I think the OP's perspective is a bit backwards and that's where the stress comes from. The OP appears to be conceptualizing these are inherently or intrinsically annoying or frustrating patients. Instead, I believe it's better to view them as a particularly bad match for the OP. It sounds like the OP is out of ideas for both, so it's time for them to move on. If this is in inpatient (particularly jail inpatient) or the ED, your job is not to fix the person. If you're going into inpatient or CL work thinking you're going to fix someone, you're going to be very disappointed consistently. That's not even a patient mismatch, that's a job expectation mismatch. Your job is to make sure they aren't an acute danger to themselves or other people and once they aren't, get them connected to someone who can actually address their issues. It can be very freeing to drop the whole pretense that you have some other role to play in inpatient or CL. You don't. Instead, focus on learning all the resources and how to connect people to them. If the resource isn't available or you don't know what it is, that's where your real work lies, not in this specific patient.
I don't do outpatient, so my advice probably isn't as good for the second group, but to be frank, you clearly aren't the right doctor for them and you need to make that abundantly clear. I'm not saying fire the patient, I'm saying help the patient see that they should move on. This includes setting firm boundaries around medications. Don't do the carousel. If the patient isn't benefitting from seeing you, then let them know. Wean them off the visits. If you aren't changing medications, and you shouldn't be if it's a patient you described, there's no real reason for you to keep seeing them with much frequency at all no matter how much drama and chaos is in their life.
So I guess the ultimate advice is, stop seeing both these patients. Get both groups to different clinicians as quickly and safely as you can. You aren't the right person for them. There might not even be one, but you aren't it.
I agree a lot with this.
I am a rheumatologist, so I’m not coming from exactly the same angle here - but there is a lot of overlap, because we also see a lot of these types of personality disordered patients with nebulous symptoms who expect medication to magically make everything better (and if one medication doesn’t get you there, maybe 2 or 3 will!) Plus, if you’re not careful, the PCPs will flood you with bone on bone OA patients, chronic back pain patients, etc which really don’t belong in a rheumatology clinic to begin with. We also seem to draw in a lot of patients with…difficult personalities who have strange expectations, like the kind of patient who shows up one or two times for initial visits, starts medication, mysteriously disappears for 11 months, and then reappears and tries to rip you a new one because they don’t feel better and the meds aren’t working (where the hell have you been for the last year?)
I trained at a rheumatology fellowship where there was a lot of pressure to make every single patient satisfied, and to have a solution for every problem for every patient. And thus early in my career, I burned a lot of time going through every single crazy somatic symptom these patients have, and prescribing medication for it. I also absorbed a lot of nonsense from patients with rotten personalities, and turned it inward and assumed that it was some sort of failure on my part that the pt felt this way. This had a lot of negative consequences. First, it made me run way behind schedule wise, and i caught a lot of flack from admin at my first (otherwise crappy) job over it. Second, it led to me prescribing a fair amount of gabapentin, duloxetine, etc…and in the long run, I don’t think these meds really helped these particular patients and their complaints much. Third, it extended wait times in the queue for new sick rheumatology patients who actually DID need to be seen quickly. Fourth, it was exhausting, mentally and even spiritually. Listening to people just bitch and bitch at you endlessly about nebulous problems that probably don’t even have a solution (or at least not one that can be found from a script pad) will really wear you down inside and out, and contribute to burnout.
Around 5 years in, it clicked. I’m not the doctor for all rheumatology patients - and I don’t want to be. I’m trained as an “inflammation doctor”, not a sports med doc or orthopedist (and certainly not as a psychiatrist or therapist). I started screening new patients much more closely. I made it clear to patients that I practiced rheumatology, not any of these other specialties - and I became much more comfortable doing a workup, ruling out anything rheumatologic, and sending the pt back to their PCP. I didn’t try to hang on to people with nebulous complaints - some of whom I had initially placed on potentially toxic DMARDs that they didn’t need, mostly because they were persistent and some of their symptoms vaguely overlapped with inflammatory arthritis.
I became comfortable thinking “I don’t care if this patient moves on”, which is huge. I work in an area where rheumatology referral volume is plentiful. I don’t need to keep all these patients. In the beginning, I used to feel really discouraged if one of these “nebulous symptoms” patients (or just a pt with a horrible, toxic personality) moved on; then, I felt ok about it. Now I actually consider it a blessing of sorts. I don’t need or want these patients. I don’t want to be arguing with new patients who show up begging for Percocet refills, or whatever. I have clear “bright line” boundaries, and I enforce them. I don’t spend long periods of time indulging patients’ often absurd fantasies of what may be wrong with them. I’m happy to spend an hour with a really sick lupus patient, but I won’t spend an hour with someone with fibro any longer. I make it clear in my waiting room and on intake sheets what I do and don’t do, and what I will and will not prescribe. And I have openly stated to some people that they perhaps would do better finding a second opinion/new rheumatologist. It has made my days in clinic much easier and more enjoyable.
