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I was just at a meeting with the good Dr. Joel Schlessinger who wrote a great editorial for the September issue ( on difficult patients. For the record, he is exactly right. Joel sees many more patients than I do and definitely knows how to navigate the most difficult medical and aesthetic issues, so we should take his advice. It just goes to show you that Nebraska has as many maintenance issues with prima donna patients as California, Wisconsin, and everywhere in between.

Joel and I both remind ourselves that it’s getting rough taking care of patients—this isn’t front page news. But instead of empty replies and double talk, maybe it’s time to take a step back and evaluate the genesis of all of this (like it or not). Is this because of patients and their ridiculous expectations as customers? Or because we are settling into a new era of medicine where we as physicians don’t have the impact on a patient’s health that we once did? Or are we fundamentally not wired for this game anymore?

Thinking about the last few editorials in this publication, with discussions of gratitude, baditude, and difficult patients, maybe the real issue is that we forget to look in the mirror when something goes sideways. Physicians in general are high achievers and competitive, and dermatologists, especially, expect everything to work out.

For example, one recent morning I had my day planned: drop off the boys, stop at the office, go speak at the Integrative Dermatology Symposium (which was a great meeting—well done, Raja!), then catch my flight to New York for a 22-hour roundtrip. All of it was expected to go smoothly because I planned it that way. Of course, what really happens: I wake up late, my little boy Kiran needs his diaper changed right as we are leaving, and my older boy Suren decides he has a stomach ache and wants to stay home to watch TV instead of going to school, which costs me 20 minutes. Then there’s traffic, which adds another 30 minutes, and now I’m in a hurry, all in a frenzy, and worried about making it to the office on time as well as keeping an eye on the flight that afternoon. What an idiot! Who does all of this and packs all of this pressure to add another arterial plaque in the coronary flow?

But, it’s not just me. I heard a story later that day about a guy who spent three hours trapped when the elevator he was on got stuck between floors without warning. In that three hours of anxiety and misery, one guy missed his flight and another missed the cruise that was leaving from the port for a week long trip he had planned for years. Another person stuck was the photographer for a wedding in the same hotel who literally only went back upstairs to use the washroom—but that wedding was basically shattered. Look at the innocence of moments that we take for granted and how one small glitch can destroy the fundamentals of what should be routine.

We’re all guilty of assuming things will go as expected and getting frustrated when they don’t. I know you all can relate—it’s what we do and we won’t stop because it’s in our fabric. And in most cases, everything fortunately works out, but when it comes to patient care, that isn’t always the case. Outcomes in the office visit have real impact once patients go home, despite (or as a result of) their behavior and our reactions to them. It doesn’t mean we should always give in to difficult patients or even those we think are acting bratty—it means we should take the extra minute to put ourselves in our patients’ shoes every so often and sit and hold their hands. Maybe they also showed up to their appointment already frazzled after a morning that didn’t go as planned.

As Joel pointed out, even his brother-in-law in the jewelry industry has to deal with temperamental patients, so customers in all spaces can be intolerable…which again goes back to gratitude on top of the “freedom to be horrible” amendment in America. In the end, there might be too much poison in the air from politics and the media, but we have to rise above it. Or maybe there are new paradigms of expectations that as physicians we will never meet. But just like my morning, we can’t control every outcome and we can’t push the limits just because we are used to success. I would bet the vast majority of you say thank you and look people in the eye in places like stores, banks, and restaurants because it’s how we want our day to go, even though there are some of you who don’t wash your hands in the bathroom. We can name names another time.

Maybe the solution is division of our overextension, although in general being detached and subdivided is not good for organization or patient care. Maybe we all should choose some days on our calendars and cut out everything that overextends us and fill that space with a massage, or a movie with our spouses, or playing with our kids, or something that forces us to unplug so that we have the bandwidth to face the next difficult day, which is any day that ends in “y.” But as Joel and I try to point out, sometimes laughing the madness off is the best remedy to the chronic disease known as difficulty.

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