"Beware of the Hateful Patient"

One of the more curious lectures we ever received in medical school was by a retired family doctor whose job was to interject some real-life medicine into our mind-numbing freshman syllabus. One day he started his talk with these words: "Beware of the hateful patient." As he said this he paused for dramatic effect while we raised our eyebrows or shifted nervously in our seats, all too ready to get back to our cadavers.

"The hateful patient?" we thought. "Oh, great. Now we have to worry about getting chewed out by people that are both sick and angry. What a bunch of ungrateful jerks they must be."

The white-haired speaker tilted his head knowingly and continued:

"The hateful patient can ruin your ability to practice good medicine and cannot be ignored. Whenever you meet him or her you must be brave and honest, and overcome the hatred no matter what it takes. Your future depends on this."

Some of us grinned at this Yoda-like advice, but with his next breath he stilled the classroom:

"Who is this person, you ask? 'The Hateful Patient' is not a patient who hates you - it is a patient that you hate."

I was skeptical of his remarks that day and could not imagine that I would ever harbor animosity toward the very people I was devoting my career to. I was wrong. After many years in practice I understand completely what he meant. All doctors who hold themselves out to the public will acquire certain patients who annoy them or even master the art of driving them perfectly bonkers. Such patient behavior is always tolerable at first but soon it becomes tiresome and the temptation to lash back or become passive-aggressive grows. Soon our good judgment itself is at risk of being poisoned by the grudge festering within. Woe to those physicians who weaken and embrace the Dark Side! (Ahem - that's Star Wars talk). My old professor was right - doctors must always retain control of their emotions, especially with patients. After an unpleasant encounter with a patient, those physicians who let anger or resentment take over the reins of their character run the risk of alienating virtues such as equanimity and empathy, that prevent them from driving the stagecoach over the cliff.

How then do we begin to cope with the hateful patient? I have my own method, but rather than discuss this today I would prefer to finish our fireside chat with a list of what I consider to be warning signs that the person whom you are attempting to care for is likely to upset you. By recognizing certain types of patients or personality traits hopefully we can all become better prepared to manage both the illness and the unfortunate soul who is afflicted with it. The signs are:

1. Displaying psychological defense mechanisms, which for some reason easily offend doctors. Examples include denial, projection and displacement. It goes without saying that the first thing oncologists learn to do in practice is to finesse the "kill the messenger" reaction of some patients or families.

2. Preexisting psychiatric illness (no surprise there - anytime we see the words "schizophrenia" or "bipolar disorder" appear in the past medical history we go on the qui vive). Depression, too, is more common than we doctors realize.

3. Rejection of traditional medical treatment and/or insistance on 'alternative' (often unproven) therapies.

4. The "Concierge" Patient, whose incessant demands make The Rolling Stones' backstage contract rider look like a request for spare change.

The science of medicine is as dense as it is vast, but with enough ambition, diligence and time it can be gathered and stored carefully for future use. Learning the art of medicine is much more bewildering, almost to the point of being ineffable. Physicians who possess this gift have not studied as much as have been taught, by masters who learned long ago how to find their own eightfold path to happiness - and to excellence.

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believe it or not, this was incredibly relevant and helpful to my job as an IT help desk technician. ;) Appreciate it!

By speedwell (not verified) on 18 Sep 2006 #permalink

Wow, great post as usual. I am a cancer patient who has a semi-conscious fear that my oncologist hates me (there must be a psychological term for this syndrome). It seems that I'm allocated about 15 minutes of quality time, after which an invisible clock runs out and he seems mildly annoyed by my questions and makes a hasty exit. Of course, I do a lot of research and tend to want to discuss studies that I think are relevant to my case. That must drive doctors bonkers. But, shouldn't he be willing to discuss options with a patient in treatment (retorical question)?

I have bipolar type II disorder (the one where depression is more is more noticeable); I've been helped quite a lot by taking Lamictal.

I've hesitated telling doctors about my condition, exactly for the reasons stated by the doctor above, i.e., concerns that I won't be given the same level of care as other patients receive. So far I haven't hid this information, though I have felt 2-3 specialists I've seen didn't care to hear it. Interestingly, it's easy to tell when a doctor is prejudiced against someone with a history of depression. They come off as ill-at-ease and rush through the appointment, as opposed to doctors who don't have these issues.

Still, I would think that a doctor would rather know this information, than treat a patient who denies that they have ever had any emotional/mental problems. My former sister-in-law is one of these individuals (diagnosed by a psychiatrist with depression, but refused treatment). Considering that her father and two brothers are doctors, it's easy to see why she feels such a stigma against seeking help. And no specialist that she sees will ever know about her history, because she keeps it hidden.

Just as the doctor above doesn't care to treat patients with any form of depression, I myself dread seeing a new doctor, since I never can tell which side of the spectrum they will be on with respect to this issue. Though oddly enough, the three times that I've had to go to see general surgeons for evaluations of suspicious lumps, I felt that they treated me respectfully and didn't have any problems with my medical history.

