I’m fond of telling patients that “no reasonable request is ever refused.” Although that makes me sound very magnanimous, the problem is that so many requests are unreasonable.
Dr. Larry Greenbaum
Unreasonable requests, like unreasonable expectations, are ubiquitous. This genre includes requests from patients who expect to get better without taking medication as well as those who think that medication is a substitute for a healthy lifestyle. Then there are patients who expect perfect results from their medications, without side effects. Some particularly unreasonable patients expect perfection from their doctors. Many patients expect an unlimited supply of analgesics or anxiolytics. In the information age, some patients think they should be able to contact the office by phone or e-mail and have all their problems solved by remote control without ever stepping foot into my beautiful waiting room. Many patients want to be seen frequently, while some patients want never to come back.
One memorable patient said, “I just want to get my refills and get the hell out of here.”
Spotting an unreasonable request is easy, but breaking the news to a relief-seeking patient – and avoiding hard feelings when doing so – is much trickier. These unreasonable requests and unrealistic expectations put a lot of mileage on a doctor. Consider the following case:
I recently saw an intelligent 60-year-old woman with osteoarthritis who wanted me to prescribe prednisone for her. She’s used this medication for sinus problems, and it always helps her arthritis as well. Treatment with nonsteroidal anti-inflammatory drugs and/or analgesics was either not effective or not tolerated.
My first line of bargaining in this sort of situation is to review the long list of corticosteroid side effects. This medication can cause osteoporosis, cataract formation, weight gain, facial swelling, thin skin, easy bruising, and atherosclerosis. Patients frequently change their mind about prednisone even before I’ve finished rattling off this list of side effects. Sometimes, just for good measure, I also mention irritability, anxiety, depression, and insomnia. The dire menu usually cools the ardor of patients who imagine that prednisone will be the panacea for their woes. Unfortunately for me, this woman wasn’t the least bit impressed or deterred by my opening salvo.
“I know all that,” she reassured me, explaining that she felt she had no quality of life. It’s tough to make a convincing comeback when patients feel their quality of life is being impaired by the doctor’s intransigence.
Undoubtedly, I was right, but it bothered me that I wasn’t able to persuade this very determined and intelligent patient. To make matters worse, she wept. I politely offered her a tissue, and although my behavior was courteous, I doubt it was interpreted as compassionate. After so many years of handing out tissues to the tearful and frustrated masses that populate a rheumatology practice, the gesture of giving out tissues has become a bit cold and clinical, not a whole lot different from handing over an emesis basin. The patient was accompanied by a home health aid who observed the proceedings with a mixture of discomfort and detachment.
The visit dragged on. As fate would have it, she was the last patient of the day, and I was tired. Nagging doubts started to erode my resolution. Although textbooks never suggest oral corticosteroids for OA, I assumed they explicitly forbade them. But I was frustrated when I opened some books and didn’t find the explicit injunction that I had expected to read.
I couldn’t argue that steroids are never indicated or used for OA, since “cortisone injections” of painful joints are a mainstay of clinical practice. If a large local dose is acceptable, why not use a low oral dose on a chronic basis? I certainly wasn’t thrilled about the prospects for weight gain and osteoporosis; these side effects only contribute to additional symptoms and problems for many patients. In some clinical situations, I tell patients that the benefits of prednisone are uncertain, but the side effects are a certainty. In the face of this woman’s insistence and despite all my misgivings about side effects, I felt unsure whether there was an ironclad rule to not use corticosteroids. Are there exceptions for exceptional patients? If a patient wears out a tired rheumatologist with her perseverance and complaints, does that make her an exception?
Furthermore, I mused, the distinction between OA and other diseases seems a bit artificial. Treatment with chronic low-dose prednisone is common in patients with rheumatoid arthritis, polymyalgia rheumatica, systemic lupus erythematosus, and other rheumatic diseases. Of course, we always aim for the smallest possible dose for the shortest duration of time, but we certainly don’t categorically deny our RA or PMR patients the relief of chronic low-dose prednisone.