Ronald B. Goodspeed

What if ...: you think a patient is faking?

THIS What if scenario isn’t as unusual as you may think. Probably the most common situation of this kind is a patient who’s exaggerating or lying about symptoms in order to gain time off from work or school or establish grounds for a worker’s compensation or liability claim (sometimes referred to as malingering). On rare occasions, you’ll encounter a patient who’s suffering from a psychological disorder called Munchausen syndrome, which involves creating a factitious disease picture purely to become a patient. It’s important to separate out patients who are knowingly misleading you from patients who are unaware that they’re falsely describing symptoms. Those unaware patients are suffering from a conversion disorder and truly believe their reported symptoms, which can commonly be as severe as blindness, paralysis, or deafness with no actual organic deficit. WARNING!!! Patients with apparent conversion disorder need psychiatric evaluation and treatment. Also be on the lookout for patients who may be deceitful because of a fear of what action will result, such as admission to the hospital, venipuncture, or other

What if ...: A patient is highly fearful of needles?

IT ISN’T UNUSUAL for a patient to fear the needles used for phlebotomy, IV line insertions, subcutaneous or intramuscular (IM) injections, needle aspirations, and even those needles used to inject something to eliminate pain (local anesthetics). The origins of the fear may be multiple and range from a previous bad experience to being threatened with getting a shot for bad behavior as a child.

What if ... a patient of the opposite sex doesn't want you in the exam room?

THIS scenario is more common today than a decade ago. It’s more likely to happen to you as a student and can be provoked by your own behavior or perceived discomfort. It’s important to remember that one of the most important patient rights is the right to refuse medical care or portions of it, such as treatment and even diagnosis. Nevertheless, it’s also important to make sure that patients are informed enough to make rational decisions about these matters.

What if ...: a patient makes a sexual advance toward you?

Ethical behavior must prevail! You shouldn’t pursue an advance toward you, even if you and the patient are single. It’s entirely unethical to develop such a relationship with a patient or former patient. Unless you’re a psychiatrist, it’s likely that you haven’t had formal training for this situation. Here are some questions to ask yourself: • Is this really what it seems? Is this the patient’s actions or is it your feelings? • Review what actually happened. Was it an explicit request or solicitation? Or was it a flirtatious comment or look? Or is it something you have said or done? • Did the patient cross a boundary such as repeatedly touching you on the arm as he or she spoke with you about symptoms or problems?

What if ...: you have to give a patient bad news?

A S MEDICAL STUDENTS we were never taught how to tell a patient they have a terminal illness or cancer. It apparently was assumed that we would learn this through the legendary “Watch one, do one, teach one” process. People seek careers in the health professions to make diagnoses and provide remedies, and not for the opportunity to deliver bad news. It’s always difficult to convey bad news. Although you shouldn’t encounter this What if situation as a student, it will most probably occur during your postgraduate training period. The lack of training for this situation should cause most clinicians to want to prepare in advance.

What if ...: you need to help someone who's a lawyer?

‘‘THIS is a 43-year-old female lawyer who presents with . . .” Have you ever heard this kind of presentation opening on rounds? Why do some physicians seem more on guard or wary when a patient is a lawyer, rather than a management consultant, an administrative assistant, a librarian, or a financial planner? Is it because certain viruses target lawyers? Do attorneys have tougher skin to penetrate with a catheter or needle? Are there environmental exposures that afflict attorneys and not others who work in similar office settings? Are lawyers actually a different species from humans? Although some defendants in malpractice cases may claim that lawyers are a different species, basic taxonomy tells you that they aren’t. With the staggering number and cost of malpractice lawsuits in this country, many physicians consciously or unconsciously associate lawyers with malpractice lawsuits and may assume that a lawyer is more likely to sue or know other lawyers who are willing to sue.

Clinical AIDS update.

In summary, although progress against AIDS is being made, tremendous hurdles still exist. More effective prevention methods such as widely disseminated education programs and an effective vaccine are essential. Effective treatment methods are critical. Coordinated ambulatory care AIDS programs are needed to reduce costs and enhance the quality of life of AIDS patients.