Dealing with Mr. Smith: Advice on managing difficult patients

My inability to figure out how to handle Mr. Smith was an ongoing source of frustration and self-criticism. A remote friend of my father, he had known me as a child, and considered himself “family.” He was not only tall, but had a large, intimidating frame, with bushy eyebrows that nearly touched when he expressed disdain, and a crooked smile that suggested constant amusement.

From the first office visit, he assumed an uncomfortable intimacy that wasn’t there. He addressed me by my first name, and reminded me that he’d known me when I was just in diapers. I just nervously laughed off his inappropriate comments, not wanting to show disrespect. Soon, I would discover this was just the beginning.

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He berated the nurses when his medicine refills were not called in promptly, then apologized with a laugh, as if he were only joking. If not seen within a few minutes of arrival, he’d open the door of the exam room, let out a loud sigh, point to his watch, and proclaim “Dr. Mike must have left for the golf course.” After I made the mistake of returning one of his calls on my cell phone, he saved my number and began calling me directly or texting me for medical concerns, large and small. He insisted on telling repetitive stories in the exam room, leaving me wondering if he was purposely wasting my time or if he just suffered from a complete lack of self-awareness.

After a year of suffering through his escalating bad behavior, I had had it. I felt angry that I had let it go on so long. I just felt paralyzed since he hadn’t crossed some nebulous line that would lead to termination of the doctor-patient relationship. I felt like my hands were tied by an ancestral obligation I couldn’t define.

I finally spoke with a mentor in the medical field, and received some advice that I’ve never forgotten. “He is here to teach you something. He is here to help you grow up.” At first I thought he was kidding-making a patronizing and cryptic statement that Yoda might deliver. But he continued. “You let him cross boundaries that make you feel resentful and uncomfortable. That’s no way to live in any relationship. You have to be true to yourself, you have to own and validate your reality, you have to be direct and you have to give yourself permission not to take his crap any longer.” It actually made sense to me.

I decided to act. The next time he texted, asking for antibiotics for a cold, I texted back: “It’s not appropriate to text me for medications. Please call my office tomorrow.” I ignored his next text (“Hey! This is your buddy Smitty! What’s up?”).

I dreaded the next few minutes, because I knew he would call. When he did, I listened to his imploring story, but told him that I couldn’t help him; we’d have to discuss it in the office. He came at me from all different directions, first trying guilt (“you’ve always done it in the past” ), then bargaining (“Just a Zpak until I can see you,”) then threats (“Now, do you really want to piss off an old friend of your father’s?”)

Despite the heat rising in my face and the catch in my voice, I held my ground. It was finally clear to me: the man was a master manipulator. I saw him in a new light, and not only felt freedom and detachment in realizing this, I also felt empowered. If I stuck to my truth, I could play his game as well.

NEXT: Dr Beckham confronts Mr. Smith and changes their relationship

He returned to my office in a few days. He started in, mocking my refusal to give him meds. “Big-time doctor, too busy to take care of an old friend.” I interrupted. I let him know the new deal. “I’ve decided to stop taking texts and direct phone calls from patients. I’ve felt intimidated, and have really gone above and beyond in the past with your requests, but it has made me feel resentful and taken advantage of. That is an unhealthy doctor-patient relationship, and we can’t continue if you are unwilling to change your behavior.”

He laughed, and started in with some more smart comments. I simply repeated the above, with a few variations, like a broken record. He finally sat silent after hearing the same response four or five times. I proceeded with standard questioning about his URI, followed by an exam and prescriptions. I told him that I appreciated his listening to me, and respecting my boundaries, and that I looked forward to meeting his medical needs in the future.

I didn’t hear from him for a while. When he showed up again four months later, he started his usual game again. He complained loudly in the waiting room about his wait. I apologized for his wait, but addressed his behavior directly: “We can’t continue to care for you if you are going to disrupt the peace and flow in our office.” Sarcastically, he said “I’m going to have to start charging you wasting my time.” I smiled and shot back, “There are plenty of physicians out there who will see you on time, and only take five minutes with you. You are free to see them. I take more time with my patients, and sometimes get behind. It’s your choice.”

Mr. Smith kept coming back. With every visit, he seemed less critical and more appreciative. At first I was uncomfortable confronting him, but found strength with each encounter. He would occasionally venture into inappropriate comments, but I was vigilant, and met these with either sharp humor or direct confrontation.

To my surprise, our relationship started to change. We developed a connection based on honesty that was freeing and uplifting. He seemed to develop a new respect for me and our office. It was as if he needed these limits I set for him, like a toddler learning boundaries, finding comfort in them. He still seemed to thrive on conflict, but developed the self –restraint to avoid those games in the office.

As time has gone on, I’ve enjoyed our candid visits, and I have learned to respect him. We’ve even touched on his fears, and the trouble he has had relating to the world, and he finally agreed to counseling. At one office visit, he told me he was glad I didn’t give up on him.

Mr. Smith taught me what it takes to connect with patients. I define my limits. I train myself to be true to my feelings and express them. I am direct. I stick to my guns and repeat my truth as often as necessary. I don’t let down my guard.

Finally, I placed more importance on the health of the physician- patient relationship than on protecting his feelings, and the result was miraculous.

Michael Thomas Beckham, MD, is an internist in Nashville, Tennessee.