Dealing with difficult patients

[Ironheme]

Any of you have any luck successfully managing a patient who argues with you that their lab results are abnormal, demanding tests that aren't indicated? I have done more of a work up than most would have done at this point and I do not think more testing is warranted.

Example platelets of 180 they state is "lower end of normal, and is therefore abnormal," "a basophil percentage of 0.3% is low" and wanting rheumatoid arthritis work up with only symptom being dyspepsia. Explaining that reference ranges are guides, not absolutes and that their blood tests are within normal limits, has not worked, and only made them more upset saying they are not being taken seriously.

I'm going to say no, but any artful ways of managing this kind of behavior?

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[VA Hopeful Dr]

For random stuff on the CBC like that I just say that as long as the total white count it OK the breakdown of cell type doesn't matter. Same with hemoglobin and something like elevated RDW or MCHC.

I had a guy make the same argument about testosterone. I tried explaining that normal is normal but he just wouldn't accept it. I finally just ended the appointment because you can't reason with some people.

If you don't think something is indicated, just say so. They can either take your advice or go elsewhere.

 

[Fatalis]

Any of you have any luck successfully managing a patient who argues with you that their lab results are abnormal, demanding tests that aren't indicated? I have done more of a work up than most would have done at this point and I do not think more testing is warranted.

Example platelets of 180 they state is "lower end of normal, and is therefore abnormal," "a basophil percentage of 0.3% is low" and wanting rheumatoid arthritis work up with only symptom being dyspepsia. Explaining that reference ranges are guides, not absolutes and that their blood tests are within normal limits, has not worked, and only made them more upset saying they are not being taken seriously.

I'm going to say no, but any artful ways of managing this kind of behavior?

I got a few tactics
1) say "well we could do that but I doubt your insurance would cover it... these tests aren't cheap and I'd hate for you to get dinged with a big bill"
2) explain again that everything looks good; if they persist, I tell them: when you go to the mechanic, do you argue with them when they say you need a part replaced? No? then why are you arguing with me" to be honest it usually stops them in their tracks.
you didn't spend all this time to argue with people who just want their voice heard.

 

[SLC]

I shut that crap down fast. Gotta train your patients some IMO.

 

[Sushirolls]

Or...
What are you concerned about?
What's your theory of what's going on?
Why do you think XYZ?
Might learn some things, and address those issues, which vicariously solves your problem with extra lab requests.

Or...
"Okay, I'll order that test but the code I'll link to the order will likely result in your insurance company rejecting the payment as not medically necessary and you get stuck with the full bill, still want to proceed?" Z65.9

 

[birchswing]

First you must have the diagnosis.

That's not a difficult patient; it's a patient with health anxiety.

 

[VA Hopeful Dr]

First you must have the diagnosis.

That's not a difficult patient; it's a patient with health anxiety.

The 2 are not mutually exclusive

 

[MedicineZ0Z]

For random stuff on the CBC like that I just say that as long as the total white count it OK the breakdown of cell type doesn't matter. Same with hemoglobin and something like elevated RDW or MCHC.

I had a guy make the same argument about testosterone. I tried explaining that normal is normal but he just wouldn't accept it. I finally just ended the appointment because you can't reason with some people.

If you don't think something is indicated, just say so. They can either take your advice or go elsewhere.

Testosterone is a huge exception when it comes to this though. If they're symptomatic at all and have a lower end of normal, then TRT can absolutely be indicated within most contexts. Also you need to look at the free testosterone. A normal-ish (but still little low) total test but a low-end free test + mild to moderate symptoms is also an indication for TRT, while also looking at SHBG.
Reference ranges for testosterone aren't ideal either. I'm in several TRT groups on FB and there are countless men who go from symptomatic --> feeling great despite labs never definitively reflecting this.
FYI, make sure you rule out vitamin D deficiency. It can be a big cause of lower testosterone.

I think the vast majority of docs who don't do TRT routinely have some challenges when it comes to testosterone. Same with treating it (not doing weekly dosing for example).

 

[deleted87716]

I'm in several TRT groups on FB

 

[MedicineZ0Z]

Physician led groups

 

[VA Hopeful Dr]

Testosterone is a huge exception when it comes to this though. If they're symptomatic at all and have a lower end of normal, then TRT can absolutely be indicated within most contexts. Also you need to look at the free testosterone. A normal-ish (but still little low) total test but a low-end free test + mild to moderate symptoms is also an indication for TRT, while also looking at SHBG.
Reference ranges for testosterone aren't ideal either. I'm in several TRT groups on FB and there are countless men who go from symptomatic --> feeling great despite labs never definitively reflecting this.
FYI, make sure you rule out vitamin D deficiency. It can be a big cause of lower testosterone.