My PCP said that I was depressed after my cancer treatment. The psychologist that I was seeing on my PCP's recommendation said that I wasn't depressed, I was grieving. My Oncologist said that it is common for his patients to become depressed but he felt that what my PCP was noticing was the low energy that the fatigue of cancer treatment caused. Whatever it is or was, I feel that I am entitled to feel the way I feel and not have to jump through hoops to feel and think the way that makes others like me. Frankly if you don't like me the way I am, you aren't going to like me if I pretend to be what you are demanding of me. Tomorrow I'm going to go see a doctor whom I don't care too much for and I think the feeling is mutual. In December when I can get an appointment with another doctor in the same field then I will ditch him, and we both will probably be happier for it. The nice thing about living in a medical hub is that there is always another good doctor down the road.

I appreciate all your comments. My point in writing about this topic, though, is not to insist that patients conform to some pre-defined rules of engagement or otherwise lose the privilege of being cared for by their doctor. On the contrary, it is the doctor who must adapt his behavior to conform with the uniqueness of his patient's personality.

To put it plainly: whether patients are hostile, or manic, or neurotic, or demanding, or haven't left the house since 1959 (true story, by the way), it isn't their problem: it's the doctor's. Patients are patients because they are sick, and any doctor who takes pride in his work had better learn how to serve them with a smile or find another line of work.

Sometimes I feel wonderful and sometimes i feel very sad and depressed but NEVER will i have it checked out by a DR. cause i don't want to be told im bipolar or something so i pretend everything is wonderful. Even when i was robbed at gun point i was asked if i wanted to go see a shrink but i refused. I've had suicidal thoughts once in a while and specially if im PMS(y)and since i was a teenager so now i just take some tylenol and feel sooo much better. YAY ME!!!!

Sometimes I feel wonderful and sometimes i feel very sad and depressed but NEVER will i have it checked out by a DR. cause i don't want to be told im bipolar or something so i pretend everything is wonderful. Even when i was robbed at gun point i was asked if i wanted to go see a shrink but i refused. I've had suicidal thoughts once in a while and specially if im PMS(y)and since i was a teenager so now i just take some tylenol and feel sooo much better. YAY ME!!!!

Just to play Devil's advocate...

Could a doctor herself be using projection when a patient described by the medical profession as "hateful" creates - through that patient's odd or annoying traits and personality - an emotion of "hate" within the doctor?

By John J. Coupal (not verified) on 20 Sep 2006 #permalink

You perspective is well taken, and I do agree with you to a point. On the other hand I feel it is my responsibility and in my best interest to try to create a congenial and respectful relationship with my caregivers. Sometimes that doesn't happen because of predjudices in me. I dislike my plastic surgeon and despise his staff, but I do my best to be pleasant when I see him because he's a damn good surgeon (my gynocologist had to ask me which one is the reconstructed breast). But then there are doctors in the area, like the one I saw yesterday, where there just isn't much in the relationship to salvage. So moving on is the best thing to do. The point that I failed horribly to make in my previous note is the feeling is mutual from the patients perspective also. One thing to note is that I always get neurotic when I have to see my oncologist because I'm always afraid that its going to be the visit where he tells me I have cancer again. If he thinks I'm the hateful patient he hides it well.

Oh the book I could write. I am not convinced my physicians hate me. I think I might drive some of them nuts. I tell them the appropriate treatment. I did the research and gave them reasons. They could not disagree. Two oncologists-tried to give me an aromatase inhibitor. Wrong med for a 40 yr old pre menopausal woman who has had osteopenia and family history of osteoporosis. After side effects, one dr decided I should change meds, no, lupron does not sound like much fun and I really like my bone density. The comment was, "Well you have to take something!" OK, I hate my current med but its all we have. 2.5 more years of us battling.

The funniest thing to me is both oncologist were convinced I would be postmenopausal after chemo. Even so, I would have chosen Tamoxifen given my family and personal history.

It just seemed like my really young oncologist did not truly enjoy a patient who researched and came in to his office completely informed. I do know if the unthinkable ever occurs, I need to get out of here, they can't handle a stage IV-at least not positively.

When I first met my Oncologist, I wanted to slug her. She had the nerve to tell me that I had 15 positive lymph nodes. Now, I love her. No one ever tells you, but on top of all the horrible physical consequences, cancer can also make you bonkers.

Did you ever see the New Yorker cartoon-- a Dr. is sitting across a desk from the patient, who says 'You made that diagnosis just to be mean'.

I hope I won't be in my doctor's list as 'hateful patient'.

On the contrary, it is the doctor who must adapt his behavior to conform with the uniqueness of his patient's personality.

I hope all doctors think this way. Great post. Thanks. C.O.

Great post. I had a rough time establishing a good relationship with my neurologist - I was sure he hated me. At one point, when I talked to one of his staff about it, she said he was very very shy. Possibly she spoke to him about things. After the next visit we were on a much better footing - but that was the visit when he started botox treatments for my migraines, which actually did me some good. The improvement in the relationship coincided with his ability to alleviate some of my pain. Are "hateful patients" sometimes the ones that doctors cannot cure or help?

I think patients with chronic pain/chronic illness may be particularly susceptible to falling into a doctor's hateful category.