are some other medicines, and I don't publically discuss my own treatment but suffice to say, contraversial definitely describes it-at least amongst physicians.

Reflex Sympathetic Dystrophy--aka, CRPS, to me it's RSD, as that is how I've always known it, so to me, that is what it remains.  And many of us are taking a beating (hopefully not in a physical sense, God knows life can kick many of us around none too gently) but in reality to speak specifically this has in my experience, a disorder as one friend says, "leaves a doc running for the trees, his or her 'mommy' and probably a few books, and once they read even part of it, you get the boot."

Unfortunately she can be right.  Often has been.  As unfair as that may be, it's also as unfair to anyone with mental health disorders, to recovering addicts, and anyone who's fought the "good fight" and come out on the winning side, only to find it extremely hard to find adequate healthcare.

Specialization has made it even more difficult, and many of us with RSD are continually exhausted to the bone simply keeping up day to day life, let alone the continual peppering of doctor appointments, and a calendar that may never feel like it belongs to you.

Along with grieving, and normally so, in terms of newly diagnosed people with RSD, I can certainly say one thing, fighting with the diagnosis makes life harder-accepting it is a step, and a hard one.  When it's a misdiagnosis, accepting it is also equally hard, but one saving grace-has really been just that: learn to trust in God, it seems easier to trust yourself.

The rest will eventually follow.

Knowing also that not only is one in no way to blame for having a chronic illness, though a fair amount of it will likely come from a doc-for example depending on what is wrong: it's easy to "blame the patient" for a problem, but even when that is the case, whether you feel it ought to be admitted to-um, keeping the faith, and letting go of blame.

And knowing when it is simply time to move on when a certain provider, though not directly clear-is not interested in treating you.  Forcing the issue is as damaging to you as it is to the relationship with a provider-if you feel that they are not interested in treating you-chances are you may unfortunately be right.

After reading on reasons that some doc-patient relationships fail-too much self-examination, I feel can be as damaging to the next doctor you see-and knowing to leave the past bad experiences where they belong-in the past-know what mistakes you made, focusing on repairing what you can: yourself.

The more healthy practices any doc sees, who is that is, honest, and that one is capable of healthy change, I think is that any doc worth their salt that can spot a person capable of spotting much of what lies in their own court, and dealing with it: be it through simply implementing change, and the ways one seeks out how to deal with pain for example, then we can also know that anyone incapable of change: is a toxic person to have around.

For myself, I know eccentric is certainly a good self-description-that my own oddities are hard for some to accept, I do the best I know how to keep them out of the doctor's office, in particular, my sense of humor, I can say one thing that will remain difficult will be keeping a provider, and little has to do with me as a person: as a "difficult patient" myself, yes, I do finally think access may have been granted-was it my first choice, no.  But few choices exist in providers for anyone with complexities in care, but sometimes, a larger hospital system is best.  I may not like being a "number" as some say, but some comfort lies in the anonymity I am beginning to feel.

I know this may shed little light as to why modern medicine is being practiced off of a computer, a Blackberry or an iPhone, but for someone who hates cell phones, I guess that is my own personality quirk.  Makes re-setting a password harder these days, but well, patience with them has to do much with it, so I guess knowing when to stop.  That can be key.

Even for some of us, it can also be when one treatment needs to be stopped-for me, I had to check off the nerve blocks: crippling was what they were for me, and second, a vey severe reaction to NDMA receptor limits what I am able to do.  Consult an expert?

Take my pick, I suppose-but if all they take is Visa, I plan to keep going.  I won't go into a great deal of debt any more than I'd sell a home to get something like one treatment with ketamine: though many hard won victories have been found, given the reaction-beginning with bloody noses and ending in a visit to the hospital for a hypertensive crisis?  I guess I would need an additional diagnosis for it.

I hardly need that, I suppose.

TO COME:  Working in repairing a doctor-patient relationship or when to move on, how to know-that part is up to the individual.

