Condescending

for the umpteenth time today, I walk into the exam room to a patient who arrived for an acute appointment.

(again this could be any of my patients, male or female, old or young, one who comes in by themselves or with a whole family group.)

“I know my body,” she says. “I have had this sinus infection for weeks and I just need an antibiotic.”

She won’t answer my questions and doesn’t take me seriously when I ask her what over the counter meds she’s tried. “You know, everything. You name it, I’ve tried it.”

Neti pot?  “No, I’m not putting anything up my nose.”

Humidifier? “no, we don’t have one, and I’m not getting one.”

Menthol, vapor rubs? “No, they stink and make me break out.”

Then she adds, “oh, I’ve had a fever. I got hot, sweaty, flush.”

I ask her what her temp was.
“I don’t know, I didn’t take it.”

I explain that a fever is a temp greater than 100.9 degrees F.

“It was at least that,” she says, shooting me a look that screams “don’t mess with me.”

I look in her ears, mouth, nose. I listen to her heart and lungs, poke on her belly and look for any rashes.

“I don’t know why you have to do that when the problem is in my sinuses,” she says, after nearly every point in my exam. “I just need antibiotics. Why don’t you people listen to me?” She puts the neck of her expensive turtleneck sweater back up with flourish and huffs as I pull it up to examine her abdomen. When I’m done she sits up, immediately putting on her jacket and standing up to check her makeup in the mirror.

I look over her medication list, updating it as we talk. She swears up and down that she always gets antibiotics from us, but I only seen one in the last two years, despite her claim that she’s had seven sinus infections in the last year.  I calmly explain that antibiotics are not the best way to treat a sinus infection, and that she will likely get better on her own faster then she will with un’needed medication.

She sighs a very deep sigh, and then starts in on a tirade about how long this has been going on (the magic term is “a month” as she’s probably heard before that she can’t get abx without having symptoms for 4+ weeks), how nothing else will work, how she can’t ever see “her” doctor and when she was seen at a different office they would just send abx to the pharmacy when she called.
I’d really like to ask her why she left that office, if she always seemed to get what she wanted.

I explain what she should do to prevent bloody noses; I don’t tell her that I saw evidence that she’s been picking her nose, but instead dance around that point and let her know that another bleed is likely at some point today. She denies that she’d ever put *anything* in her nose, as she’s “not that kind of person.”

I encourage her to put boiling water in a bowl,  lean over it with a towel on her head to help  open things up.

“But you’re going to give an antibiotic, right? I came here for an antibiotic.”

I then tell her that the best thing she could do would be to use a nasal spray, as it will get to work right where it needs to go, and will help things clear up faster.

“I’ve tried them in the past and they don’t work. I’m not using that stuff, it’s messy and just gets on everything.”

I take a deep breath, look away and start typing in the computer.

“I need amoxicillian because that’s what I had last time, and it worked great.”

I look back at her and say that it isn’t the best choice and that if she had that recently it’s a sign that it didn’t work.

“Oh it worked, this just came back.”

I enter another medication into the computer, and also send a script for a nasal spray to the pharmacy.

She has a new bounce in her step as she leaves the room as she pulls out her cell phone, dialing a number as she walks away from me. She then adds,  “I know my body. I know what I need. If you had just listened to me in the first place we wouldn’t have had to go through all that.”

(Where is the line between good medicine and keeping the patient happy? and why does that line change with every patient I see? )