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Loving the Difficult Patient

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Recently, I found myself ending a phone conversation with a long-term patient with the words “Love you!”

KJ is a squat, emotionally volatile 77-year-old woman who tends to compensate for her small stature with an outsize presence. She has an expressive face, arched eyebrows, upturned nose, and mobile lips. Her whole demeanor exudes energy. 

A yoga enthusiast, she used to plant herself in lotus position next to my computer so she could view her lab results on my screen. If having her perched next to my chair like a little bird made me feel a bit awkward, that was not her concern. 

In addition, KJ used to insist on calling me “Marjorie” or “Marjorie Ordene” instead of “Doctor,” and characterized my practice of reviewing blood results in picayune detail as “bean-counting.” One day, I ran out of patience, and I fired her as my patient. 

She would not stay fired. Annoyingly persistent, KJ sent me e-cards not just on my birthday but on any occasion or no occasion. I didn’t have either the time or the inclination to open them, but eventually she wore me down with her charm, and I let her back into my practice.  

KJ has been reformed in her second run with me as a patient, but she is still stubborn. Who goes to a holistic physician and smokes? I don’t mean in the office; that is not allowed. But she has refused to even think about quitting. She rolls her own cigarettes and says it’s mostly paper that she’s smoking. Now, how can that be healthy?

KJ is as adamant about remaining my patient as she is about not following my advice. I can’t blame her for smoking. That is, after all, an addiction. But when I advise her to avoid sweets, citing her imminent diabetes, she replies, “If I feel like having a piece of cake, I’ll have a piece of cake.”  

Frankly, she rejects most of my suggestions, saying simply, “I’m not doing that.” Yet she insists on coming, and despite myself, I find those two words slipping off my tongue at the conclusion of our visits.

A patient like KJ raises many issues in the doctor-patient relationship. Patients come to us for much more than medical advice. If it was my medical expertise she sought, KJ would have stopped coming years ago. But over the years, she has developed a certain attachment to me, and I to her. The fact that she is difficult only endears her to me more.  

When do patients cross the line in a doctor visit? Now that I am doing mostly telemedicine, I don’t have to concern myself with KJ squatting next to me while I review her results. But wasn’t that a bit odd? Should I have put my foot down and said, “Stay on your side of the desk?” 

In my old, rented office, I would encourage patients to sit catty-corner to me rather than on the other side of the enormous man-sized desk. But in my own, more modest space, there simply is no room for another chair next to mine –– and so patients must face me across the desk, albeit a much smaller one. Still, only KJ has ever insisted on squatting next to me while I reviewed her results. 

This leads me to wonder: Under what circumstances do you fire a patient and when do you invite them back? I’m sure today, I would have handled KJ much differently. My self-confidence and poise as a physician have grown, and sensing this, KJ would never have attempted such antics. 

Nowadays, I restrict my practice to a select group of patients I really want to treat and feel sure I can help. With this in mind, I recently advised a patient with a nasty disposition to choose another physician from the list of certified practitioners for his condition. Unlike with KJ, I had only been seeing him for a short time, so I felt comfortable doing so.

Finally, those two words. Over the course of decades-long acquaintance, we do develop feelings for our patients. They become more than just patients, they become important figures in our lives. So much so it feels natural to use those affectionate words to end a visit. And so, I do — and I feel like a better doctor for it.

What do you do when you encounter "difficult" patients? Share your strategies in the comments below.

Marjorie Ordene, MD is an integrative physician practicing in Brooklyn, NY. Her essays, short stories, and poetry have been published in various magazines and anthologies including The Sun, Tablet, Lilith, and Michigan Avenue Review.  

All names and identifying information have been modified to protect patient privacy.

Illustration by Jennifer Bogartz

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