A STUDY (RE-POST) ON..THE DIFFICULT DOCTOR?

Research article

TEST LINK:  http://www.biomedcentral.com/1472-6963/6/128

The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data

Erin E Krebs^1,2*, Joanne M Garrett³ and Thomas R Konrad⁴

• *Corresponding author: Erin E Krebs krebse@iupui.edu

Author Affiliations

¹Center for Implementing Evidence-Based Practice, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA

²Department of Medicine, Indiana University, Indianapolis, IN, USA

³Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

⁴Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

For all author emails, please log on.

BMC Health Services Research 2006, 6:128 doi:10.1186/1472-6963-6-128

The electronic version of this article is the complete one and can be found online at:http://www.biomedcentral.com/1472-6963/6/128

Received:	5 May 2006
Accepted:	6 October 2006
Published:	6 October 2006

© 2006 Krebs et al; licensee BioMed Central Ltd. 

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Literature on difficult doctor-patient relationships has focused on the "difficult patient." Our objective was to determine physician and practice characteristics associated with greater physician-reported frustration with patients.

Methods

We conducted a secondary analysis of the Physicians Worklife Survey, which surveyed a random national sample of physicians. Participants were 1391 family medicine, general internal medicine, and medicine subspecialty physicians. The survey assessed physician and practice characteristics, including stress, depression and anxiety symptoms, practice setting, work hours, case-mix, and control over administrative and clinical practice. Physicians estimated the percentage of their patients who were "generally frustrating to deal with." We categorized physicians by quartile of reported frustrating patients and compared characteristics of physicians in the top quartile to those in the other three quartiles. We used logistic regression to model physician characteristics associated with greater frustration.

Results

In unadjusted analyses, physicians who reported high frustration with patients were younger (p < 0.001); worked more hours per week (p = 0.041); and had more symptoms of depression, stress, and anxiety (p < 0.004 for all). In the final model, factors independently associated with high frustration included age < 40 years, work hours > 55 per week, higher stress, practice in a medicine subspeciality, and greater number of patients with psychosocial problems or substance abuse.

Conclusion

Personal and practice characteristics of physicians who report high frustration with patients differ from those of other physicians. Understanding factors contributing to physician frustration with patients may allow us to improve the quality of patient-physician relationships.

Background

Approximately 15% of patient encounters in adult primary care settings are unusually difficult from the physician's perspective[1,2]. Most of the literature related to these difficult doctor-patient encounters has focused on the patient, rather than on the physician or practice setting involved. Patients who are perceived as difficult or frustrating are more likely than other patients to have psychiatric conditions, abrasive personality traits, and personality disorders [1-5]. They are more likely to report multiple physical symptoms, which are often medically unexplained[1,2,6]. Not surprisingly, these patients are also more frequently dissatisfied with their medical care[2,7].

Although it is generally acknowledged that physicians share responsibility for difficult relationships, characteristics of physicians who report frustration with patients are not well defined. Data about the influence of practice settings and health care systems on perceived difficulty of patient-physician encounters are also scarce. It has been suggested that system factors such as time pressure, administrative burdens, and lack of control over clinical care may lead to more physician frustration with patients, especially in managed care settings [8-10]. The objective of this study was to describe physician and practice characteristics associated with greater physician-reported frustration with patients.

Methods

The Physician Worklife Survey measured personal and practice characteristics and work satisfaction of a national sample of US physicians in 1996–97. The survey was developed in a multi-step process and pilot tested with a large sample of physicians. Detailed descriptions of this process have been published [11-13]. The Physician Worklife Survey was mailed to a national stratified random sample of physicians in family medicine, internal medicine and pediatric specialties, selected from the American Medical Association Masterfile. The sample was stratified by race, specialty, and regional level of participation in managed care. Physicians returned 2326 usable surveys, yielding an adjusted response rate of 52% after correction for incorrect addresses, refusals, and ineligible responses[11]. We excluded pediatricians and pediatric subspecialists from our analysis, leaving 1391 eligible family medicine, general internal medicine, and medical subspecialist physicians.

