MRI's demanded

Seeing Kimberly’s name on the schedule brings tightness to my chest.  I know it’s going to be a confrontational, tense appointment.  Kimberly just called two days ago.  She has pain in 7 different body areas, and she wants MRI’s ordered on all of them.  She does not see why she should have to come in for this, as she is too busy, and frankly the co-pay is not worth it.  My message through the nurse: you must come in if you want to be evaluated for these problems.

 

I open the door.  Kimberly is smartly dressed, all business.  She has a page long list of her symptoms, and further questions.  She has pain in her shoulder, back, neck, abdomen, left side of her head, knee and wrists.  When asked to focus in on the main, or most pressing problem, she states, “All of them are equally important”.   When asked to go through the history of the complaints, she rolls her eyes, as if to say, “Here we go with this game again.”  I spend about 15 minutes going through her history.  In addition I notice that her blood pressure is quite high.  “Are you taking your blood pressure medication?” I ask.  Yes, but she changed it back to an old medication, and she really doesn’t believe it is that high.

 

Getting back to her physical exam, I examine each of the areas she is concerned about.  Although she has 10 – 15 minutes scheduled, I know there is no way this is going to take less than 30 minutes.  It’s better to put the time in now, I say to myself.  Her physical exam is really rather unremarkable.  It would be hard to list a single significant physical finding.   Once again I share with her my impression from my physical exam.  As I do so, I see her body language of defiance.   I ask her, “Do you believe anything I am telling you?”  “No,” is her reply.

 

Now is when I am going to have to be very direct and lay it on the line.  “Kimberly,  I believe that there can be a physician-patient relationship unless there is trust, and unless you are willing to follow my recommendations, or at least to discuss and manage our areas of disagreement.  But we have none of those.   There is no trust here and I am not willing to order tests just because you demand them.  I am not willing to continue as your doctor.   “That’s fine”, she responds, “ I was going to switch to another doctor if you did not order those tests.”  

 

I am relieved that I have been able to deal directly with Kimberly’s demands  and have been able to tell her what I am willing to do, and, in her case, not willing to do.  It is so easy for physicians to become burned out when they do not tell their truth about unreasonable expectations or demands.  In my early years of practice, I could not have dealt with Kimberly as directly, and I would carry around the stress, feel guilt and anger that would seep out on other innocent people.