The Most Difficult Cases

[jmj11]

I was thinking about this morning when I was seeing a patient with a significant somatization disorder.I think these are the most difficult cases in medicine. I have been to this rodeo thousands of times and it almost never ends pretty. It is a damn if you do and damn if you don't situation. I will add the caveat that the only time in my career I was physically assaulted was when I told a woman, who had just faked a seizure in my headache clinic, that was not a seizure. It took two security cops and two EMTs to strap her down and carry her out after that encounter (and after she had punched me in the face and kicked me in the nuts, then struck me over the head with her cane). I've tried each of the choices below them many times.

 

But here are the unpleasant options that we have, and the consequences of those:

 

1) Go along with them by confirming (per their wishes) that they are indeed very sick. Order the huge panel of the tests that they want. The problem is, besides running up huge bills, is they will love you like you are their savior you for a while, but there is always an end game because their desire to be sick is a bottomless pit that cannot be filled with tests and more tests.

 

2) Tell them point blank, "The test say you are fine, I think you have a mental health issue of the way you see sickness, I want to send you to a mental health provider." The response is, almost always, outrage by the patient, the patient's mother (even if the patient is 50), the patient's entire family, their friends, their pastor, their mailman . . . that you are a stupid jerk and you will have hell to pay for not taking them seriously. Then, the extremely unlikely chance they will agree to go to see the mental health professional, that profession does NOTHING to help. They can deal with simple anxiety and depression but I have rarely seen one address somatization disorders head on. To give them credit, I know it is a hard thing to treat.

 

3) You can refer them to specialist of the complaint. That's what the family this morning wanted from me. That gets them out of your hair for a few days. But then they see the specialist (who is facing the same quandary as you) and responds by a) calling you and wanting you pulled out of a room to explain to you of course this patient doesn't have X and any moron would know that so why in the hell did you refer them, thus wasting the specialist's time. Or option b) the specialist tells the patient that they are nuts (option # 2 above), to return to see you and that really pisses them off. They are back to see you the next week and demand that you send them to see another specialists and are mad you sent them to the "heartless nut job" in the first place.

 

4) In our neck of the woods there is another option. Sending them to the naturopath. The naturopath always confirms that they are very sick and orders an X, Y, Z panel of meaningless tests and starts meaningless treatments. This last for about a year. Either the placebo effect finally kicks in and they"get better" or, just like with the specialists above, the naturopath becomes the next jerk and they are back in your office, more pissed than ever.

 

I just wished we had competent and available psychiatrists who could help them see their desire to be sick is not healthy (pun intended) and that they must address the root cause, often the lack of nurturing as a child and now using sickness, the only socially approved way to get make-up nurturing as an adult. But that kind of therapy is intensive and not reimbursed well by insurance companies. It is more lucrative to do procedures on them (abdominal surgery) than to help them see that their belly pain, like their chest pain, like their spells, like their tremor, like their imbalance, like their hard and soft stools that are purplish, like their hair falling out, like their skin peeling off, like their feet that smell like onions, like the lump in their throat . . . you get the point  . . . are part of a larger, mental health picture. 

[sas5814]

I tell them they need to see someone smarter than me.  I don't necessarily point them anywhere...just away.When asked who they should see (generally looking for a specialist) I tell them I don't know. I'd start with another PCP, get another opinion, and go from there.It isn't a perfect solution but then again...there isn't one.

[Reality Check 2]

I tried focusing on the idea of "I know what you DO NOT HAVE".

 

Pointing out each test, the results and the diseases that are ruled out.

 

I have tried humbly stating that medicine "doesn't have a concrete answer to everything" but, again, "we know what it isn't". I try "there aren't specialists for everything. You have great blood pressure, regular pulse, good oxygen levels. We should focus on the positive".

 

A colleague taught me to let them guide themselves at that point - "what have you done that makes you feel better? GREAT, keep doing it".

 

It works about 1/3 of the time. 

 

Yep, they hate me too and they usually revert to a naturopath or get a referral for someone from a "friend with the same issues". I say RUN, go see this person since they helped your friend....................

 

I agree, we need more psychiatrists in general and those who aren't afraid to confront a complete loss of connection to reality. 

 

People experience symptoms and to them they are very real. I have a set of skills to help preserve life and fix some things. By no means, do I have a magic wand...............

[GetMeOuttaThisMess]

I tell them they need to see someone smarter than me. I don't necessarily point them anywhere...just away.When asked who they should see (generally looking for a specialist) I tell them I don't know. I'd start with another PCP, get another opinion, and go from there.It isn't a perfect solution but then again...there isn't one.

You sir have just recommended one of the most admired techniques in The House of God. The non bounce back turf. Kudos when successful.

 

Sent from my KFFOWI using Tapatalk

[jmj11]

You sir have just recommended one of the most admired techniques in The House of God. The non bounce back turf. Kudos when successful.

 

Sent from my KFFOWI using Tapatalk

I like that, but bounceless truf is a little hard to find at times. These are boomerang patients. So either they love you and keep coming back and back, or they hate you and try to spread the word that you are an heartless idiot. 