Measurements

Frustration with patients

Physicians were asked to estimate the percentage of patients in their practices who were "generally frustrating to deal with." We categorized their responses into quartiles and defined physicians in the top quartile as "highly frustrated."

Physician and practice variables

Participants rated their general health on a 5-point scale from poor to excellent. They reported how often, on a 5-point scale, they felt "sad or depressed" in the past year. We refer to physicians as "often depressed" if they reported symptoms occurring fairly or very often. Participants also reported how often they felt "anxious or nervous." We referred to them as "often anxious" if they reported symptoms fairly or very often. Stress was measured using the 4-item version of the Perceived Stress Scale[15]. We calculated the total number of hours worked per week by summing the hours spent seeing patients in the clinic and in the hospital, performing other patient-related activities (such as paperwork and phone calls), and doing other work-related activities (such as administration or teaching).

Physician control scales

A total of 12 items measuring perceived control over aspects of practice were included in the survey. We performed principal component analysis with oblimin rotation using our sample of non-pediatricians (see 1). Ten items loaded on 2 factors, which we described as clinical control (4 items) and administrative control (6 items). The alpha coefficients for these scales were 0.702 and 0.803, respectively. The remaining 2 items, which could represent either administrative or clinical domains depending on the work context, had cross loadings on both factors and were excluded from the control scales. We imputed missing values of component items using best subset regression when only 1 value from a scale was missing, and excluded responses if >1 value was missing.

Additional file 1. Factor analysis of control measures. The table shows factor analysis results for survey items measuring physicians' perceived control over aspects of practice.

Format: DOC Size: 33KB Download file

This file can be viewed with: Microsoft Word Viewer

Patient case-mix variables

Physicians were asked to report the percentage of patients in their practices who were white, black, Hispanic, Native American/Alaskan, and Asian/Pacific Islander. For our analysis, we used a dichotomous variable of percent white/non-white patients. Physicians reported the percentage of their patients who were uninsured, who received Medicaid, who had substance abuse problems, and who had "complex or numerous" medical problems or psychosocial problems.

Data analysis

We used Pearson's chi-square tests to compare characteristics of "highly frustrated" physicians to those of other physicians. We fit multivariable logistic regression models using a two-stage strategy to assess characteristics associated with greater physician-reported frustration with patients. In the first stage, we modeled associations between frustration and physician and practice characteristics, which included all physician and practice variables from the bivariable analyses. We used multiple degree-of-freedom Wald tests to remove groups of variables that were not significantly associated with high frustration. Secondly, we added patient case-mix variables (percent of patients who are white, who are uninsured, who receive Medicaid, who have substance abuse problems, who have complex medical problems, and who have complex psychosocial problems) that might explain any of the observed associations between physician and practice characteristics and frustration. Case-mix variables that did not confound these relationships were removed from the final model. The final model included the set of variables that were statistically significant (p < 0.05) after adjustment for other variables in the model. Results did not substantially differ when continuous variables in the final model were categorized into dichotomous variables. Therefore, we used the dichotomous form of the variables for ease of interpretation, reporting percentages for the bivariate analyses and odds ratios (OR) and 95% confidence intervals (CI) for the logistic regression models. We adjusted all analyses for sampling weights and strata included in the sample design using the statistical package Stata version 8.0 (Stata Corp, College Station, TX).

Results

Table 1 shows personal and practice characteristics of the 1391 physician participants. Their mean age was 47 years, and most were male (77%) and white (82%). Forty percent worked in a small group practice setting, 21% worked in solo practice, 18% in a large group practice, 7% in academic medicine, and 6% in a group or staff model health maintenance organization. 12% of physicians were often anxious, 10% were often depressed. Physicians worked a mean of 55 hours per week. Physicians reported, on average, that 12% of their patients were "generally frustrating to deal with." Those who reported that >15% of their patients were frustrating were in the top quartile (Figure 1).

