Should I say “Goodbye?”

It was 1:35pm when we realized that Tom was not just late for his chemotherapy treatment; he probably would not show up at all.  A call from one of our staff confirmed, he had “troubles getting a ride” and wanted to move the vital therapy to another day.  This was the third time in a month he had missed an appointment, thus wasting a treatment slot, nursing time and more importantly delaying critical care. He promised to come in next week.

Annette was 50 feet away, in another room, when I heard her exclaim, “I must see him now.  I am certain he can fit me in!”  The secretary buzzed into my office to announce that even though her appointment was for 4:00pm and it was only 11:35am, Annette “needed” to be seen at that moment to discuss her scan results, about which I had called the night before.  I understand how anxious patients can get and agreed to see her, there-by losing the mid-day break I use for catching-up and grabbing a bite at my desk between keystrokes and calls. My front desk manager pointed out that in some form or another, ignoring conversations and accommodations, Annette had done this multiple times.

Our triage nurse inserted Maria into my schedule as an emergency-add-on.  Maria had “discovered a tumor” in her breast and was adamant about being seen right away. Even though my schedule was packed, she refused to see our nurse practitioner, and so she was squeezed between a chemotherapy patient and a young man who was bleeding.  However, there was no mass, other than a scar, which Maria admitted was unchanged.  She did present a jury notice for which she needed an immediate excuse.

Four letter words, and I do not mean “love,” embellish Allan’s vernacular. Despite several interventions by our head nurse, our office manager, and me, Allan cannot limit his colorful verbiage and has reduced nurses and front desk staff to tears when frustrated by inconvenience or inconsistency.  Allan is receiving successful life-saving treatment for a highly aggressive cancer and he is doing well, but he is, one-by-one, reducing my staff to cinders.

Sue spends a fortune on printer ink. Each visit she presents an inch of Internet printouts. She has seen four oncologists and half a dozen other doctors for “second” opinions.  Each week there is a list of new minor or major questions and the rehash of prior decisions. We often alter her therapy to accommodate both her desires, as well was the recommendations of her stable of doctors. Our relationship is such that neither one of us trusts what the other plans.

Frankly, I do not understand Mike’s problem.  He has money.  He has insurance.  He is intelligent and organized in his life.  He understands fully his medical condition and the need for treatment.   Nonetheless, whether or not he actually fills his prescriptions, he almost never takes his medication.  Ours is an almost worthless relationship.

Patients leave or change doctors all the time.  However, only very rarely, in the most egregious situations, will doctors leave patients.  As with all patients, challenging patients deserve the best care.  Physicians, with their staffs, work very hard to serve them.  However, it occurs to me that we sometimes reach a critical loss of confidence.  Not loss of trust of the patient in the doctor, but a lack of trust of doctor in the patient.  A doctor may feel that a patient does not listen and undermines the doctor’s advice.  If the patient cannot comply with the physician recommendations, if the relationship deteriorates for any number of reasons, the patient’s care is harmed.  Then, if we assume that a physician’s job to help and that is not happening, perhaps the doctor has a practical and ethical responsibility to walk away.

In examples, such as the patients above, physicians usually accept the old adage, that we learn the most and become even better at our jobs by serving the most difficult cases.   Therefore, we try to accommodate each patient’s needs and when those needs are extreme, we counsel, adjust and try to exercise patience.  Most of the time, the relationship can be patched as the doctor’s office adjusts and patients learn the sick role.  Nevertheless, sometimes, that does not happen.

There is a medical – legal issue to be recognized. Patients who do not connect well to their caregivers are more likely to get poor care, more likely to have bad outcomes and more likely, therefore, to sue.  However, while that is clearly a concern for most doctors, the problem is more basic.

There is a moment where the failure of a doctor’s office to build a relationship with a particular patient results in a failure to heal.  At that moment, it is the doctors responsibility, both for that patient, and other patients, and for the physician’s staff, to help that person get care elsewhere and to walk away.