[sas5814]

I like that, but bounceless truf is a little hard to find at times. These are boomerang patients. So either they love you and keep coming back and back, or they hate you and try to spread the word that you are an heartless idiot. 

Given that most of them are nuts and people know it I choose heartless idiot. :-)

[sk732]

I'm generally blunt...after I've heard them out, checked them over, put insides on outsides.  I'll tell them I can't find anything physically wrong with them and tell them that, in my experience, alot of these things have some sort of unerlying issue "between the ears, in the mind, in how we handle stress, etc" (depending on your mood or how ou think it'll be received) and ask if if they're handling some sort of anxiey or loss or depression well.  The worst thing about a lot of these folks is most are generally smart...or think they're at least smarter than me or you (and sometimes are).  If they get upset, I tell them that you came to me for advice and my job is to give you the best possible advice on how to look after yourself, even if it means telling you things you don't want to hear - the old "I'm here to hold your hand if you need it, but also to kick you in the arse if you need that too" sort of philosophy.  They'll either take it or leave it...if they leave, odds are, if you've been a good listener, they'll be back after getting the run around from other folks for a bit OR they'll just toss their teddy in the corner and never come back.  Either way, you get a break, but if they come back, they're sometimes a bit more receptive.

 

SK

[BruceBanner]

I think mild somatization is actually fairly common. You know, like a 'nervous stomach', stress headaches, etc.

 

I get all sorts of bowel disturbances from stress, which I suppose by definition is somatization.

 

I know what you are talking about though--the people with chronic pain and no obvious organic cause who bounce from doc to doc and somehow end up on your schedule....demanding answers and disgusted or furious when you don't have one. Then they either file a complaint against you or give you an awful satisfaction score (dont even get me started on this abomination).

 

I avoid them like the plague, but usually they catch you unawares. It's a simple CC, you think no big deal, then the floodgates open. 

 

The problem like you said is if you send them to a specialist there is a high chance of bounce-back. Stegall had a great tactic--send them to "get a second opinion" from a different, nameless PCP. Then say a prayer for that poor soul.

[Reality Check 2]

I think mild somatization is actually fairly common. You know, like a 'nervous stomach', stress headaches, etc.

 

I get all sorts of bowel disturbances from stress, which I suppose by definition is somatization.

 

I know what you are talking about though--the people with chronic pain and no obvious organic cause who bounce from doc to doc and somehow end up on your schedule....demanding answers and disgusted or furious when you don't have one. Then they either file a complaint against you or give you an awful satisfaction score (dont even get me started on this abomination).

 

I avoid them like the plague, but usually they catch you unawares. It's a simple CC, you think no big deal, then the floodgates open. 

 

The problem like you said is if you send them to a specialist there is a high chance of bounce-back. Stegall had a great tactic--send them to "get a second opinion" from a different, nameless PCP. Then say a prayer for that poor soul.

90% of serotonin is in the gut - so, nervous stomach is very real.

 

I think the folks the OP is talking about are those that NEED to have a million diagnoses and LIVE in their identity as chronically ill, unique, special and they crave the attention - almost a Munchhausen syndrome - they just KNOW their issues are the most unique, never before seen issues that make them disabled, special, in need of attention and, if not given the attention - they flail.

 

I have a few wandering my halls now. Sad that this is their life.

[ventana]

I tell them they need to see someone smarter than me.  I don't necessarily point them anywhere...just away.When asked who they should see (generally looking for a specialist) I tell them I don't know. I'd start with another PCP, get another opinion, and go from there.It isn't a perfect solution but then again...there isn't one.

 

 

I have only had this a few times - (most people get tired of me before I tire of them-maybe due to me being pretty straight shooter and saying "I have nothing for you" followed by "you should find another provider.

 

But a few times I have had to literally state clearly I don't know as I have ruled out all the physical medicine things I was worried about, and pass them off down the road....

 

In general, I do a nice work up (not exhaustive) review their old notes and consults, then give an opinion that there is nothing more I have to offer them beside a psych consult.....

[sas5814]

Add to the most difficult patients the ones that have no insight into their problem and no desire to participate in their own care. Last night I had a diabetic come in whose blood sugar was over 600. She said "I don't understand why my sugars are good when I am in the hospital but fly out of control when I go home." I asked her if she was counting carbs and she said "counting what?" Do you walk? "No." What did you eat for dinner? "Fried chicken and waffles with syrup." How much insulin did you take before your meal? "I dunno."

In reviewing her chart she had been hospitalized several times for the same problem. Had been given exhaustive teaching on diet/exercise/weight loss etc over and over. These type patients throw themselves on the alter of medicine and yell "fix me!" and blame you when you can't. I have likened it to having a sore thumb and a hammer in the other hand. You keep hitting yourself in the thumb with the hammer while demanding to be fixed.

[Guest Paula]

^^^^^ ditto to the above.  Somehow the patient just doesn't understand the insulin drip and they need to take insulin when they get home.