A Patient Encounter

 Another Patient Encounter

Last week at work I saw a man in his fifties who had come for pain in the elbow. He had a fall about 3 weeks back. That day he went to urgent care and had an xray. No bone was broken. He couldn’t take Motrin or similar group of drugs due to underlying kidney disease. Instead he was given Tylenol and suggested using a brace.

A week or more later the elbow remained painful and swollen so a referral was placed for physical therapy. 

The following week again he went to urgent care for the same problem. Physical therapy had not yet started. He went asking for MRI. That was denied. He was told that the MRI order needs to come from primary clinic. He was given stronger pain medication ( narcotics).

This was just two days before he came to see me. He wanted the MRI order. He was having a hard time believing nothing was broken when he continued to have so much pain and difficulty moving the elbow. 

Here’s the issue. His concern was a broken bone. Xray already proved that no bone was broken. An injured soft tissue such as muscle or tendon or ligament was a possibility but these can be often managed with conservative care. His physical therapy referral was part of the conservative care and he hadn’t even started it. 

He kept arguing with me for finding out what was going on and I went on reasoning with him. We already know from his symptoms that there is inflammation. The swelling, tenderness and pain were all symptoms of inflammation and treatment was directed to treat the inflammation. He was mixed up about the process ( inflammation) vs symptoms arising from the process. I went on clarifying with him. At most if physical therapy did not improve his range of motion and pain the next option would be a local steroid injection into the elbow. Again the aim was to treat underlying inflammatory process.

He was getting increasingly frustrated with me because I wasn’t ordering the MRI. He accused us doctors as trying to save money. Again I remained patient. I explained that even if we did the MRI it was not going to change the course of treatment. He would first need the conservative treatment before considering more invasive treatment. 

“ At least I will have peace of mind to know nothing is broken “! He said.

I said to him” peace of mind is not an indication for ordering MRI”.

He leaned back suddenly. My voice was firm yet not attacking him. It was a voice of reason and somewhere he sensed it. 

“ I misspoke. You are right. MRI can’t be for peace of mind”. 

He again had questions about inflammation, role of physical therapy, what is is expected to do, role of the medication given to him etc. I patiently answered his questions. 

In the end he agreed to take up my offer to refer him to see an orthopedic surgeon who could give him a steroid injection into the elbow if necessary.

I knew he would not be pleased because I had not caved in to his demands for the MRI. I just couldn’t. Reasoning didn’t allow me to order it. 

Just as I was getting ready to take leave of him, he surprised me. He extended his hand to me for a fist bump. A gesture of truce. As we did that he apologized to me for his “ offensive behavior and tone” earlier. And went on to acknowledge that after whatever I explained he was already feeling much better about his condition than he did when he had entered the room.

I had not seen this coming at all. Usually patients do not leave the room happy when their demands are not met. They go see another doctor and leave a complaint about how I did not help them. I have got so used to this routine that I really didn’t think this appointment would have any different outcome. 

The man was extremely difficult, argumentative and pushy. I had navigated through the pressure he was putting on me and held my ground. Yet somewhere reason and compassion won him over. I don’t know what to think of it. It certainly reinforced my faith in doing what is right for the patients, not what will please them. I am not paid to please them. Though I’m judged by how much I please them! I may never win in this competition when my fellow humans will be judges. But I never looked at my life as a competition. My judge sits higher up than me and my fellow humans. Whatever verdict comes from my judge is totally acceptable to me. I know it will be fair.