Rule 191: If there are difficult patients, then there are difficult physicians

A case study of the doctor-patient relationship, starring Elaine Benes

If I were to ask you “what is the greatest sitcom of all-time?” what would you say? The Office? Friends? Leave it to Beaver? No no, dear reader, all are good answers (some are better than others) but there is, objectively, only one correct answer.

And that is Seinfeld.

In its eighth season, the greatest sitcom known to man aired an episode with Elaine attempting to gain medical treatment for a rash on her arm. In her pursuit for relief, she also tries to persuade her doctor(s) that she’s not a “difficult” patient. It’s a pursuit that leads her to see multiple physicians, albeit to no avail. Below are some clips from the episode…

If you didn’t watch or can’t watch the video, here’s a quick recap:

At her first appointment, Elaine peeks into her medical chart (the 90’s had paper charts) and sees that someone had characterized her as difficult. The doctor walks in and placates Elaine by “erasing” it. However, Elaine points out that it was written in pen and is, therefore, unerasable…

Oops.

The doctor’s demeanor changes. Annoyed, he scribbles something else in her chart, states she’ll be fine, and walks out. Elaine finds no relief, but remains undeterred as she tries again with a different doctor. At the beginning of this appointment, he opens her paper chart, which he received from her previous doctor, and sees it states that she’s difficult. In response, he takes a quick glance at the rash, says she’ll be fine, and attempts to flee the examination room. Elaine protests, saying that the rash is “really itchy,” but the doctor, becoming annoyed, takes a pen from his jacket pocket and jots down yet another something-or-other into her medical chart.

No relief!

The woes continue as Elaine resorts to employing Kramer, of all people, in a scheme to steal her medical chart; a scheme that ultimately fails. The episode culminates with Elaine, Kramer, and Uncle Leo sitting in the office of a rural doctor (for reasons that are too complicated to get into here - just watch the episode). As they are waiting, the doctor takes a phone call… can you guess who’s on the line? Elaine’s previous physician warning him about her “difficult-ness.”

Still no relief!! And yet, the question must be asked - is Elaine difficult?

Maybe… Probably… Jerry and the gang seem to think so. However, it’s important to note here that, no matter if a patient is difficult or not, they are still entitled to complete and effective medical care. This is something the cavalcade of physicians repeatedly failed to provide; to the audience’s amusement but to Elaine’s continued misery.

So what does she do that’s considered difficult?

She looks inside her medical chart, which ironically is something now commonplace with the advent of electronic medical records. After seeing what was written, she felt the need to defend herself and so she did! However, the doctor’s response to her defense forces fulfillment of her documented difficult-ness.

Let me explain.

As the episode unfolds, Elaine goes to greater and greater lengths to (A) achieve relief from incessant itch and (B) change her medical chart from difficult to not-difficult. This crescendo of questionable behavior is indicative of Elaine’s desperation. It’s a desperation related to the burdensome nature of her rash and that’s borne out of her doctors’ obstinate behavior. Put differently - her doctors’ behavior created an environment that made it impossible for Elaine to be anything other than difficult.

And that, I would say, is a truer example of being “difficult.” It’s self-fulfilling prophecy of the worst order… or patient-fulfilling prophecy, I suppose.

Gentleness and Positive Interaction

This interaction gives important insight into the doctor-patient dynamic, namely that it’s defined by its unequal nature. Physicians see people at their lowest points. Physicians have knowledge to which the public is generally not privy. Patients generally go to the doctor not out of a cheerful desire, but because of an urgent need - just look at Elaine.

It’s that urgency coupled with a lack of agency that make it easy for people to act in ways that are perceived as difficult. However, the doctor’s role is to see through it, to see through the anger and wrath, desperation and frustration, anxiety and despondency, and see the behavior for what it truly is: clear evidence of someone in need of help.

So what do you do when your patient is angry, frustrated, filled with wrath and taking it out on you? First, you must recognize that it’s not directed at you personally and it’s not your fault (unless you messed up and it is actually your fault, then you must take your lumps). Second, understand that positive interaction with your patients is paramount for effective care. This is because clear communication is KEY and positive communication is CLEAR. Then the question becomes - how to create positive interaction?

The answer lies in some imagery. Picture a hill: blue skies and green grass.

• You’re at the bottom of the hill. The bottom of the hill is peaceful, tranquil, and joyful. It represents gentleness.

• You look and see someone at the top of the hill. The top of the hill is harsh, caustic, and spiteful. It represents wrath.

• The higher you go up the hill, the angrier and more toxic you communicate.

Got it in your mind? Ok… now let’s say your goal is to get the other person to the bottom of the hill - to a more positive state - how do you do it?

I suppose you could walk up the hill, getting angrier and angrier and angrier as you ascend, and then attempt to force them down. In a way, you try and out-anger them “for their own good.” Or, you could stay at the bottom of the hill, staying in a realm of gentleness, and coax them down. In a word, it’s the difference between pushing and pulling.

Continuing to use the hill as a metaphor - if you seek to push someone, then you must meet them at the top of the hill in their frustration and force them down the hill, to the place you deem better because you say so. But… this never happens. Instead, you end up getting vacuumed into wrath, unable to discern up from down. The result is multiplied anger, frustration, and time lost.

The better way is to pull, or attract. These are the benefits of the gentle approach. First, you protect yourself from the swirling vortex comprised of “negative” emotions. Second, gentleness is an antidote to wrath. Instead of using fire to smolder, burn, and rage, the gentle approach builds a warm and inviting campfire.

Side note: gentleness does not mean you are a pushover or that you have no backbone, but rather refers to your tone, demeanor, and intent.

Finally, it’s important to note that your patient probably won’t join you at the bottom of the hill - BUT - if they are able to expel even a teaspoon of frustration, then their experience and outcome will be that much better.

What’s great is that this principle is applicable outside of the doctor-patient relationship. Parent-to-child, boss-to-employee, person-to-person… everyone can benefit from refusing to walk up that hill.

To end, I think it’s fitting to quote Dr. Meador, from whom the “if difficult patients, then difficult docs” rule was created. He elaborates on it, saying that doctors and patients “are of the same species, believe it or not.”

I believe it.