Balancing Tempers and Treatments

Not long ago, a patient got angry with me. I'll call her Nancy. A slim, athletic woman in her 40s, Nancy wanted--no, demanded--another round of antibiotics for sinusitis. When I balked, her jaw tensed and her eyes shone with tears.

"You don't understand--I feel terrible," she said. I explained that a CT scan, blood work and possibly a culture were needed before I could prescribe more antibiotics. She told me about another specialist she recently had seen who also had declined to give her an antibiotic. I gathered that he and I were now in the same doghouse.

Finally, I thought: whoa. "You were angry at this other doctor when you arrived," I said, "and now you're angry at me." In my mind, I added: "And I'm angry with you."

Anger is a touchy subject in medicine. When faced with hostile or demanding patients, most doctors count to 10 and bury their emotions, keep the patient at arm's length or simply end the visit.

But struggling with Nancy got me thinking. What if superhuman control was the wrong approach? In other words, when a patient pushes a doctor's buttons, what's better? Staying mum or shooting straight?

I'll admit, my history in this area has been checkered. I first tested a patient's tolerance for the unvarnished truth 25 years ago. That's when, as an intern, I admitted a woman with a kidney infection and spiking fevers to a hospital in Chicago. Although sick enough to make me nervous, she (joined by her husband) was not too sick to carp as I hurried to finish the history and physical, obtain labs and start treatment.

First she wanted a different room. Then she sent back her dinner. Then she discovered dust in her closet. One last bleat and I heard myself saying, "Ma'am, this is a hospital, not a hotel." Her husband reported my impertinence, and I was on the carpet in the chief of medicine's office.

I deserved the reprimand. Why? Because even though she was a difficult patient, I had taken the bait too willingly and responded disrespectfully.

In Nancy's case, however, my middle-age medical intuition told me something else. She needed honest feedback to stop the broken record in her head.

I've read many tips for dealing with the "difficult patient": Acknowledge emotions; avoid trigger words such as "can't," "no" and "policy"; don't be defensive; don't interrupt.

Sound contrived? Perhaps. But at least it's a step toward greater empathy on the part of doctors. The next step is the real challenge: to figure out the meaning behind patient anger. Experts say the most difficult patients are hiding fears of serious illness, abandonment and feelings of worthlessness and guilt.

Back to Nancy. When she left that day, without a prescription, she and I were not on great terms. After I confronted her, we spent the next 15 minutes in a continuing wrangle that went nowhere. But neither of us gave up completely, and in the end she consented to the work-up I wanted.

A few days later I received the report of Nancy's scan: air-fluid levels in both maxillary sinuses, consistent with longstanding infection. Her blood tests also showed unusually low levels of serum antibody, which explained her poor response to prior antibiotic blasts. Unlike the average person with sinusitis, Nancy needed a much longer course of treatment to clear her infection. She took the news well, happy at last with a plan that made sense.

As for me, I was glad our dust-up bore fruit: an accurate diagnosis and proper therapy. I still wonder, however, if I could have handled Nancy's case better.

Until I get smarter, at least I can take solace in this: Whether we're talking doctor-patient, parent-child, or husband-wife, negotiating human relationships equals lifelong learning.


Claire Panosian Dunavan is an infectious diseases specialist practicing at UCLA Medical Center. She can be reached at

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