The basic premise of the physician-patient relationship is simple: Patients are ill and we want to make them better. But the true nature of the relationship is not so monochromatic. Patients and physicians can differ, either on what ails the patient or on what will make the patient better, and it can be challenging to navigate that divide.

One common source of conflict for me is test ordering. I tend to be somewhat conservative when it comes to ordering tests, but patients will often feel shortchanged if they are not subjected to needlesticks and radiation. One of the most common requests I get, being in New England, is for Lyme testing. Patients have gotten so sophisticated now that they expect a Western blot. “My primary care doc just refuses to order a Western blot for me,” one lady complained.

Settling on a mutually acceptable diagnosis can be tricky as well. Of course, “mutually acceptable” is not the issue: a patient either has a diagnosis or does not. But in order for the patient to accept your recommended therapy, they have to believe that you have the right diagnosis. And some diagnoses are hard to accept and even harder to prove than others. A few patients refuse to believe that they have rheumatoid arthritis, particularly if they test negative. And how many of your patients refuse to believe that they have fibromyalgia? How many insist that they have that catch-all, “autoimmune disease,” despite evidence to the contrary?

On the matter of treatment, there are disagreements, too. The most obvious example, and one of the biggest challenges, is narcotic prescription. Patients with chronic pain often rely on narcotics to feel better, but narcotic use is not recommended in such patients. Physicians and patients can expect to be in a perennial tension over who prevails.

Mental health issues are the most challenging for me. For example, I have a young patient who has a polysubstance use disorder and gets admitted repeatedly for alcohol-induced pancreatitis, yet refuses to get mental health therapy for it despite multiple inpatient psychiatric consultations exhorting her to do so. “It doesn’t do anything for me,” she says. She lies about everything, from medication compliance to where she gets medications to how much she drinks, yet I do not feel equipped to handle these problems.

If any of the above scenarios were board exam questions, choosing the proverbial next best step would be simple. But when does life really operate so neatly? The old paradigm of doctoring was that the physician rendered an opinion informed by his or her education. Today, our exam-room interactions often take the shape of a democracy, one in which an overworked, bandwidth-depleted physician might butt heads with a strong-willed patient, armed with all the wisdom of anecdotes and the Internet. If I were fresh out of med school, I might have had more energy to explain to you why you don’t need that Lyme test or that narcotic prescription. These days though, I find myself waving the white flag far more than I should.

Dr. Chan practices rheumatology in Pawtucket, R.I.


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