Re: Patient predicament with (?) happy ending - maybe...

[Guest guest]

Pamela, I’m not so punchy (see

previous email) that I can’t send a little TLC up north to you. There’s

no need to feel guilty as you tried to do what you thought best for your

patient, and there are times when we have to stick to our convictions and not

compromise just to please a patient. Sometimes that extends to the cases

where “if I don’t do this for this patient then no one will.”

Sometimes we have to bust out the line “I won’t compromise my

medical license to do that for you” (and it’s not just a line as it’s

the truth). Lastly, if anyone should feel guilty it’s the patient

for not paying you for your valuable time and effort on her behalf.

Marty

p.s. I did not know that insulin

could be obtained without a prescription as I’ve written scripts for it

as well as syringes/needles in the past. Perhaps a script is required for

insurance to pay for these things???

From: [mailto: ] On Behalf Of roxywible

Sent: Wednesday, May 16, 2007

11:17 PM

To:

Subject:

Patient predicament with (?) happy ending - maybe...

I feel bad about this but I have a gal who has out of

control

insulin dependent diabetes. She is noncompliant and

doesn't like doctors. I spent the first 3 months just

trying to get her to the lab for a FBG/HgA1c etc..

Finally registered in at around 400. I feel for her

because of a lethal combination of denial and a good

dose of resistance mixed with an active dislike

for allopathic medical doctors. She wants to do things

her way and there is no way in the world she is

gonna come back at the intervals I would want or

get the labs that I want/require....it goes on and on.

There was a lot of tension when I saw her last. She basically

said she wanted to be able to get her own insulin with

out seeing a doctor and monitor herself at home.

She did not understand why I wanted all these tests

and why I even care despite me explaining things

over and over agian. So much resistance! I mean the

air was so thick with resistance. I mean we spend the

atleast 50% of every visit processing this resistance.

It s hard to accomplish anything.... and then she gets

mad because I didn't cover all her issues. She admits

she is difficult and I think she has implied she even

feels sorry for me having to deal with her contrary

nature.

If I liked fighting I would have gone into boxing

like those wild huge women on late night TV

duking it out throwing each other over the

ring into the audience.

Amazing and not sure any of you know this but

NPH and regular insulin is available WITHOUT

a prescription.

So we parted ways. I wish I could have made our relationship

work somehow but the OCD part of me can't deal with a

patient like this. I feel relieved and a tinge of guilt.

She did tell me I'm the only doctor she will ever go to so

essentially she will never see another doctor again.

This sort of stabbed me through the heart.

I think Joanne would have kept her. Joanne, you are

amzing. Anyone get where I'm coming from?

Help with the late night guilt here....

I did the Joanne thing and did not accept any money

from her as she sort of fumed out the door. It was

a sad scene.

Pamela

[Guest guest]

Hi Pamela -

I'm answering off list, my preference.

It sounds as though this patient is probably pretty PTSD from the medical system

and also has a strong personality (i.e. borderline).

How old was she when diagnosed? Probably teenaged. A few people with serious

chronic disease seem to get locked into their emotional age at diagnosis pretty

dramatically. You've already said that you are just not comfortable managing her

without the correct labs, which is an appropriate assessment of your needs. She

did have a choice to keep you by agreeing with what you needed, but that was

unlikely to happen, as that would have changed the power balance.

I do feel bad sometimes when patients like this separate, but that feeling is

part of the push-pull interaction. Don't feel guilty about the " You're the only

doctor " line - that's why she said it and probably not very accurate, frankly.

When I work with patients that fight this hard, I sometimes remember an old judo

teacher who translated a saying:

" When they come, invite them, when they go, send them. " Not meant at all

literally, but part of that wonderful emotional sense of working with the forces

that are presented to you by the other person, keeping your own emotional forces

separate and intact, in that " adult " way.

If we didn't care about people like this and want to save them from themselves,

we wouldn't be doctors.

-------------- Original message ----------------------

> I feel bad about this but I have a gal who has out of control

> insulin dependent diabetes. She is noncompliant and

> doesn't like doctors. I spent the first 3 months just

> trying to get her to the lab for a FBG/HgA1c etc..