I think the vast majority of docs who don't do TRT routinely have some challenges when it comes to testosterone. Same with treating it (not doing weekly dosing for example).

Thank you so much!

I had no idea about any of that. If only there was some kind of school I could have gone to that might have taught me things about medicine, including how to find resources to stay up to date about things. Maybe even expert guidelines that were updated last year by both the hormone specialists and the male reproductive specialists.

Physician led groups

That doesn't make it any better. One of the FM attendings in the residency program I rotated through in med school now has a "wellness clinic" where she does IV chelation and essential oils.

I used to be in a DPC FB group lead by doctors. There were a shocking number of anti-vaccine doctors in that group.

 

[MedicineZ0Z]

Thank you so much!

I had no idea about any of that. If only there was some kind of school I could have gone to that might have taught me things about medicine, including how to find resources to stay up to date about things. Maybe even expert guidelines that were updated last year by both the hormone specialists and the male reproductive specialists.


That doesn't make it any better. One of the FM attendings in the residency program I rotated through in med school now has a "wellness clinic" where she does IV chelation and essential oils.

I used to be in a DPC FB group lead by doctors. There were a shocking number of anti-vaccine doctors in that group.

TRT isn't really taught in med school. And many aspects of it are highly debatable. Some uros and endos do it effectively, but the general approach to it is quite questionable by most doctors.


And the groups are literally about sharing evidence and discussing literature.

 

[VA Hopeful Dr]

TRT isn't really taught in med school. And many aspects of it are highly debatable. Some uros and endos do it effectively, but the general approach to it is quite questionable by most doctors.


And the groups are literally about sharing evidence and discussing literature.

We can definitely agree on that.

The AUA and the Endocrine Society both updated their guidelines last year. I follow those as they agree probably 95% of the time. Where they disagree, I use my judgment as to which one to follow.

 

[MedicineZ0Z]

We can definitely agree on that.

The AUA and the Endocrine Society both updated their guidelines last year. I follow those as they agree probably 95% of the time. Where they disagree, I use my judgment as to which one to follow.

My only issue with the guidelines is that once per week injection dosing should be pretty rigid and anything beyond that should be avoided. The use of AIs should also be shunned.

 

[VA Hopeful Dr]

My only issue with the guidelines is that once per week injection dosing should be pretty rigid and anything beyond that should be avoided. The use of AIs should also be shunned.

I have only seen AI's used in fertility, and then only as a short term treatment.

Do you have a decent source about weekly v biweekly dosing because most of what I'm seeing says it shouldn't matter.

 

[MedicineZ0Z]

I have only seen AI's used in fertility, and then only as a short term treatment.

Do you have a decent source about weekly v biweekly dosing because most of what I'm seeing says it shouldn't matter.

The main point is to minimize fluctuations. Symptoms are minimized when levels stay stable and you do that with more frequent dosing.

 

[VA Hopeful Dr]

The main point is to minimize fluctuations. Symptoms are minimized when levels stay stable and you do that with more frequent dosing.

So no, you don't have an actual source

 

[Bacchus]

HRT is a beast I fully admit my incompetence in. Off to endo or urology you go.

 

[MedicineZ0Z]

So no, you don't have an actual source

Source for what? Less symptoms with more frequent dosing?

Ideally you should be dosing even 2x a week.

As to your point about AIs, they've been used religiously with anabolic steroid use and somewhat with TRT. The principle is that you should minimize estrogen or keep it within a certain range to prevent gyno and other high E symptoms. Now we're seeing that slightly higher estrogen is acceptable and that estrogen actually has some anabolic properties. Plus... crashing your E carries lots of side effects. If it does become a major concern than tamoxifen should be the go-to choice rather than an AI.

HRT is a beast I fully admit my incompetence in. Off to endo or urology you go.

Definitely a niche I plan to keep pursuing. But I do agree that it's something to refer off to asap if one isn't fully well versed in it.

 

[VA Hopeful Dr]

Source for what? Less symptoms with more frequent dosing?

Yes, exactly that.

 

[BigSib]

I'm still a little romantic about 'fighting the good fight.' I will usually try to hear them out for at least a moment. I re-phrase their concerns to validate that I've heard them, then go in for the kill to explain the real situation. Only the real crazies don't tag along which is when you have to shut it down quick.

Last week I had a vaccine hesitant mother who was talking nonsense about quantum mechanics and chaos principles; this week a lady who was convinced she was poisoned from a PPD. Sometimes you just have to normalize the situation in a calming manner. It's not going to be the same for everyone but you do have to hone in on this skill.

 

[simpler2]

Any of you have any luck successfully managing a patient who argues with you that their lab results are abnormal, demanding tests that aren't indicated? I have done more of a work up than most would have done at this point and I do not think more testing is warranted.

