Don't let patients step all over you

For the most part, my blog entries are patient-centered. I don't like it when patients do not get treated fairly and if I see something wrong in the health care system, I am going to point it out. But on the flip side, I also do not like when patients try to take advantage of the system. All health care providers know what I am referring to. How many times have you had a patient in your office who you suspected was not as disabled as he/she claimed, asked you to fill out disability paperwork, and you filled it out against your better judgment? What was the real reason why you filled it out? My theory is that some health care providers are afraid to confront patients. When I say "confront" I do not mean yell, scream, make fun of, etc. Confrontation can actually be done in a respectful way and can be used to save you and your patient a lot of unnecessary nonsense.

Let me give you a perfect example. Trust me, this is worth reading. I once evaluated a patient who suffered a mild head injury (possibly a concussion) about two and a half years prior to the evaluation date. The patient always worked in manual labor jobs and reported that several months after the injury that he suddenly developed pain and numbness in both hands. The patient was evaluated by multiple physicians and the most anyone could conclude is that there was a mild cervical strain. No explanation for the hand symptoms though. For years, very physician stated he was disabled and it wasn't until very recently when one said he could go back to work without restrictions. However, others still stated he had some level of disability.

So the guy comes into my office and was very nice. On several self-report scale measures, however, the level of reported symptoms he described was much higher than groups of patients who had suffered much more severe injuries. His workers compensation benefits had been terminated and he was appealing the decision at the time I evaluated him. He was also working with an agency that was trying to get him back to work but every time they tried to help and put him through some work trials, he suddenly became too symptomatic to continue.

My job involves the administration of many objective tests to assess brain functioning but I also like to employ some non-standardized tests as well. The use of such tests can tell you a great deal amount a patient and they were popularized by the famous Russian neurologist, Alexander Luria. One test I like to use is called the pen test. In patient's who are paralyzed on one side of the body, have severe neurological damage in a part of the frontal lobes, or who have significant damage to the hand, the patient will not be able to grip the pen. It will slip out very easily. In just about any other patient, however, there is no way the pen is coming out. Even a five-year-old can grip a pen strongly enough that pulling it out will be very difficult without using significant force. So when I get a person who isn't paralyzed, doesn't have severe frontal lobe damage, and does not have something significantly wrong with the hands that can't hold on to the pen, I know the patient is not trying. Also, it is very easy to detect this while doing the test, because the examiner can feel that the patient is not gripping the pen as strongly as possible.

The first day I saw the patient, the pen came out of BOTH hands extremely easily. "Are you trying your best?" I asked. He said he was. I told him to try again and to imagine that I would give him a million dollars if I could not get the pen out. Same result. I could feel that he was not trying. So he came back for a second visit and we repeated the test. The same exact thing happened over and over and he kept saying he was trying his best.

So when testing was over, I pointed out to him how there were several times on testing where he told me he was trying his best but then when I asked him to try harder that he did much better, even though he originally said he was trying his best. I showed him concrete examples of this by showing him the test results. And then I said, "You know, I am not a physician, but I have done this pen test enough times that I know you were not squeezing the pen your hardest." The patient looked back at me as if I caught him with his hand in the cookie jar. And then I had an idea. I didn't think it would work, but if it did, I knew I would have invaluable information. I said to him, "So let's try this again shall we?" So I walked over to him again, put the pen in his hand, and for each side, I COULD NOT GET THE PEN OUT OF HIS HAND, that's how strong the grip was.

This is a perfect example of how respectful confrontation can be helpful. It helped point out to the patient and all his providers that he can do much more than he says he can and that people need to give this guy a motivational push to get him going. He was quite depressed and that was likely contributing to this motivational problem and highlighted the need to treat the depression. Two and half years of being essentially non-responsive to physical therapy and chiropractic care yet no treatment for depression before I see him. Go figure. So we have now identified why treatment of depression is so important and hopefully can get him back to work one day based on the results of the evaluation. The moral of the story: Don't be afraid to confront patients. If done in the right way, it can helpful to everyone involved. Incidentally, this approach will only work if you have a good bedside manner and have established a rapport. Doing so will increases the chances that the patient listens to what you have to say.