Saying ‘No’ to Patients Means a Little Compromise by Physicians

As I sat in the exam room towards the end of a busy, hectic, overscheduled day, I regarded the patient before me. Convinced that the medication he had been taking for the last year all of a sudden caused a vague symptom that was no longer evident on exam, he urged me to stop the medication. What he really wanted was for me to tell him that I thought it was a good idea to stop the medication. He could’ve stopped it on his own, as many of my patients do.

I calmly and in my most pleasant voice summed up his options. Having already suffered an array of somewhat unusual side effects from other medications, our treatment options were limited. He was in search of what we all are - the pill that cures 100 percent of the time without side effects that you only have to take once and which is generic. Explaining that all of the medications used to treat his particular condition would have potentially troublesome side effects, I asked him which of the three options I presented seemed the most appealing.

“I don’t know,” he responded. Then he looked at me and said, “What do you think?”

Truly, at that moment, he did not want to know what I think.

I believe that I entertain improbable stories my patients offer with more willingness than most. I know that medical science can be wrong or our understanding incomplete. In another 10 years, some of the bizarre things my patients describe may make perfect sense. That said, I get worn down by some of my patients who want me to use my medical training and my license to act as their agent, doing what they are convinced is the right thing. If it is not harmful and comes close to something reasonable, I often give in. I allow medication trials and authorize trials off medications. Sometimes, what patients swears works for them makes no sense to me - the paroxetine used on an as needed basis for anxiety or the homeopathic dose of naltrexone that improves fatigue.

I try hard to walk the fine line between holding firm to my convictions about what is the best treatment for my patient and being flexible enough to accept that the patient may know more about their disease than I do. It’s much easier for me to feel successful in accomplishing this when I have some margin myself - a little give in my energy and my schedule and my time.

Days like today remind me of another reason I seek work-life balance. Without that balance, I grow not only physically fatigued but also mentally and emotionally fatigued. And when I am fatigued, worn out, and worn down, I’m much more likely to scoff at the patient who is convinced that antibiotics cure the common cold than to spend some time exploring their belief and negotiating a compromise in the treatment plan that convinces me they received excellent medical care and convinces them of the same thing.

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