Example platelets of 180 they state is "lower end of normal, and is therefore abnormal," "a basophil percentage of 0.3% is low" and wanting rheumatoid arthritis work up with only symptom being dyspepsia. Explaining that reference ranges are guides, not absolutes and that their blood tests are within normal limits, has not worked, and only made them more upset saying they are not being taken seriously.

I'm going to say no, but any artful ways of managing this kind of behavior?

This thread appears to have gone WAY off topic. In response to the OP, I personally try to shut down conversations where I feel that the patient is trying to convince me to change practice inappropriately. I may try up to twice to explain my clinical reasoning if it is respectfully received. Rarely, someone will continue to push in a way that is offensive for inappropriate management. I can only think of a few cases that required curt refusal to engage further on my part.

I am also very comfortable admitting lack of knowledge in cases where an individual is requesting services that I simply don't offer and did not encounter in training. I think its is good practice to continue questioning our own knowledge, even during clinical encounters. I've been humbled before by having to learn about my own short comings in clinical knowledge and suspect I will be again. Even with topics where my footing is less sure, I will not provide possibly inappropriate management in response to patient insistence.

 

[clausewitz2]

The 2 are not mutually exclusive

The point is that in this particular case, there may be something specific going on from the general run-of-the-mill schedule-buster. Health anxiety is increasingly being thought of as part of the OCD spectrum, which fits very well with what is described here by the OP. This is important because reassurance that the lab results are normal is exactly the wrong thing to do, because reassurance simply strengthens the compulsive behavior and is ineffective in providing anything but momentary relief. If you are someone who is up to the challenge of validating the distress while at the same time acknowledging that it is certainly possible that they have cancer or whatever it is that they are worried about, this is likely to be more effective.

I personally would probably try something like "I don't have any reason to believe you have [Terrible Dread Illness X] but it is not impossible. The problem is the test results we have don't tell us anything about whether you have it and don't prove anything. We can definitely keep an eye out for this moving forward but ordering the tests you are asking for is not going to tell us for sure that you won't develop [Illness X] so I'm not going to order them. I understand that it's very scary and I can see why you're worried, I wish it was possible to do a test or tell you something that would prove forever that you will not get [Illness X]"

Tolerating uncertainty is the thing they have to learn to deal with and while it is very natural for physicians to want to try to reassure and explain why everything is alright it is actively unhelpful in these situations. The idea of the regular scheduled appointments regardless of symptoms or test results is to weaken the reinforcement of the compulsive behavior by making it independent of the anxiety.

At the same time if you read my suggestion and roll your eyes or groan that is probably a good sign that this is not a tack you should take, as it is really easy to invalidate people and tick them off something fierce operating in this framework. You gotta at least kind of mean it or it's going to be really hard to pull off. In that case probably just a firm "no, I'm not willing to do that" is your best bet and move on to something else.

Pretty much any time you find yourself arguing with a patient you lose, game over, move on.

 

[SXMMD]

The point is that in this particular case, there may be something specific going on from the general run-of-the-mill schedule-buster. Health anxiety is increasingly being thought of as part of the OCD spectrum, which fits very well with what is described here by the OP. This is important because reassurance that the lab results are normal is exactly the wrong thing to do, because reassurance simply strengthens the compulsive behavior and is ineffective in providing anything but momentary relief. If you are someone who is up to the challenge of validating the distress while at the same time acknowledging that it is certainly possible that they have cancer or whatever it is that they are worried about, this is likely to be more effective.

I personally would probably try something like "I don't have any reason to believe you have [Terrible Dread Illness X] but it is not impossible. The problem is the test results we have don't tell us anything about whether you have it and don't prove anything. We can definitely keep an eye out for this moving forward but ordering the tests you are asking for is not going to tell us for sure that you won't develop [Illness X] so I'm not going to order them. I understand that it's very scary and I can see why you're worried, I wish it was possible to do a test or tell you something that would prove forever that you will not get [Illness X]"

Tolerating uncertainty is the thing they have to learn to deal with and while it is very natural for physicians to want to try to reassure and explain why everything is alright it is actively unhelpful in these situations. The idea of the regular scheduled appointments regardless of symptoms or test results is to weaken the reinforcement of the compulsive behavior by making it independent of the anxiety.

At the same time if you read my suggestion and roll your eyes or groan that is probably a good sign that this is not a tack you should take, as it is really easy to invalidate people and tick them off something fierce operating in this framework. You gotta at least kind of mean it or it's going to be really hard to pull off. In that case probably just a firm "no, I'm not willing to do that" is your best bet and move on to something else.

Pretty much any time you find yourself arguing with a patient you lose, game over, move on.

Time consuming process up front but so far I'm finding it pays dividends in the long term. Happier patients, shorter appointments = happier me