  • Mary
    Dear Dr. S, Your comment "only rarely, do dr.s leave patients" compels me to write. In the course of treating my stubborn, in curable, and chronic condition, several doctors have quit on me. There was the one that assured me he would solve my complex case only to tell me in the next appointment that was all in my head and I needed to get laid. There was his good friend (who had referred me to that dr.) and with whom I had worked successfully in the past, who dropped me when I said I couldn't work with his friend. There was the one who said that my condition could only lead to an ugly death and he only wanted to work with more positive cases. Please understand that these three represent a minority of the medical professionals that I have encountered in my few years as a sick person. Do not think for a nanosecond that I am unappreciative of the team that allowed my miracle cure to happen - I will live the rest of my life in gratitude that they respected me enough to try my crazy idea based on a stack of research off PubMed even though my labwork didn't support it as a solution and my rapidly deteriorating condition made the detour dangerous. They can finally count me in the WIN column!!!
    • Liz
      And of course even doctors are human LOL, have their own hot buttons pushed, their own issues triggered, and so when they can't deal with certain kinds of patients they chose to fire them. Fortunately doctors, like every other human being, have different pet peeves although I would suspect that fewer doctors tolerate disruptive to other patient behaviors than tolerate the patient who arrives with a thick pile of stuff found on the internet.
      • Mary
        I had a doctor that went into tizzies with a one page printout. I went to an Urgent Care, and I had a scrap of paper with dates of hospitalization, symptoms, etc. He asked for it, and dropped it in the trash. He said that he wanted the basics from the mind. He asked me if I had any imaging and when-I said-the date is on that piece of paper-that's so.I can be accurate. He dug it out without saying anything. I gave him the date without any comments.
  • Mary
    Your last paragraph about it is the doctor's responsibility to help the patient to get help elsewhere, has been my rant for several months. I had a good PCP for 3 years. He sent me to a wonderful surgeon for the biopsy on my face. He got me into what's supposed to be a good cancer clinic. They wanted to do radical surgery-remove-eye-nose-bone in a hurry. They just didn't do any lab work for anemia, clotting-anything. I contacted him about lab work and he ordered it, That is the only thing I contacted him about, even when I had radiation. I had ear troubles, and he was helpful. Then I got bit by a dog. The hospitalist released me without any antibiotics-and I developed a chronic sore throat and a variety of symptoms. I had strep from may to October. Basically something that could have been cured by one more IV antibiotic pack, while in the hospital became a $12,000+ problem. This still could have been treated with an office visit and a strep test-still about $200. I don't think that I need to send you an attachment that says-Imaging does not show strep-only the results of strep in the kidneys, heart, etc. In my senior plan, I can change primary doctors, but I must have permission and be on a waiting list. The cardiologist made the phone calls that released me from that. I have a new PCP-an internist, as I also have thyroid problems. I had so much anger and fear that I cursed like the cowboy that I used to be when I saw my new PCP. At one point, the new PCP asked me why I stayed with my old doctor-the circumstances for changing. I said that he had been a good doctor for 3 years. I was conflicted because of this, and hoping it was a temporary glitch. Something happened to him when I bit by the dog (I was in the ER by 15 minutes, and they mishandled the treatment), I don't know what- maybe he had health or personal problems, maybe he was creeped out by the cancer. I said that I just can't understand why my old PCP didn't say--you need more specialized care than what I can give you, or I need to reduce my patient load and you need another doctor. I'll help you to get a new doctor. Anything except-come back in October and we'll see how your thyroid screen is.
  • Liz
    And the sad part is, due to problems/issues of the patient, they are unlikely to be a "good fit" with any doctor anywhere. The reasons are varied: their needs are too great and go well beyond the "usual" for their disease, their pain in the rear factor prevents them from getting the help they need because they alienate everyone, they get some sort of positive reinforcement for acting the way that they do (even if it is counter productive) that meets another need of theirs and so nothing you do will change that, they are so stressed out they can't manage their life (my guess is that these patients might be able to be helped if they get appropriate treatment for their distress/stress levels)… the list of "reasons" for "dysfunctional" patient behavior is probably quite long… I also think that doctor tolerance of these kinds of behaviors varies significantly between doctors. There are doctors who fire patients at a drop of a hat, others that hang on and on and on driving themselves crazy and burning everyone who works there out… Often when a patient is fired they get no warning from the doctor - just the letter telling them they are fired and some are totally blindsided. Personally I think it would be wise to meet with the patient (with a witness present and then document this well with the witness and patient signing off too with the patient getting a copy) to discuss the behaviors that you can not deal