By: Marven Ewen, MD, Medical Director
When you're a new doctor in a small town, all the dissatisfied patients come to check you out. The very worst are referred directly to you by your new partners in an attempt to turf them to the unsuspecting new guy. “Go see the new doctor - he specializes in your problem.”
One morning while covering the ER, something we took turns doing as a group, I got to meet one of these people who had fired every doctor in the town at one time or other. One of my senior partners handed me his chart and said, “Go see this guy, he is really interesting.” Naively, I enthusiastically agreed. I have since come to learn that “really interesting” is code for “difficult patient.”
I entered the room. A middle-aged man was holding his abdomen, clearly in pain. He seemed reasonable and responded appropriately to my questions. I made the usual inquires: How long have you had this discomfort? Where is it located? What does it feel like? What makes it better or worse? And so on, in an attempt to characterize and deduce the differential diagnosis. So far, so good. I wasn’t finding anything “interesting” yet.
I examined him thoroughly. He was quite cooperative, even including a rectal exam that was performed to rule out gastrointestinal bleeding. I was a bit puzzled. It seems he had experienced this pain for many years. There were not any red flag findings like fever, vomiting, weight loss, or diarrhea. Yet here he was presenting to the ER again.
At that time we had paper charts, and his was very thick with numerous visits. Prior to the electronic medical record, it was sometimes faster to just ask patients about past results rather than dig through a giant paper chart. So I asked him, “Have you had any x-rays or CTs?”
He reacted like I had expressed a profanity. While making a face of disgust, he claimed they had almost killed him when he had an x-ray. “It tore up my abdomen!” He explained that he cannot have any x-rays because he is allergic to them!
At first, I was speechless as he ranted on about what the x-rays did to his abdomen. Then I tried to reason with him. He became more irate. I excused myself from the room and said I would be back, but he would need some further investigation.
Stepping out to gather my wits, I took a deep breath and went to the radiology department. In my training I had never heard of such a thing. I couldn’t see how it was possible to be allergic to x-rays, especially since plain x-rays use little radiation, but this patient was so adamant. So I sheepishly asked the radiologist, “Is there any possibility of an adverse reaction to a plain abdominal x-ray?”
I was really embarrassed to be asking such a question, but I was operating on the age old teaching of “listen to your patients.” He chuckled and said, “You’re seeing Mr. X-Ray, aren’t you?”
“Yeah,” I said.
“It’s all in his head,” he told me. “All the new guys see him.”
I returned to discuss my plan with the patient but he had left the ER, apparently not happy with me either.
About a year later, I had a medical student doing a rural rotation with me. I saw Mr. X-Ray’s chart in the que. I handed it to my medical student. “You should see this guy - he is really interesting.”