Figure 1. Distribution of reported percent of patients who are frustrating. The bold line marks the 75^th percentile; we defined physicians to the right of the lines as "highly frustrated."

Table 1. Characteristics of participating physicians

In the unadjusted analysis, all of the personal physician characteristics, with the exception of physician race (p = 0.96), were significantly related to high frustration (Table 2). Similarly, nearly all of the practice characteristics assessed were significantly associated with high frustration (Table3). Physicians who practiced in group or staff model health maintenance organizations (HMO) and those who practiced in miscellaneous settings (such as urgent care or emergency departments) were more likely than physicians in other settings to be highly frustrated. Having less reported control over administrative aspects of practice was associated with greater frustration (p < 0.001). The association between control over clinical practice and frustration was of borderline statistical significance (p = 0.053).

Table 2. Personal characteristics of highly frustrated physicians

Table 3. Practice characteristics of highly frustrated physicians

Multivariable model results

Physician and practice characteristics

In the model considering physician and practice characteristics alone (without case-mix), the characteristics independently associated with high frustration were younger age, higher stress, greater number of hours worked per week, medicine subspecialty, HMO practice setting, and miscellaneous practice setting (such as urgent care).

Patient case-mix

When we added case-mix variables to the model, the only variables with an effect were percentage of patients with substance abuse (p = 0.024) and percentage of patients with complex psychosocial problems (p < 0.001).

Final model

The final multivariable model of characteristics independently associated with high frustration included younger age, higher stress, more hours worked per week (borderline significance), medicine subspecialty, and higher reported percentages of patients with psychosocial and substance abuse problems (Table 4). Practice setting was no longer significantly associated with high frustration when adjusted for case-mix.

Table 4. Physician and practice characteristics associated with high frustration, multivariable model

Younger physicians and those with above-average stress had greater odds of frustration. Specialty was also independently associated with frustration; both subspecialists and general internists appeared to have greater odds of high frustration than family physicians, but this difference only reached statistical significance for medicine subspecialists (OR = 2.0, 95% CI 1.3–3.3). After adjustment for case-mix, the association between longer work hours and frustration was of borderline statistical significance (OR = 1.5, 95% CI 1.0–2.2).

Additional analysis

Moderate correlation was present between the anxiety, depression, and stress variables (r = 0.36–0.58). To assess for independent associations between these variables and high frustration, we evaluated 3 additional logistic regression models, excluding all but 1 of the 3 correlated variables at a time (data not shown). Each of the individual variables was significantly associated with frustration when the other 2 variables were excluded; this did not substantially change results for other variables in the full model.

We also conducted analyses evaluating physicians in the top decile of reported frustrating patients (those who reported more than 25% of their patients were frustrating to deal with), but found similar results to those we have reported using our quartile definition.

Discussion

Although the difficult doctor-patient relationship has been a focus of inquiry for many years, research has largely focused on characteristics of "difficult patients." Personal and practice characteristics of physicians who report frustration with patients have received less attention. We found that physicians vary substantially in the percentage of patients they perceive to be frustrating, and that physicians who report a high percentage of frustrating patients differ from other physicians in a number of ways. In particular, highly frustrated physicians were younger, more likely to practice subspecialty internal medicine, and more likely to have high stress. Some of the variability we observed between physicians may be due their differing tendencies to perceive a given patient as frustrating. However, physician behaviors may also affect reported frustration with patients. The clinical encounter is a dynamic process, and physician behaviors, especially communication methods, may alter the character of a patient encounter in ways that promote or alleviate interpersonal difficulty.