> Finally registered in at around 400. I feel for her

> because of a lethal combination of denial and a good

> dose of resistance mixed with an active dislike

> for allopathic medical doctors. She wants to do things

> her way and there is no way in the world she is

> gonna come back at the intervals I would want or

> get the labs that I want/require....it goes on and on.

>

> There was a lot of tension when I saw her last. She basically

> said she wanted to be able to get her own insulin with

> out seeing a doctor and monitor herself at home.

> She did not understand why I wanted all these tests

> and why I even care despite me explaining things

> over and over agian. So much resistance! I mean the

> air was so thick with resistance. I mean we spend the

> atleast 50% of every visit processing this resistance.

> It s hard to accomplish anything.... and then she gets

> mad because I didn't cover all her issues. She admits

> she is difficult and I think she has implied she even

> feels sorry for me having to deal with her contrary

> nature.

>

> If I liked fighting I would have gone into boxing

> like those wild huge women on late night TV

> duking it out throwing each other over the

> ring into the audience.

>

> Amazing and not sure any of you know this but

> NPH and regular insulin is available WITHOUT

> a prescription.

>

> So we parted ways. I wish I could have made our relationship

> work somehow but the OCD part of me can't deal with a

> patient like this. I feel relieved and a tinge of guilt.

>

> She did tell me I'm the only doctor she will ever go to so

> essentially she will never see another doctor again.

> This sort of stabbed me through the heart.

>

> I think Joanne would have kept her. Joanne, you are

> amzing. Anyone get where I'm coming from?

> Help with the late night guilt here....

>

> I did the Joanne thing and did not accept any money

> from her as she sort of fumed out the door. It was

> a sad scene.

>

>

>

> Pamela

>

>

>

>

>

>

>

>

I feel bad about this but I have a gal who has out of control

insulin dependent diabetes. She is noncompliant and

doesn't like doctors. I spent the first 3 months just

trying to get her to the lab for a FBG/HgA1c etc..

Finally registered in at around 400. I feel for her

because of a lethal combination of denial and a good

dose of resistance mixed with an active dislike

for allopathic medical doctors. She wants to do things

her way and there is no way in the world she is

gonna come back at the intervals I would want or

get the labs that I want/require....it goes on and on.

There was a lot of tension when I saw her last. She basically

said she wanted to be able to get her own insulin with

out seeing a doctor and monitor herself at home.

She did not understand why I wanted all these tests

and why I even care despite me explaining things

over and over agian. So much resistance! I mean the

air was so thick with resistance. I mean we spend the

atleast 50% of every visit processing this resistance.

It s hard to accomplish anything.... and then she gets

mad because I didn't cover all her issues. She admits

she is difficult and I think she has implied she even

feels sorry for me having to deal with her contrary

nature.

If I liked fighting I would have gone into boxing

like those wild huge women on late night TV

duking it out throwing each other over the

ring into the audience.

Amazing and not sure any of you know this but

NPH and regular insulin is available WITHOUT

a prescription.

So we parted ways. I wish I could have made our relationship

work somehow but the OCD part of me can't deal with a

patient like this. I feel relieved and a tinge of guilt.

She did tell me I'm the only doctor she will ever go to so

essentially she will never see another doctor again.

This sort of stabbed me through the heart.

I think Joanne would have kept her. Joanne, you are

amzing. Anyone get where I'm coming from?

Help with the late night guilt here....

I did the Joanne thing and did not accept any money

from her as she sort of fumed out the door. It was

a sad scene.

Pamela

[Guest guest]

Woops -

thought I was replying off list ( - :

Using foreign email engines, a little more complicated. . .

N

-------------- Original message ----------------------

From: NGuinn555@...

> Hi Pamela -

>

> I'm answering off list, my preference.

>

> It sounds as though this patient is probably pretty PTSD from the medical

system

> and also has a strong personality (i.e. borderline).

> How old was she when diagnosed? Probably teenaged. A few people with serious

> chronic disease seem to get locked into their emotional age at diagnosis

pretty

> dramatically. You've already said that you are just not comfortable managing

her

> without the correct labs, which is an appropriate assessment of your needs.

She

> did have a choice to keep you by agreeing with what you needed, but that was

> unlikely to happen, as that would have changed the power balance.

> I do feel bad sometimes when patients like this separate, but that feeling is

> part of the push-pull interaction. Don't feel guilty about the " You're the

only

> doctor " line - that's why she said it and probably not very accurate, frankly.

