Cure sometimes, relieve often, care always!

Doctors sometimes have patients who are 'difficult'. When a person comes to me for treatment, they are often not in the best frame of mind. Some of them are in distress, some are unhappy, some are suffering in pain. Some of the patients do not have the luxury of being in their best behaviour when they come to me. Therefore, patience, understanding and empathy are always taught as core values in the practice of medicine. One category of the 'difficult' patient is someone who is not in their best frame of mind and so the clinical encounter becomes terse. Another category is patients who come with some preconceived notions about their illness, often misinformed by wrong information, and find it challenging to accept an alternate explanation. This blog is about a third category namely, patients with 'wicked problems'. 

A wicked problem is defined as a problem that is almost impossible to solve because of contradicting knowledge related to the problem, complex interplay of medical, social and cultural factors, or unrealistic solutions that are not feasible. This blog is about one such 'difficult' patients whom I am treating. He is a very nice man and we have an excellent patient-physician relationship. It makes me feel bad to label him 'difficult'. But as much as he is a good friend, he is also the reason for great concern and worry for me. So much so, that sometimes as I enter the clinic, if I see him waiting in the hall, my heart sinks. "How am I going to help him?" my mind starts wondering. 

This elderly man has multi morbidity, the presence of many chronic illnesses at the same time, which is quite common in the elderly. He has hypertension, a heart arrhythmia called sick sinus syndrome, benign hypertrophy of the prostate which causes urinary obstruction, small fibre peripheral neuropathy leading to severe burning sensation over his feet, heart burns due to gastro-esophageal reflux where the acid in the stomach returns to the food pipe and erodes it and chronic low mood state. Giving medications for his prostate problem worsens his heart condition. Treatment for the burning sensation of the feet causes dizziness and constipation. Constipation kills his appetite and that worsens his heart burns. Treatment for hypertension causes dizziness, and this in turn makes his mood worse. A typical clinical encounter with him is a constant balancing act between various medications that he is taking. 

Once, out of sheer frustration the poor man went to a different doctor for an acute pain in the lower abdomen. Understanding the medical history and treatment of patients like him can be extremely challenging to any clinician who is seeing him for the first time. The doctor admitted him in the hospital. The next day during rounds, the patient called me on my phone and put me through to the treating doctor. When I tried to explain the complex treatment process to the doctor, the doctor gave up and said that he will discharge him and send him back to me as soon as possible! Is the wicked problem that he has wicked only because of the complexity of the medical condition? Not in the least! There are some super-complex family dynamics in play too. 

He lost his wife to cancer several years ago. Now his living arrangement is moving between his two sons and two daughters all of whom live in different cities in Tamil Nadu. He moves around and does not have one permanent space to call his home. One of his sons is a problem alcohol user and whenever it is his turn to stay with that son, he gets into major fights with him. Once he even got into a physical altercation with the man and had to undergo suturing of a laceration injury. This distresses him a lot. 

I have had several mishaps in addressing his medical problems. Once he developed swelling of the feet due to his hypertensive medication. So I stopped the medicine and started him on another medication, which messed up with his heart condition. So I had to stop the new medicine and put him on a different one that doesnt interfere with the heart. Once, I put him on a medication for his burning sensation over the feet and it worsened his constipation and he started developed bleeding in the stools due to hard stools injuring his anal passage. I had to then stop that medication. I have referred him to different specialists at different times, desperately trying to find out some solution. But nobody has been able to help him so far and he comes back to me every time. 

Sometimes, the 'burden' of this 'difficult' patient is very challenging to bear. But over the past 8 years of treating him, I have realized that just being there, listening to his problems, and trying to help itself helps him. He finds some comfort in just coming and hanging out with us in our clinic. Treating patients like him is a great lesson in humility. I guess physicians should try to 'cure sometimes, relieve often and care always'!