We found that physicians who reported more patients with psychosocial problems and with substance abuse problems were more likely to be highly frustrated, while those who reported more patients with complex medical problems were not. This finding is consistent with studies of difficult doctor-patient encounters, which have consistently found that patients with psychiatric illness are more likely to be perceived as difficult by their physicians [1-5]. Physicians in general are better prepared by training to address biomedical problems than psychosocial problems[17,18]. However, individual physicians vary in their perspectives on the importance of psychosocial care. This variation may explain some of the differences we observed between physicians. In one study involving 38 primary care physicians practicing in a walk-in clinic, investigators found that physicians with negative beliefs about the value of psychosocial care rated more encounters as difficult[2]. Notably, patients involved in these difficult encounters had worse outcomes in terms of less satisfaction with the visit, more unmet expectations for care, and higher subsequent health care utilization.

Physician beliefs about psychosocial aspects of practice may be a factor in the association we observed between specialty and frustration. We found that family physicians were less likely to report high frustration with patients than physicians in both general internal medicine and medicine subspecialties, although this association reached statistical significance only for subspecialists. The philosophy of family medicine embraces a relatively holistic approach to patient care, [19] and there is some evidence that family physicians may have more favorable beliefs about psychosocial care than internists [20].

Older physicians were less likely to report high frustration with patients, perhaps because of greater clinical experience or a more flexible and humanistic approach to patient care. It is also possible that there are fewer highly frustrated physicians in the older age group because these physicians are less likely to continue practicing clinical medicine.

In our preliminary exploration of the relationship between practice factors and frustration with patients, we evaluated practice factors that have been hypothesized to be potential contributors to difficult doctor-patient relationships, including length of appointment time, type of practice, number of hours worked per week, and perceived control over administrative and clinical issues. The association between frustration and HMO or miscellaneous practice setting was no longer statistically significant after adjustment for case-mix. Only number of hours worked per week was associated with frustration in the full model; this association had borderline statistical significance after adjustment for case-mix. The effect of prolonged work hours on physician wellbeing, physician-patient relationships, and patient safety is an area of ongoing interest, especially in the context of policies limiting resident physician work hours. We speculate that working long hours may decrease tolerance for dealing with challenging patient issues, but this hypothesis requires further study.

Several limitations of our study deserve consideration. First, our data are based on physician report, so we are unable to determine how much of the variation in reported frustrating patients is due to differences between physicians' case-loads and how much is due to differences between physicians themselves. While some physicians certainly have more challenging patient panels, prior research has found that physicians report substantial differences in perceived difficulty with patients even when patients are new and arbitrarily assigned[2]. Second, our measures of physician mental health characteristics relied on brief measures. Detailed assessments of physician personality, mental health, and interpersonal skills were beyond the scope of this survey. Finally, because the data are cross-sectional, we cannot draw conclusions about the direction of relationships between physician factors and reported frustration with patients.

Conclusion

Are the highly frustrated physicians we identified truly "difficult doctors"? More likely, they are a diverse group of doctors facing varied personal and clinical challenges. Among them may be physicians who are inadequately equipped to address the complex psychosocial needs of their patients. Ultimately, we need better understanding of the role that physicians play in frustrating doctor-patient relationships so we can develop strategies to improve the wellbeing of both patients and their doctors.

Competing interests

The author(s) declare that they have no competing interests.

Authors' contributions

EEK developed the study design, performed statistical analyses, and drafted the manuscript. JMG participated in the study design, performed statistical analysis, and edited the manuscript. TRK participated in the design and administration of the original survey, participated in the design of this secondary study, performed statistical analysis, and edited the manuscript. All authors read and approved the final manuscript.

Acknowledgements

■ An earlier version of this work was presented as an oral abstract at the 28^th annual meeting of the Society of General Internal Medicine, May 11–14, 2005.

■ Both the Physician Worklife Survey and the authors of this secondary analysis were supported by the Robert Wood Johnson Foundation. Dr. Krebs was a Robert Wood Johnson Clinical Scholar at the University of North Carolina at Chapel Hill when this study was conducted.

■ We thank the Society of General Internal Medicine Career Satisfaction Study Group for making their data available for this secondary analysis.

■ We thank Carol Q. Porter for help with data management.

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Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1472-6963/6/128/prepub