The Rat Hole

2013
Cogan, Samantha

My son is always asking me to tell him work stories. He wants to be a doctor and is fascinated by what my husband, an otolaryngologist, and I, a family doctor, do. However, it is not merely the medical “stuff” that interests him with my work, although he is more than happy to watch sinus surgery and other gruesome surgical videos with my husband. With me, he wants to hear more of the human side of family medicine, not the clinical.  More specifically, it is the tales of patients who act out inappropriately in my office that intrigues him.  I think he was shocked the first time I relayed such a story to him, as he could not imagine that a patient would “misbehave” in a doctor’s office.  (He forgets his first encounter with the dentist.  To be fair, since that time, he has been a model patient.)

After nearly fifteen years in practice, I have quite a few tales to tell.  All family doctors have experienced difficult patients and many have found themselves in threatening situations.  This encounter was not the first or the last of these interactions, but it was the time I felt the most at risk.  As a doctor who has worked in street youth and homeless clinics serving addicts and convicted criminals, this is somewhat remarkable.

The incident occurred early in my career while doing a shift at a dank walk-in clinic that my friends and I affectionately referred to as ‘the rat hole’.  The exam rooms were located at the rear of the clinic and well out of earshot of the receptionist, the only other staff in house.  Even if she could hear me, her small frame and quiet demeanor did not provide me with a great sense of security. I hadn’t given the set-up any thought until the day an irate patient I had never seen before came in requesting narcotics.  (I also learned from this experience that the doctor’s chair should be nearest to the door and to leave the door ajar with patients that appear to be aggressive).  I reviewed the chart and noted that it was not his first visit for this reason.  I also knew that he likely selected shifts with different doctors in order to escape the designation as a drug-seeker. My residency at St. Michael’s Hospital, located in an inner city neighbourhood in downtown Toronto, provided me with the training to identify drug-seekers and their patterns of behaviour.  

After I explained that I did not provide prescriptions at the walk-in for such medications and that he would have to go to his original prescribing doctor, he became agitated and began yelling at me. He blamed me for any future harm he may cause others, as I had not prescribed him what he needed in order to calm himself down.  Fearful, I started to reach for my prescription pad, feeling that my life was worth more than denying an addict a prescription for a medication I knew he didn’t need.  The patient lurched toward me, still shouting and now swearing, and, instead of assaulting me, ran out of the room before I could begin writing the word Percocet.  My heart racing and hands trembling, I leaned back in my chair, and felt somewhat nauseated.  Moments later, my receptionist entered the exam room where I remained paralyzed with fear.  She had not heard any of our interaction but was alarmed when this man came barreling down the hallway, screaming and swearing all the way to the waiting room and through the front door.

For the rest of my evening shift, I continued to see patients.  After a while, I was able to forget what had transpired and began to enjoy the quick pace of the walk-in again.  It had such a different feel than family practice and it was a nice break from the intense involvement that can develop in my own office.  A couple of hours later, the receptionist caught me in between patients as I ran from room to room.  She had just received a call from the patient’s girlfriend.  The girlfriend had yelled at her on the phone, questioning why the f------ b---- of a doctor hadn’t given her boyfriend his medications.  He was angry and agitated and she seemed to be concerned for her safety.  I tried to call them back at the various numbers we had on file but none were in service.  I called the police but I doubt much ever came of the situation.  Perhaps they were jaded from their experiences with addicts, but they did not seem at all concerned with what had occurred.

I wrote a note at the front of his chart and the receptionist put a flag on his computer file to not allow him back in the clinic and to call the police if he returned.  He never returned on my shift and I doubt he would have come back to the clinic all together.  He knew he was persona non grata.

Months later, I was driving near the Rogers Centre on a game night.  I saw someone that looked familiar standing on the sidewalk talking to strangers as they passed him by.  As my car approached, I recognized him as the patient who had come to the walk-in looking for a prescription of controlled substances.  It was then that I realized he was not an addict but a dealer (or perhaps both).  He had been angry, as I had interfered with his “business”.  I drove off quickly although there really was nothing to fear at this moment.  This was a turning point in my understanding of the variety of doctor-patient relationships.  They were not all about getting well, improving quality of life, increasing survival, and preventative care.  Some were an attempt at business transactions.  I had not signed up for a job as a drug dealer, an enabler of false disability claims, or a provider of unnecessary paid days off work.   However, this is what some patients expect of us.  They are the most difficult to deal with. 

And now, I must call a patient to let him know I will not fill out a form for him that would provide him with years of shortened workdays and limited responsibilities until retirement as he has the ‘severe disability’ of being unable to multitask or work past 2PM. Welcome to the ins and outs family practice…

Theme: Health Care Delivery | Prestation des soins de santé
Theme: Patients | Patients

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.

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