We live in an age where information and gratification are a few short keystrokes away. Want to know who that guy was that did that thing that one time…? Google it. Feel like a pizza? Order one online – guaranteed delivery to your door in 30 minutes or less.  What a time to be alive!

There are still a few things the Internet and technology haven’t replaced (yet). One of them is the practice of medicine. Maybe one day your smartphone (or whatever the future iteration is called) will scan you head-to-toe, diagnose your ailments and prescribe the appropriate management – but for now, when you’re feeling ‘under-the-weather’, you have to go see a human doctor. The key word there is human.

You know how they call it the ‘doctor-patient relationship’? That’s because like any other (healthy) relationship with another human being, it depends on some fundamental and basic implied ground rules and etiquette that both parties agree on. For example, I think we can all agree that a hallmark of a good relationship is having open and honest communication between both parties. Good relationships are also characterised by mutual respect and a modicum of courtesy extended to the other person, even when disagreements arise. Some people even think it’s a good idea to like, or at least tolerate, the other person you’re in a relationship with.

You may be surprised to know that your doctor expects a certain level of these elements to exist in the therapeutic relationship you share with them. But unlike ‘normal’ relationships you’ll have with other people, the doctor-patient relationship carries with it some responsibilities. From your doctor’s perspective, they have ethical, moral, legal and professional responsibilities and standards to uphold. In return, the patient's responsibility is to recognise that the doctor is a doctor, and to treat them as such.

In saying all that, here are a few (stereo)types of patients that seem to repeatedly break the unspoken etiquette…

THE DEMANDING PATIENT

“I need antibiotics!” or “I need to see a specialist!” the demanding patient says emphatically as soon as their doctor asks how they can help - and sometimes they are right. They really do need antibiotics, or they really do need to see a specialist. However, sometimes (most of the time?) they are wrong.

In the circumstance where the doctor disagrees with the patient's demands, the doctor can react in three distinct ways: a hard-lined no, a middling compromise, or a total surrender. Sometimes surrendering or making compromises is no big deal. For example, a patient may want an MRI, even though they absolutely don’t need it, but they’re willing to pay out of pocket for it, so it really is their own prerogative if they choose to waste their own money and time. However, sometimes your doctor cannot compromise – or more accurately, they should not compromise. A good example (but not the only example that could be made) is antibiotic prescribing and good antibiotic stewardship. Your doctor has a duty of care not just to you, but also to the community at large, and if they prescribe antibiotics purely because Mrs. Smith is sure she needs it, despite absolutely no signs indicating a bacterial infection – well, that’s how ‘superbugs’ are made.

The issue here is not necessarily stubbornness, but more selfishness. Our consumerist society teaches us that ‘the customer is always right’ and that we should always have it our way. If you want to know what I mean, just walk down the aisles of your local super market and have a look at the variety of milk and bread that are available. People take this mentality in to see their doctor and they forget that their doctors are not their personal pill dispenser or referral generator. They forget that their doctor’s job sometimes involves thinking about what is best for the community or the long-term benefit of the patient, rather than blindly helping the individual or serving them for the immediate here-and-now. In this consumerist approach to medicine, people lose respect for a doctor’s expertise. I’m not trying to suggest that we should deify doctors or put them on a pedestal (as nice as that would be), but you gotta admit, for your doctor to be a doctor, they did have to learn some stuff...

THE APATHETIC PATIENT

On the completely opposite end of the spectrum, there’s the patient who really doesn’t care; like, at all. Sometimes they’re quietly apathetic, where they say all the right things but then their doctor sees them 2 years later for ‘follow-up’ and they did nothing their doctor recommended to improve their health. And that blood test request their doctor gave them to screen their cholesterol levels and blood sugar… oh yeah, they lost that ages ago. But sometimes they’re borderline aggressive with their apathy. Usually a 'Good Samaritan' has dragged this type of patient along – and they’ll be sure to point that out to their doctor. They hate everything about being in the doctor’s office: the funny way the clinic smells, the way they have to check-in with the ‘phony’ receptionists, the waiting room, the waiting and waiting and WAITING, and then, having to talk about their health.

They grudgingly show the doctor their festering wound that is very clearly infected. They’re fine, they tell their doctor. There really is nothing at all to worry about. Their doctor doesn’t know if they really believe that, or if they just really resent being there.