with anymore, what needs to change, how they need to behave instead, and let the patient know the consequences of not changing. Exploring the why behind the behaviors may or may not help (sort of depends on the "why" though). There will be some patients who may well pull it together enough, get the other help they need, etc. so that you can again feel like you can deal with them without driving yourself crazy, others will be, for whatever reason, unable to change and you privately hope that aliens abduct them LOL. Some people are really, really dense when it comes to interpersonal relationships (have a low "emotional IQ") and metaphorically speaking need a sledge hammer on the side of the head to realize they are being a pain in the rear. Others are so stressed out by what is happening in their lives that they can not cope and the fall out is everywhere (they need a different kind of help that does not involve sledgehammers LOL). Others have mental illnesses that get in their way… The fundamental underlying problem is that there are dysfunctional people in this world who need health care. Someone has to treat them. They will not be patients anyone wants. The big question then becomes - who treats them? Does each doctor take "their share" of pain in the rear patients so that no one is overwhelmed by them? Does everyone fire them and they then don't have any care anywhere? There are underlying moral/ethical issues involved that have no easy answers (and might be worth a class discussion session with medical students). See too many of these kinds of patients and the doctor is drained, staff are stressed out, other patients suffer due to too many schedule upheavals… Yet the cancer diagnosis (although this is not an oncology exclusive problem obviously) brings an emotional earthquake and some people do not cope well with that and at times are incapable of being the pleasant, "nice" patient. Instead they are angry, grieving, etc. and the behavioral symptoms of this are hard on everyone in that patient's life, not just the doctor. Do doctors only see patients who are able to cope well? There are no easy answers. The additional problem - one that your new large practice is going to have to decide what to do about - is what happens when you fire this patient. Do you fire them from the entire practice which in this day and age of increasingly large practices means they may not, in effect, be able to get competent care, or even any care at all… Competent care may be an issue since it is likely your practice tries to keep out the docs you perceive to be incompetent, or any care at all if you are the only group of in network oncologists - then what moral obligation does the practice have? Do you fire them just from that doc - but then what do you do about telling the new doc the realities of this patient because if you tell them they may not take them? Do you have a practice wide discussion about how to divvy up the pain in the rear patients between docs so no one gets burned out or decide just how many it is your "civic duty" to treat and dump the rest? These are not easy questions with easy answers. When I worked with adjudicated youth I could not fire the ones who were scary, dangerous, pains in the rear beyond belief. I had to learn how to cope and put limits in place (and it sounds like some limits need to be put in place for some of your patients - with a conversation with them that here is where you are crossing the line, from here on out here is the line in the sand, here is how you need to behave instead, here is the consequence of you not respecting that line in the sand- e.g. separation from the practice) and then stick to my guns over that. When I would cave to the adjudicated youth to prevent scenes, more trouble, etc, what I finally learned (and I had to learn this lesson more than once before it stuck; I was a slow learner LOL) was that I was rewarding bad behavior, thus increasing the odds it would be repeated. When I changed how I dealt with it (eg. do this then you are choosing X consequence) they first tested me before they caved and changed their approach. WHen I stuck to my guns they tried to make the sky fall (because the way humans behave is that if something worked in the past, is not working this time, then trying that behavior harder/louder/longer until it is dead obvious it is not longer working is the usual response so things gets worse before they get better). When they saw that this no longer worked, they got consequences, many of them changed their approach. I had fewer kids crossing lines in the sand. Some of your story has some rewarding bad behavior aspects (caving to demands to be worked in for non-emergencies). I now have a PhD and teach. I can't fire disruptive students from the class, although I can ask them to leave while they are being disruptive, I still have to let them back in the door and I need to tread carefully enough that they don't go complain to the department chair or dean as many of them will do at the drop of a hat (or in some cases their parents will complain to those people). I dread certain students (I teach several required classes and so see some of them multiple times). I have, however, learned to put rules in place that I stick by concerning behavior that drives me nuts (late work, fake excuses, texting in the classroom…) and I hand those rules out with the consequences of breaking them. Zeros for fake excuses, late penalties for their grade on the late work, and cell phone jail (put them on the chalkboard with their name over their phone) for their phones each and every time they come to class… I do find that being up front about my pet peeves helps reduce the number of "offenses". Doesn't stop all of it, but at least reduces it to a