The patient pauses, looks a little sheepish, and says, “Well, actually, I Googled my symptoms and it said this might all be gluten sensitivity. Do you think I might have gluten intolerance? Too much mercury in my fillings? My childhood vaccinations making me sick? Maybe just a highly chemically sensitive person?”
How best to handle this interaction depends on the kind of patient who is before you, and choosing the correct response is crucial in maintaining the alliance.
The scientist is highly educated, works as a professional in a technical but non-medical field, and knows that the medical literature is vast. She knows the difference between “google” and “google scholar” and has her references lined up.
Helping the scientist First, check your arrogance. The scientist is your ally, not your competition. Validate her experience and education, and ask that she continue to bring relevant literature to your attention for your review. Ask if she is familiar with the literature you favor and offer to send her some references. Use scientific terms, but be sure that she understands them the first time. Recognize that she is the one making important decisions about her life and deserves honesty, respect, and humility. Join her team and she will gladly follow.
He is moderately obsessive, probably has a few compulsions. He’s been in your office before with relatively minor complaints. He has difficulty moderating his anxiety and fear, and is especially afraid that he may make a fatal error. This fear is projected to you.
Reassuring the worrier Bring the anxiety into the room. Tell him, “I can see this is really scaring you. I wonder if you're afraid I might miss something important.” Tell him about the process of making an accurate diagnosis, and that we operate like pilots, using checklists and guidelines to be sure we don’t miss anything. Make an appointment for a follow-up visit, but invite the patient to cancel it if he is feeling well. Give him an assignment to bind his anxiety, like measuring and recording the diameter of his abscess, or checking his blood pressure at the same time every day.
This can be among the most distressing personalities to deal with. You will not cure this patient of his arrogance and getting into a competition will get you nowhere. Trust is difficult for narcissists – it makes no sense to them.
Pacifying the narcissist Acknowledge this distrust directly: “I can tell it's hard for you to rely on my expertise. Let’s just give it time and see if you start to trust me.” When the narcissist makes unreasonable demands, acknowledge the frustration of having to put up with the hassles of medical care but set firm limits, “All of our patients are given the same level of individual attention and care.”
The somatic patient
She feels her feelings in her body, but has no insight into the mind-body connection.
Reorienting the somaticizer Explain that in some African cultures, people get broken stomachs, not broken hearts. Somatic symptoms are highly culturally determined, so invite her to help you figure out what her body might be trying to tell her.
In my residency, I experienced cervical tension every time I was in supervision with a certain attending. She was a literal pain in the neck. My pain was real, but not an indication of any overt cervical pathology. Now whenever I have that same pain in the neck, I know that my childhood anxiety is getting stirred up, and I have an opportunity to deal with the true cause of the pain.
More frequent office visits can be beneficial because they can help amliorate her fears of abandonment.
The tramuatized patient
Medical procedures can be traumatizing, especially to children. Children imagine their skin as a balloon, and puncturing it with a needle, or worse yet – a scalpel – can be terrifying. Their insides will leak out, and that can’t be good! They have no concept of the limitations of our ability to feel pain. Pain to them has the potential to escalate exponentially to infinity and beyond, and they don’t particularly want to explore that dimension. Frightening medical trauma can leave permanent terror; even if the original trauma occurred at too young an age for a dear memory.
Validating the trauma survivor Ask. “Has anything especially frightening ever happened to you in a hospital or doctor’s office?” (This is a good question to ask every new patient.) If so, move slowly and explain everything. Explain not just what you are doing but also why it is necessary. Invite the patient to give you suggestions about how to make this easier for him. If the trauma occurred in very early childhood, he may be apologetic but also anxious and unable to trust. This is different from the narcissist who is unwilling to trust.
The paranoid patient
Paranoid disorders are disturbingly common. The paranoid patient is unable to trust, but is angry, not anxious. She feels victimized and exploited, and the medicopharmaceutical conspiracy is just one more group trying to deceive and injure her. She will not be shy about showing her hand and might even volunteer that she “knows” that doctors are shills for the drug companies and she won't be fooled.
Managing the paranoid My favorite exercise to assign medical students is to have them try to talk a paranoid patient out of their delusion. Spoiler alert – it can't be done.
These patients are highly litigious, so document well. Remember that people have a right to self determination, even if they are deluded, and document that you assess the patient to be competent to refuse medical care. Be straightforward about your diagnosis and treatment recommendations, and then let the patient decide the next steps. Don’t confront the delusions, but don’t entertain them either. Move the conversation along quickly.
Figuring out what is beneath your patients’ internet searches is key to becoming their ally. If they Google it, Grugle it!
Thomas Grugle, MD, is a private practice psychiatrist in Dallas. He is medical director of Texas Health Dallas Presbyterian Hospital psychiatry partial hospital and a clinical professor at UT Southwestern.
This article was originally published in the Dallas County Medical Society's Dallas Medical Journal.
Tex Med. 2019;115(7):30-31
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