My patient Mrs. X is a composite, but if you practice primary care, you will recognize her immediately. This 72-year-old woman comes in for a problem visit to discuss right thumb pain. She has had mild discomfort at the right metacarpophalangeal joint, especially when she bends it, for about three days. She has been applying arnica cream without relief. Also — I steel myself, as I know what’s coming — her back hurts all over. She has occasional “zings” of pain in her right temple. Her digestion is bad. She worries about her Hemoglobin A1C of 9.2, but is “scared” of prescription medications so she wants to “try harder” with her diet. She still has that chronic cough but did not get the chest X-ray I ordered because “isn’t radiation bad for you?” Did she mention that her back hurts all over? She still does not want physical therapy. Then, as usual, we move on to her poodles. Her one dog didn’t eat much last week, but his appetite is picking up now. He even swiped a cheesecake off the kitchen counter when her back was turned! That naughty puppy! We spend a lot of time, always, talking about her poodles.
My scribe shuffles uncomfortably in her chair as, finally, the conversation circles back to Mrs. X’s thumb pain. I palpate the joint. Likely mild osteoarthritis. I gently suggest icing the area. “Oh no, won’t that burn?” I suggest acetaminophen. “I can’t take Tylenol! It knocks me out for days!” Time to wrap this up. I ask, “What do you think would be best?” Mrs X sighs, “I guess I’ll keep using my arnica cream. I think another few days should do the trick.” I nod my assent and ask about her granddaughter. She cheerfully chatters about a recent piano recital and gives me a hug before she leaves. “Thanks, Doc. You always know just what to do!”
My scribe shakes her head as the patient retreats down the hallway. “Wow, that was a waste of everyone’s time,” she says. I used to think the same about my "Accepts No Advice” patients, but now I realize I was wrong.
It took me several years of medical practice to understand why a patient would reject any prescription, diagnostic test, or treatment that I recommended, but would keep coming back to see me.
I have had many patients like Mrs X. through the years, young and old, educated and not. Some harbor a deep distrust of the health care system and only want herbs and natural treatments. Many are deeply anxious and obsess over minor aches or quirks in their bodily functions that other people would hardly notice. Some have had medical traumas in their life (a missed diagnosis, a severe illness) and are terrified of a repeat experience. Unfortunately, these patients are often retraumatized by medical practitioners who don’t acknowledge their concerns and autonomy. I have received consult notes that exude despair, anger, or that even “fire” the patient because they won’t adhere to the specialist’s directives.
It is hard when a patient won’t take our “excellent” medical advice. But we need to check our egos and provide what this particular person needs.
What can we offer a patient who wants nothing?
These patients come in to be seen and heard. They want to be affirmed as a full person, not a body part with a problem to be solved. (Don’t we all?) Often they feel relief just from cataloging their concerns. Especially as patients age, they know that many symptoms may be inevitable, but they want their problems to be acknowledged.
The beauty of primary care is that we’re there with our patients for the long haul. I tend to spend visits with my “Accepts No Advice” patients discussing their pets, family, hobbies. These are often my most enjoyable encounters of the day. But it's not just chit-chat. It’s about developing trust. Asking the patient, “What do you want to do?” is powerful and affirming. Over months and years, we often make slow progress toward goals. Maybe they will finally try some physical therapy for the back pain, or accept a low dose of metformin for the diabetes. If a truly alarming symptom occurs, hopefully I will have earned the trust so that the patient will work with me to develop a plan we can both feel comfortable with.
Often, these are some of the patients who I get to know the best and who ultimately have the strongest loyalty to me as a doctor. Some of them are among my favorite patients, and favorite people. After all, whose day wouldn’t be brightened by a funny poodle story?
Do you have a favorite patient who refuses your advice? Have you ever been that patient yourself?
Melissa Schiffman, MD is a community-based primary care physician who practices in Suburban Philadelphia. She enjoys books, birds, gardens, and word nerdery. Her favorite medical term is "borborygmi." Find her on Twitter at: @MSchiffmanMD. Dr. Schiffman is a 2022–2023 Doximity Op-Med Fellow.
Image by Alphavector / Shutterstock