more manageable level. It might be wise for your giant practice to create some rules that you type up and hand out to each new patient and post on the wall… Patients will only be worked in when there is an emergency - work excuses, getting test results prior to your scheduled appointment (and whatever else is common) can not be worked in because this compromises the care of patients who have appointments and causes long waits for them which is not fair to them. We understand that it is stressful not to get your test results back immediately, however it is also stressful for patients who have appointments, and may compromise their care, to have their appointments cut short or have to wait a long time so that you can get your test results prior to your appointment… If you were the one having your appointment shortened for non-emergency reasons or having long waits, you would not be happy. (Not worded diplomatically enough). My primary care doc has something along the lines of this posted: To be worked in for an emergency you must be willing to be triaged by the nurse. If it is determined that this can wait, we will make you an appointment or you can chose to go to urgent care. We will not work in patients without appointments if we are more than 30 minutes behind or it is after 4pm. If you are the patient being worked in, and we are behind, we will see the scheduled patient first. This means you might be waiting a long time, possibly be the last patient of the day. If this will not work for you, go to urgent care. If you want a refill on your prescription it must be requested prior to 9am for this to happen the same day… That being said, I had a temp of 101.8 at 8:30 in the morning while my counts were still low post chemo and I was worked in almost immediately - so you have the ability not to follow the posted rules. They are just there to enforce if you have to, if you are dealing with some of the patients you described that drive you nuts… A non-compassionate or jerk doctor has no problems firing patients left and right, although I question the ethics of that. Medical school didn't say that only the "good", "well behaved", "compliant" patients deserve to get medical care. The compassionate ones sometimes burn themselves out by allowing bad behavior to continue beyond a reasonable point. There are certainly hard ethical issues involved, not just pain in the rear issues. Good luck.
    • Liz
      PS, meant to add that if you sit down with a patient and spell it all out (paragraph 2), the patient might fire you and move on to someone else without you having to decide if you are going to fire them. That will not solve the underlying problem, and in that respect is not ideal, but then again you are not dealing with that patient any more. And perhaps someone else is better able to cope with that patient because their pet peeves are different, they have fewer pain in the rear patients, they have not yet burned out on this particular person and so it is easier and less stressful to deal with them… again we are back to the problem of who is going to treat patients like this if we live in a society that believes everyone who needs it should have medical care...
      • Mary
        I was asked what my underlying problem was. I said, "administration." It was little things like being scheduled with different doctors @ different sites on the same day and time, etc. My first doctor was a pompous jerk. I requested a new doctor after the 2nd visit. 6 weeks later I was still requesting a different doctor. I called up ACS for guidance, and they finally told me to use the SUE word. My current doctors are keepers. If I had 'problems', why would I have the same dentist for 25 years, and be friends with his staff?
  • Dr. Salwitz, thank you again for a glimpse behind the curtain of being a doctor. I am confident that those who read your essays become better least I hope so. You give voice to all practicing physicians and healthcare professionals who don't steal precious minutes out of their days, as you do, once or twice a week to write such compelling essays.
  • You have a very difficult and rewarding job. People that have cancer, me being one of them, are not always their most centered selves. But what I will tell you is that you are appreciated and loved by many. You see we put our lives in your hands. You listen and you do not fear facing death with us. On a difficult day or one filled with loss know that you are treasured.
  • Mary
    What is disruptive to one person isn't disruptive to another. Students love to get a teachers' goat-and the more drastic the teacher is in reactions, the more motivated the students are to cause further chaos. I gave a late test or paper the grade it deserved-an 'A" got an 'A'. When the confused student asked why, I told the student that they were behind, and their GPA would come down because of being behind. I removed all of the drama, all of their arguments. Students turned everything in on time. I refused to waste my time listening to excuses. The city police come into the class and arrested students for various felonies. Patients are something else. I had one nurse that consistently over-weighed me. I could see my weight on the scale, and the chart had an extra 8-10 lbs added to my weight. The doctor wouldn't believe that. I went to a dietician-explained the problem, and had her write a description of what I wore- shorts-tank top with my real weight-went to my Dr. appt. was weighed in as usual had another argument with my PCP. Then I went to the clinic manager and showed her everything. The next day I had a new PCP. Many people that have cancer are angry at the cancer, and they take it out on the staff. There have always been patients that lie about taking meds or