There are difficult patients, and ideal patients. A cardiologist offers advice on relating to them all.
It’s 5 am and my i-phone's on-call text message wakes me with alarming news
:" hospitalized heart attack patient has decided he doesn’t want his cardiac angiogram this morning and left against medical advice".
Barely understanding the context of this text, I start to try to comprehend the deeper meaning of what just happened..
Have I failed my patient?. Or, possibly, did he fail himself?
Later that day, though he still had not returned my checking-up phone call, this patient called my staff , emphatically demanding a follow-up office appointment.
What is a physician to make of this kind of patient behavior? Is it our fault? Can we change it?
In my medical experience, as a frontline real-world cardiologist working in ERs, hospitals, and outpatient settings, patients and their families often echo common statements when it comes to decisions about their care. I often hear “Do everything, Doc," or another favorite, "You're the doctor," sometimes followed by "You should know."
Patients tend to fall into two categories when it comes to their care.
Many patients seem to set up an external center of control--believing their health or dealing with their cardiac condition is someone else's responsibility or taking a "not-my-fault" mentality. Others have a take-charge, personal center of command--the I-will-do-what-I-can" approach.
As doctors, we all know patients who bring their entire medical history, list of active medications with full dosing and the times of day pills are taken, including their own online research- all to be used to optimize care. Other patients? Not so much.
For example, I have seen people eat to be healthy and maintain good health with occasional cheat days, while others find comfort in overeating and dietary indiscretion. These patients get seduced by food, because it is comforting, doesn’t fight back, and is extremely important culturally as well as providing a pleasurable experience.
Many poor cardiovascular outcomes generally stem not from medical treatment but from missed opportunities..
Those can be a paitient's failure to make personal lifestyle choices and or to deal with lack of motivation.
I've also seen patients who feel their situation is hopeless--not because it really is but because they have the likely irrational feeling of being fated to ill health since their family has a history of early heart attack, for example.
These patients may think their cardiac condition is heriditary and that their poor health is a predetermined event.
This pessimism can have an impact on outcomes.
It’s been shown that the glass-half-full optimist will do better in life and have better health outcomes should they fall ill with cardiovascular problems or other diseases for that matter.
I have seen patients with multiple co-morbid medical problems do far better than expected. These tend to be patients who have good and strong family relations, social outlets and good caring friends, as well as some level of faith. Those with healthy support networks stay physically healthy more than those without the same.
Sadly, I have also seen mentally unstable individuals hurt themselves, either overtly or subconsciously, or even lash out at the doctors, nurses, or caregiving staff who are all simply trying to help.
It’s also true many people are hesitant, resistant, or deviant in starting/continuing healthy behaviors. This can be as simple as taking a pill, or more difficult, such as agreeing to have a procedure or surgery.
It helps to convince them the potential positives are greater than possible negatives. My patient who left against medical advice comes to mind.
There can be many explanations why some patients are "difficult" or "challenging." Sometimes it is as simple as clashes of personalities. Other times it can be that patients have more deeply rooted psychosocial or even psychiatric deficiencies.
That is no reason not to try to treat these underlying problems.
If needed, personal behavioral and cognitive reshaping could start with small steps.
For instance, getting patients to try a low-grade exercise routine which then could also serve to improve motivation, lower depressive feelings or tendencies.
Patients, like all of us, feel more energetic and positive when they exercise more.. Perhaps getting a taste of the so-called athletes’ high would be helpful for many who struggle.
For the anxious, confused, poorly insightful patient, multidisciplinary care strategies need to be strengthened.
For overtly threatening or dangerous patients having multiple psychiatric and medical problems, cautious optimism at bridge building over time needs to be pursued more but not at the expense of the security of the caregivers.
Ultimately, the doctor patient relationship is just that---a relationship. It will have give and take on both sides of this rewarding equation.
We can positively reinforce and encourage heart healthy living and speak in terms that the sick patient, sitting or lying in front of us at the time, can understand, offering advice that they can take away.
This teachable moment is part of medicine. Making the most of it is who we are as doctors.