Saturday, October 18, 2008

Countertransference

Last month, I worked in a walk-in clinic off the emergency room/department (whatever). A "fast track" if you will, this is the clinic where the not-so-emergent patients get seen. If the chief complaint is "medication refill" or "back pain" or "tooth ache" or "suture removal", they get sent to this clinic. As always, this clinic is a victim of its own success: they take the pressure off the emergency room/department, which allows more patients to be seen, therefore more patients come to the emergency room/department for non-urgent complaints because this clinic exists. Lather, rinse, repeat.

I read several emergency room/department blogs, including WhiteCoat Rants, Ten Out of Ten, and Crass-Pollination, and while I hoped that they were all exaggerating, I had a suspicion they weren't. They're not. I occasionally saw people who really needed help, but more frequently (it seemed) I saw people whose whole existence seems to be about gaming the system for every free thing they can.

One person came in with a list of requests. Not complaints, but requests. He/she wanted pain medicine, refills of all other meds, a cane, free clothes, free food, dentures, and several other things which I can't even remember because the list was so long. I said no, okay, fine, no, no, referral. Since when is the emergency room/department a soup kitchen or the Salvation Army? And I wholeheartedly agree with today's post by Nurse K about the homeless "patient" with the bogus complaint. This same patient with the laundry list was homeless, but was currently NOT sleeping on the street, but instead staying with family. He/she also told me how many beers they drank in a day (the answer was a number >1). So, you have enough money to support your beer habit, but you get angry with me when I won't give you free clothes and insist that you go to a dental clinic to get dentures? Ugh.

Sometimes, it's a family affair. A brother and sister combo came in the other day, one asking for pain medication and a new cane as it had been "destroyed", the other asking for pain medication and a glucometer as it had been "destroyed". It was probably a little passive aggressive of me to document carefully in the chart that this was the patient's third cane in a year. Is there a black market for canes and glucometers?

I'll be totally honest. When I pick up a chart that says "tooth ache" or "back pain", I get put on my guard. I walk in, and make a split-second judgment. If the patient's face is swollen, or they're sitting all tense and not moving, I kind of relax. If they're all relaxed, and smiling as they tell me "doc, I'm doing TERRIBLE", and they have "10/10" pain from a skin rash, I get a little suspicious. One patient was sobbing hysterically when I came in, to the point I could hardly examine them because they wouldn't stop. "OH JESUS DOCTOR I'M HURTIN' DOC PLEASE HELP ME OH DOCTOR HELP ME!" I asked them to calm down, please calm down, TOLD them to calm down, but to no avail. I actually wrote on my physical exam "could not auscultate heart or lungs due to patient's crying". I looked in their mouth, and saw some brown teeth, but nothing red or swollen or infected, so I said "I'll give you the phone number for the dental clinic." "OH JESUS DOCTOR DON'T LET ME LEAVE WITHOUT PULLING MY TEETH OH DOCTOR THANK YOU DOCTOR I'M PRAYING FOR YOU DOCTOR!" This was also, coincidentally, a patient who had been seen previously, given the phone number they needed but failed to call, and somehow needed to call an ambulance to come to the emergency room for this pain.

WTF? So you can call an AMBULANCE for your tooth pain, just to sit in the ER/ED and complain to the nurse that we're wasting your Medicaid by sending you to a different clinic? Oh, the irony. I'm wasting your Medicaid, you're wasting my tax dollars with your ambulance call.

To those of you who may not know, here's a public service announcement: if your tooth is rotten, but not infected, no matter how much it hurts it's not a medical emergency. The emergency room doctors will NOT pull your tooth for free. Spread the word.

I'm being totally honest here because I'm not proud of this response in myself. Why do I feel like every chronic pain patient is scamming me? Why do I care? Seriously, what is it to me if these patients want pain medication? Why does it irritate me?

I could say it's that these patients are difficult, but really, only a few of these patients are actually nasty to me. Sure, it's hard to tell a patient "no" when they ask for Vicodin (by name and dose, and 'nothing else works'), but most of them accept my reasons and whatever I feel like I can give them (usually ibuprofen, sometimes tramadol). It's the few who get nasty who stick in my mind, though, and put my hackles up.

There's also the occasional patient who seems to "dupe" you into feeling sorry for them, or giving them pain medicine because their pain seems genuine, only to find out they were faking, or they start cursing you for taking too long reading their xray, or do something that makes you feel like a huge fool for believing them. This happens to me from time to time, because I really try to believe my patients. I keep trying to fight the cynicism, but it's hard.

A lot of it is in the environment. The attendings I worked with last month would say "Oh my god, another tooth pain? What a waste of time!" It's easy to spread irritation like that. In fact, it seems sometimes that it's easier to spread a bad mood than a good one...

Although not always. One patient had us all laughing hysterically with him (not at him). The attending came out and told me I HAD to go see this 80-year old guy's hand. I walked in, and his thumbnail was hanging off, dangling by a tiny piece of skin; he was totally nonchalant. "WHOA! I've never seen anything like that!" I said. "You've never seen anything like ME!" he said back. He also told us his only allergy was to "women" and that he was "a real tough guy." He was right. We all told his story for days to come, repeating it and laughing, tickled by this patient's attitude. So sometimes the good stories get passed around, too.

I just wish there were more of them, and less frustration. But still, why so much frustration? I haven't found the answer yet. I can totally understand some of the attitudes in the ER/ED blogs, though. There are some NASTY people out there.

6 comments:

s said...

Yeah. It's enough to break your spirit fast. Especially the $1000 taxi service you are paying for every time they call 911.

About countertransference, well, that's a whole other story...I noticed that once I was more aware of it (my negative attitudes toward certain types of patients) and went in with a conscious effort not to think of them as "hysterical mothers" etc, the interactions went a lot smoother.

And...well, I think I need to fire my shrink because his countertransference toward me is way out of control and he's totally unaware.

WhiteCoat said...

Do I complain that much?
Hope you don't mind, but I have to link to this. It just gives people a fresh perspective on what we always complain about.

Tiny Shrink said...

Again, thanks for the link, WhiteCoat.

And to S, I agree that once I acknowledge that I'm feeling that way, it's easier to get past it. Which is why I wrote about it. Just because this rotation is over doesn't mean I'll never have patients like that again. And just because someone likes their pain medication it doesn't have to ruin my whole day.

Braden said...

"I haven't found the answer yet."

The answer is in the entitlement mentality that is more and more rampant in our society and that goes hand in hand with a lack of personal responsibility... "I need it now and it's not my fault."

Braden

keepbreathing said...

I try not to be too judgmental of my patients, but I rarely succeed. There's a Dilbert strip somewhere out there where he says he began to hate people in advance because it "saves time," and try as I might to be nice and think happy thoughts, that's sort of the direction I wind up going in.

BC63 said...

Just as soon as you admit that these patients are ENTITLED to whatever they so desire, you'll do just fine (of course, I'm being EXTREMELY sarcastic).