don't follow instructions. Doctors just have to cope. My family doctor complained about that when I was a child-he wanted to make sure that his patients were educated about side-effects-more medical tests, etc. Education with a contract should take care of this problem. People that don't show---they should pay for the missed appointment out of their own pocket. My radiation clinic and my insurer made this clear before treatment started. I have a history of being 20 minutes early, which my dentist of 25 years would attest to. I do not agree with the mental problem-whatever-I had to fill out my "last wishes", which is the name for the paperwork in this state, multiple times. I took my proxy with me when I was called back, and when I picked out my same choices-they were choices listed on the form, pre-printed. The counselors tried to bully my proxy into making me change my mind about my choices. They suggested counseling, when I asked them why the document had these options, if the options are illegal or immoral. Sometimes the anger isn't directly caused by the cancer or the treatment, but by counselors that believe they know what a patient needs. I have a team of really great doctors. I just ignore the social workers and nurse navigators. It makes it more difficult for me, as a patient-but they were making it more difficult for me anyway. This causes me to wonder if they can cope with a patient that actually does have problems. I think most cancer staffs are used to desperate people that will grasp at anything to live 5 minutes longer. They seem to have difficulty in dealing with somebody that doesn't feel this way. i have been asked if I was suicidal. I told them that if I was suicidal, I would have already offed myself. They don't know how to take that. e.g. My husband of 37 years drove off with a blonde that is younger than our youngest child. That was a real kick in the stomach. Do doctors get irritated? F-ing A! Do they have blogs where they can vent about these many problems, and be hopeful that patients will examine their actions? d'accord! por supuesto!, hai! This is therapy for all of us, besides a learning experience.
    • Angela Evans,R.N.
      I agree with you completely. Trust between physician and patient is paramount. Unfortunately,patients that feel as if they can control their physicians often stay for just that reason. If in the end their care is compromised then for the physician has the responsibility to try & put the patient in the best position to get good quality care.
      • Mary
        Unfortunately, power sometimes comes into play. Patients want power over those around them-play the pity card, bully, whatever. Then medical- social staff can get where they expect the patient to conform to their norms. I hate mind games. I want to say-what I mean, and not have it psychoanalyzed. I want my doctors to truthfully state the facts-I'll accept kindness with that. Then my doctors all have a wicked sense of humor, which suits me. The nurses aren't sure what's going on when we laugh. The radiologist was trying to gently explain possible effects of radiation on my lip and the edge of my nose. I said, "it might come out like a fried pork rind," and I smiled. We began laughing, and he's been very honest with me. It's in my chart that I like to laugh and joke, but that I understand what's going on. There's a great difference between guidance and a power play. Medical staff isn't supposed to be acting like freshman girls trying to push a patients buttons.,
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  • Mike
    Sometimes the problem is the treatment center not the doctor. I've heard "we do don't that here" when asking about treatments that have worked in the past. I've been given explanations that "it's easier to find newly dx'd cancer patients than to fight with insurance companies for payment." I've been to one of the best hospitals in the world, only to be lectured on all sorts of rules and regulations that turned a routine colonoscopy into a logistical nightmare- no consideration for out-of-town patients. When I asked about clinical trials, I was told "we don't have that here." As a group, we are trying to remain independent, working, insured at a price we can pay, and productive..... juggling the impossible- with rising dollars for everything except our incomes. Last time in treatment, the above situation got the better of me, and my blood pressure went sky high--- so the medical assistant kept taking it over and over as it went higher and higher, until I ripped the device off my arm. It's been said that we can't imagine the pain and suffering of others. Perhaps not everyone on the treatment plan understands. I've been told I was probably cured of an incurable disease, setting me up for the inevitable disappointment, which should not have surprised one of my (former) oncologists. Those doctors who are just trying to "get through the day" should really choose a specialty other than hematology/medical oncology imho. And we, as survivors, can not begin to imagine the degree to which we must advocate for ourselves and our care. Many of us are either not well-versed in this type of negotiation (is our health care really negotiable), or else we have too much "skin in the game" to be objective. Don't even get me started on access to care issues coming soon to an insurance provider near you. Sorry for the rant, but listening to and learning from survivors is not something taught in a classroom, resulting in standard, legally guarded answers. Oncologists have heavier workloads than ever- I get that..... but I challenge them to return to an era when loyalty and interpersonal relationships actually meant something.

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