September 23, 2010
Dan Tennenhouse, MD, JD, FCLM
What types of patients are we talking about?
- Patients who are a danger to others, including drunk drivers and perpetrators of violent crimes.
- Patients who deliberately place themselves in situations where harm is likely – for example, a battered spouse who keeps returning to the same domestic situation.
- Patients injured by their own immature actions – racing motorcycles on city streets, for example.
- Substance abusers.
- Non-compliant patients who don’t bother to follow their doctors’ advice to change their behavior, including chronic smokers and overeaters.
- Hypochondriacs and other patients whose neuroses make treatment time-consuming and futile.
- Patients who demand specific care after reading about some disease on the Internet, and then require extensive explanation to convince them they don’t have the disease.
- Patients with an extremely assertive spouse or parent who demands specific but unnecessary care.
- Patients who exaggerate minor symptoms and expect physicians to react with great concern.
- Patients who exaggerate symptoms for secondary gain, including pain-killer abusers and serial litigants.
- Patients who show general lack of confidence in physicians or medical science. This category includes patients who see chiropractors and those who recite stories about others who (in their view) received improper medical treatment.
- Patients who have a concurrent psychiatric disorder that interferes with treatment of their physical disorder. (Many non-psychiatrists are suspicious or intolerant of psychiatric symptoms.)
When treating unsavory or difficult patients, doctors may find it impossible to be objective. They might spend less time on diagnosis, treatment, and communication with the patient. They could try to minimize the number of patient visits and telephone calls. And ultimately, they may not be very kind to the patient in the medical records.
Difficult patients may be characterized in a negative light by their own doctors as well as expert witnesses. The doctors seldom reveal their prejudice initially. As a result, you may not recognize the bias until the doctor writes a report or testifies.
If you encounter one of these patients in litigation, assume the worst and try to “detoxify” the patient when you first approach the treating doctor or expert witness. This means acknowledging how unsavory the patient may be, and asking the doctor to try to be clinical, objective and fair anyway.
If you’re on the other side, expect the doctor to be biased – and play it for all it’s worth.
For a more detailed discussion of this subject, see Attorneys Medical Deskbook, 4th, § 27. 17.
Dan Tennenhouse, MD, JD, FCLM, is a graduate of the University of Michigan School of Medicine and the University of California Hastings College of the Law. He teaches legal medicine at the University of California San Francisco School of Medicine and practices as a medical legal consultant for attorneys. Dr. Tennenhouse is the author of Attorneys Medical Deskbook, now in its fourth edition.