And then, the topic of preventative health comes up… What’s their diet like? It’s perfect – ok, yes, they do have take-out 3 nights per week, but that’s normal for anyone. Do they exercise? Absolutely – at work – they work really hard.  How much alcohol do they drink? Just a few, like everyone else: 6-10 beers every night, maybe ‘a few more’ on the weekend. Are they ok with their doctor screening them for early-detectable cancers or checking their cholesterol and blood sugar? Definitely not; needles are a no-go. The patient says they don’t need any of it – not the tests, not the blood pressure tablets, not the diet or exercise advice. They’re healthy! They feel fine! And, of course, everyone knows that when you feel fine, it means everything must be fine, and there’s no need to think about tomorrow, today.

THE HOT MESS

Everything is not fine for this type of patient. They walk in with a list of problems, some of them not strictly medical. Google and Web-MD are their best friends. Some of them are apologetic about this, but most of them aren’t.  As soon as they sit down, they rapidly fire off a list of seemingly disconnected symptoms and then after a 5-10 minute tirade, including a ‘brief’ list of what they have diagnosed themselves with (usually bizarre, rare and mispronounced eponymous syndromes), they look at their doctor expectantly for the beginnings of some answers and/or solutions. They always inevitably throw out some buzzwords that they know will trigger a response with their doctor (chest pain is worth 1,000 points). So their doctor sends them for tests, an ungodly amount of tests, and when they usually all come back with normal results, this patient will come back with a brand new list of problems.

If the doctor probes a little bit deeper, they may find some deep-seated anxiety, or perhaps a troubled personal life. Many of these medical complaints that they bring up are manifestations of their real underlying issues that are haunting them in the form of mystery symptom after mystery symptom. And these symptoms are, knowingly or unknowingly, acting as barriers, helping them avoid facing the real issues at hand.

All this type of patient wants to do is keep lopping off the heads of the hydra, rather than address the heart of the matter and kill the beast once and for all. Insight, although terrifying to gain, is their only hope.

THE ANGRY PATIENT WHO WANTS A FIGHT

Their doctor wonders why they even bother to come see them at all. The patient makes no effort to hide their disgust and disdain to both the doctor’s profession and the doctor as a person. They bring in printed journal articles and newspaper clippings, always from reputable sources (note: sarcasm). They tell their doctor why vaccines are dangerous and medications are poisons. They share the exploits of their wonderful naturopath, who has singlehandedly cured their years of migraines when all ‘modern/western medicine’ has failed. If they took a more moderate approach, their doctor might actually agree with some of their points, however, this patient is always at '11'.

It seems like they feed off conflict and there is absolutely no way to reason with them, although their doctor will try, and try and try again. Just like a blind religious zealot, the patient cannot see that conversion is not a possible goal; they’re just straight up preaching to the wrong crowd.

THE DRUG SEEKER

When I say drug-seeker, most would likely think of a shady looking man with a hoodie, unkempt beard and bad dental hygiene. While there are certainly these kinds of ‘drug seekers’ and addicts out there, that try to hit up their local doctor for a quickie script of oxycontin or valium, most drug seekers are very different. They come in because they’ve been having trouble sleeping, or their chronic pain has amped way up. They just need some sleeping pills or some strong painkillers to see themselves through to next week when they’re sure it’ll all be better or when they’ll be able to see their usual doctor again. 

They might say that they’ve been on these medications before and they know what they can handle. They may tell their doctor not to worry because they know they’re ‘bad for you’ - after all, they only ever take it once in a blue moon, only when they’re absolutely necessary.

Some of them know they’re trying to score, but others don’t know they have a dependence problem at all. Their doctor’s guard would most likely already be up. They’ll delicately dance around the subject of drug abuse and/or dependance, until finally a decision must be made. Does the doctor prescribe or refuse? Everyone in the room holds their breath with anticipation…

ON DOCTORS:

Of course there are two sides to every story, and two sides to every relationship. So in the spirit of openness and conciliation, I thought it would be worth mentioning some types of doctors that patients wish they'd see less of.

There are the doctors who create more problems than they solve. There are the doctors who don’t listen and who don’t care. There are doctors who care too much. There are doctors who don’t know enough, or know plenty but don’t explain. There are arrogant doctors, pushy doctors, and downright rude doctors. There are doctors who are ethically questionable, morally contentious and legally dubious. There are your Dr Hibbert’s and your Dr Nick’s. Your JD’s, Hawkeye’s, House’s and McCoy’s.

We are all human, and we will all make mistakes. The best thing we can do, as both doctors and patients, is to try our best to make this relationship work. That is, until our computers can solve all our problems for us.