My Frustrations with Medicine 2 - Making the Patient Happy

For some inexplicable reason, the last two days have been extremely light, thus I write again much sooner than I anticipated. I want follow up my last post with a secondary frustration from a recent rotation.

I'd like share with you a story of an encounter I had with a patient, then explore its foundations. Of course with HIPAA being what it is I'll try to be as vague as possible, without blurring the fundamental point of the story. I stepped into the occupied patients room, introduced myself and started the interview portion of the encounter. To make a long story less long, the patient (who I will refer to as 'X') explains, tearfully, that she has gained so much weight recently she doesn't recognize herself and can't walk because her legs are so big and has never looked like this and doesn't eat breakfast or lunch and exercises 20 minutes every day and her daughter's wedding is in 4 months and she doesn't fit in her dress anymore and so on.... At this point, I am trully feeling sorry for her and empathizing as much as possible, but also slightly confused. Anyone who eats one meal a day and exercises everyday does not gain weight, unless there's a metabolic problem. Thus, I go down the hypothyroidism route. In conjunction with the weight gain she's constipated, cold all the time, and fatigued. In the setting of a 'normal' exam, I feel like I have a pretty strong case for hypothyroidism as a diagnosis - at the very least a reason to check a TSH. I mention this to her and say if her thyroid levels are low we can replace it. Then the interview turns sour. She says to me "there's nothing wrong with me, I just need a diet pill... give me a diet pill." I hedged. "If Dr. _____ won't give me a diet pill, I'll just go find another doctor. That's what you are here for, to help me, to give me what I need. How can you say your a doctor and not give someone what they need." I'm a little perturbed at this point. I assured her I (we) wanted to help, but also wanted to do what was best for her. Again she scolded me. So I challenged her a little (my frustration surfacing) about the exercise and find out she sits on her stationary bike and watches T.V. every morning, sometimes actually moving the pedals, but never sweating. Tiring of the tension between us and the energy to persistantly respond kindly, I exited to find the doc and report my findings.

After the doc and I are both in the room, X continues to insist she needs a diet pill today. "When I broke my foot years ago I couldn't do anything for 4-weeks and gained so much weight. I went to my doctor and he gave me a pill and all the weight came off." After going back and forth for a while there is no happy conclusion to be had. X insists on a diet pill she doesn't need and refuses to let us take blood to run basic labs.

So what would I do at this point? Peace out, cheerio, ciao! As a future doc, if my patient is not willing to work with me in their care and is simply using me to get a medication, I don't feel there is any reason to continue our relationship. I'm young, inexperienced, and jaded - heck, I'm not even a real doc yet - but I'm not going to prescribe a medication with a risk-benefit ratio far schewed to the former. That being said, what did happen? The doc prescribes Lasix, which is a diuretic! Are you kidding me?! Her exam was completely unremarkable - no fluid in the lungs, ascites, or edema in the extremities! No indication for a diurectic whatsover, but the patient left happy.

Here is an abridged list of the possible adverse effects of Lasix:
COMMON
Dermatologic: Photosensitivity, Pruritus, Rash, Urticaria
Endocrine metabolic: Electrolyte imbalance (14-60%), Hyperglycemia, Hyperuricemia (40%)
Gastrointestinal: Constipation, Diarrhea, Loss of appetite, Nausea and vomiting
Neurologic: Asthenia, Dizziness, Headache, Vertigo
Renal: Glycosuria
SERIOUS
Cardiovascular: Hypotension
Gastrointestinal: Pancreatitis
Hematologic: Hemolytic anemia, Thrombocytopenia

So I ask the question, how far should we go as docs to make the patient happy?


Two interesting articles from today's news:
http://www.healthday.com/Article.asp?AID=601105

http://news.aol.com/topnews/articles/_a/nicotine-increasing-in-cigarettes-study/20070118122009990001?cid=2194