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Susan had neither the trust of a nurse nor the teachability of an engineer. She would ignore no theory of any culture or any quack, regarding her very common brand of knee pain. On and on she went as I retreated further within. I marveled, sitting there silenced by her diatribe. Hers was such a fully orbed and vigorous self-concern that it possessed virtue in its own right. Her complete and utter selfishness was nearly a thing of beauty.
When to punt is not a topic taught in medical school. There is but one observation that I can offer: Patients like Susan, as self-absorbed as they are, know it immediately. They can tell when you're about to punt.
I knew full well what was wrong with this woman, and I could treat her, probably as well as anyone. But treating her condition, which was chronic patellofemoral pain, would test the mettle of patient and surgeon. What we have doesn't work very well nor very quickly. The swelling takes months to go down, the muscles take even longer to strengthen. Good patients often complain, "It was better before we started," in desperation or anger, before they see improvement. But with plenty of therapy, braces, exercises and one or two operations, this knee does improve. It's often tough going, though, and patients have to stick with you. I like to be straight "It gets worse before it gets better" is what I tell them. Susan's style, her history and, somehow, most telling, the way she treated her son said she was not going to make it through this. Not with me, anyway.
A seasoned doc gets good at sizing up what kind of patient he's got and how to adjust his communicative style accordingly. Some patients are non-compliant Bozos who won't read anything longer than a headline. They don't want to know what's wrong with them, they don't know what medicines they're taking, they don't even seem to care what kind of operation you're planning to do on them. "Just get me better, doc," is all they say.
At the other end of our spectrum are patients like Susan: They're often suspicious and distrustful, their pressured sentences burst with misused, mispronounced words and half-baked ideas. Unfortunately, both types of patients get sick with roughly the same frequency.
I knew Susan was a Googler queen, perhaps, of all Googlers. But I couldn't dance with this one. I couldn't even get a word in edgewise. So, I cut her off. I punted. I told her there was nothing I could do differently than her last three orthopedists, but I could refer her to another who might be able to help. A certain Dr. Brown, whom I'd known as a resident, had been particularly interested in her type of knee problem.
Disappointed and annoyed, Susan stopped for a beat.
"You mean Larry Brown on Central Avenue?"
"Uh, yes " I started.
"I have an appointment with him on Friday. And, Dr. Haig?" she said, pulling Junior by the arm out my office door, "Watch out on your drive home tonight. There was an accident near your exit."
Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.