Physician frustration can lead to a better treatment path

Rebekah was 37 going on 75. She was a round woman with sad eyes, heavy arms, and stringy hair. I don’t think she meant to walk with her nose in the air, it just pointed that way. Rebekah took her health seriously and she remembered everything the doctors ever told her that she wanted to hear. She brought three things to every visit: a plastic grocery sack of pill bottles, an allergy list, and a lumbar spine MRI report from 2009. The report smelled like stale cigarettes and her allergy list included water because it made her vomit. Before I had electronic health records, Rebekah’s paper chart was four inches thick.

Rebekah’s enabler was her husband, a man she’d known since childhood and married at 16. Troy never left her side. He was her walking stick, her chef, her housekeeper, and chauffeur. While Troy made the world go round, Rebekah sat. On good days, she sat and ate raw veggies with a bottle of ranch dressing and she drank diet Pepsi. On bad days she sat and ate Doritos straight out of the bag, washed down with Mountain Dew. Rebekah had a lot of bad days.

When I came to town, I was gifted Rebekah’s care from one of my partners, along with a number of other patients given up as lost causes. Rebekah was on a long list of conflicting medications and had a problem list including chronic pain, atherosclerosis, heartburn, headache, bipolar disorder, anxiety, lupus, degenerative disk disease, and fibromyalgia. I made several attempts to wade through her chart and make sense of it all, but many key records were missing and no matter how many requests for information I made, the records never got faxed.

Over time, I tinkered with Rebekah’s meds, dutifully tracked her labs, and saw her regularly in the office. I provided her with guideline-based care and made numerous referrals. But Rebekah never got better. Better from what, I didn’t know exactly, but she never seemed to have any improvement in her daily function no matter how much I mucked with her meds and tried to help her set tiny, highly achievable goals.

After innumerable visits where Rebekah went on about her problems and I attempted to check all the right boxes so as to bill appropriately for the encounter, I lost it. I mean, I. Lost. My. Sh*t. I shut my computer and said, “Enough.” And then, I unleashed years of pent up frustration and anger on this poor woman. I told her I was tired of listening to the same complaints. I had exhausted my vast arsenal of ideas. I was frustrated with her refusal to help herself. I told her that perhaps she would be better served by a different physician, because clearly, I had failed her.

Almost as soon as the words were out of my mouth, I regretted them. It was unprofessional, selfish, and childish. I apologized. Rebekah looked at me as if realizing for the first time, I was in the room with her. And then we both started to cry. I handed her a box of tissues and grabbed one for myself.

“Don’t leave me,” she said. “You’re the best doctor I ever had.  You’re the only doctor who ever listened to me and tried to help.”

I sighed. I was angry that I was stuck in this untenable, unfixable situation.  And now, I was ashamed at my own behavior. I took a long look at my patient and then a long look at myself. Why was I so angry with her? Where did her responsibility lie? How did it come to this and how could I fix it?

I sat on my stool with my eyes closed for several long minutes while I considered each of these questions. Then I took a deep breath and opened my eyes. “Let’s start from scratch. Let’s look at everything again, like you were a new patient.” I cleared my throat. “Hello, I’m Dr. Zook. How may I help you today?”

I interviewed Rebekah in the same probing manner I use with each of my new patients. I listened with new ears and examined her with fresh eyes. I did a review of her medication list to be sure that each one made sense and was at the proper dosage. I looked to see where there were holes in diagnostic testing or where testing needed to be updated. I found more than a dozen simple-but important-issues in Rebekah’s chart that potentially affected her health.  Together, we set a new plan in motion. I wrote everything down for Rebekah and reviewed it with her. I had my tasks and she had hers. We agreed to meet again in a month.

Four weeks later, Rebekah was ebullient. She was walking out to the mailbox daily and had cut back on her soda pop intake. Her weight was down three pounds. We continued with the changes we’d made and together implemented a few more. As Rebekah saw improvements in her health and weight, she was motivated to do even more. Little by little, and with few setbacks, we transformed Rebekah’s health. Today, Rebekah is 40 pounds lighter and walking a half mile most days of the week. She is on one quarter of the medications she used to take.

Rebekah taught me three lessons I carry with me every day, to every patient. First, complacency is dangerous. It’s easy in a busy office to just carry forward what’s been done. It takes time and effort to do a detailed review of a complex patient’s chart, tidy up loose ends, and thoroughly reassess a medication list.  But taking the time to do so reassures me that there are no missing documents, no abnormal tests that need follow-up, and no alarming trends.

Second, when I see a patient I dread on the schedule, I ask myself why I’m looking for the emergency exit. If I can identify why I want to avoid the visit, then I can work toward a solution. There may be nothing that I can do differently. In that case, it may be that the patient would be better served by a different provider in the practice, or even by a different practice. But the burden is on me to have the introspection and courage to identify and put thoughts into action or remain silent and work through my feelings.  In either case, awareness is the first step toward acceptance or change.

Third, when I am angry or annoyed at a patient during a visit, I need to check myself in that moment, and think about what’s triggering me. This gives me pause to take a deep breath and temper my response. Boundaries may have to be made clearer and put in writing, or I may need to encourage agenda-setting or more frequent visits.  I can’t always identify the source of my emotions at that moment, but the consciousness prompts me to put the chart aside for review and reflection at a later time.

I am grateful for the lessons Rebekah has taught me.

Editor’s note: Names of the patient and her husband have been changed to preserve patient privacy.

Melissa Zook, MD, has practiced family medicine in London, Ky., for 14 years, focusing on addiction medicine and caring for patients with HIV. She derives great satisfaction from seeing patients in her care regain their mental and physical health. “Often the interventions with the biggest impact are the smallest and least expensive, like active listening and appropriate describing,” she says.

Zook’s choices of specialty and practice location have been driven by wanting to make the best use of the nearly $1 million worth of education she has acquired. “There is no better way to use that gift than in medical service to one of the poorest and sickest communities in the U.S,” she says.

Like most primary care doctors, Zook struggles with the reporting requirements imposed by payers and government agencies, as well as the ever-rising costs of medications and procedures her patients require. “Simple tests cost more than they should. Patients are forced to switch off meds that work well for them because their formulary changed, etc.”
When away from her practice, Zook enjoys writing, cooking, knitting, and reading with her two children, ages 12 and four. She hopes one day to sail the Indian Ocean and explore Asia.

Zook offers this advice to doctors starting out: “Give your family your undivided attention on a regular basis. Don’t work harder for your patients than they are willing to work for themselves. Whatever you’re going to be, be a good one.”