>

> When I work with patients that fight this hard, I sometimes remember an old

judo

> teacher who translated a saying:

> " When they come, invite them, when they go, send them. " Not meant at all

> literally, but part of that wonderful emotional sense of working with the

forces

> that are presented to you by the other person, keeping your own emotional

forces

> separate and intact, in that " adult " way.

>

> If we didn't care about people like this and want to save them from

themselves,

> we wouldn't be doctors.

>

>

>

> -------------- Original message ----------------------

>

> > I feel bad about this but I have a gal who has out of control

> > insulin dependent diabetes. She is noncompliant and

> > doesn't like doctors. I spent the first 3 months just

> > trying to get her to the lab for a FBG/HgA1c etc..

> > Finally registered in at around 400. I feel for her

> > because of a lethal combination of denial and a good

> > dose of resistance mixed with an active dislike

> > for allopathic medical doctors. She wants to do things

> > her way and there is no way in the world she is

> > gonna come back at the intervals I would want or

> > get the labs that I want/require....it goes on and on.

> >

> > There was a lot of tension when I saw her last. She basically

> > said she wanted to be able to get her own insulin with

> > out seeing a doctor and monitor herself at home.

> > She did not understand why I wanted all these tests

> > and why I even care despite me explaining things

> > over and over agian. So much resistance! I mean the

> > air was so thick with resistance. I mean we spend the

> > atleast 50% of every visit processing this resistance.

> > It s hard to accomplish anything.... and then she gets

> > mad because I didn't cover all her issues. She admits

> > she is difficult and I think she has implied she even

> > feels sorry for me having to deal with her contrary

> > nature.

> >

> > If I liked fighting I would have gone into boxing

> > like those wild huge women on late night TV

> > duking it out throwing each other over the

> > ring into the audience.

> >

> > Amazing and not sure any of you know this but

> > NPH and regular insulin is available WITHOUT

> > a prescription.

> >

> > So we parted ways. I wish I could have made our relationship

> > work somehow but the OCD part of me can't deal with a

> > patient like this. I feel relieved and a tinge of guilt.

> >

> > She did tell me I'm the only doctor she will ever go to so

> > essentially she will never see another doctor again.

> > This sort of stabbed me through the heart.

> >

> > I think Joanne would have kept her. Joanne, you are

> > amzing. Anyone get where I'm coming from?

> > Help with the late night guilt here....

> >

> > I did the Joanne thing and did not accept any money

> > from her as she sort of fumed out the door. It was

> > a sad scene.

> >

> >

> >

> > Pamela

> >

> >

> >

> >

> >

> >

> >

> >

>

>

Hi Pamela -

I'm answering off list, my preference.

It sounds as though this patient is probably pretty PTSD from the medical system and also has a strong personality (i.e. borderline).

How old was she when diagnosed? Probably teenaged. A few people with serious chronic disease seem to get locked into their emotional age at diagnosis pretty dramatically. You've already said that you are just not comfortable managing her without the correct labs, which is an appropriate assessment of your needs. She did have a choice to keep you by agreeing with what you needed, but that was unlikely to happen, as that would have changed the power balance.

I do feel bad sometimes when patients like this separate, but that feeling is part of the push-pull interaction. Don't feel guilty about the " You're the only doctor " line - that's why she said it and probably not very accurate, frankly.

When I work with patients that fight this hard, I sometimes remember an old judo teacher who translated a saying:

" When they come, invite them, when they go, send them. " Not meant at all literally, but part of that wonderful emotional sense of working with the forces that are presented to you by the other person, keeping your own emotional forces separate and intact, in that " adult " way.

If we didn't care about people like this and want to save them from themselves, we wouldn't be doctors.

-------------- Original message ----------------------

From: " roxywible " <roxywiblecomcast (DOT) net>

> I feel bad about this but I have a gal who has out of control

> insulin dependent diabetes. She is noncompliant and

> doesn't like doctors. I spent the first 3 months just

> trying to get her to the lab for a FBG/HgA1c etc..

> Finally registered in at around 400. I feel for her

> because of a lethal combination of denial and a good

> dose of resistance mixed with an active dislike

> for allopathic medical doctors. She wants to do things

> her way and there is no way in the world she is

> gonna come back at the intervals I would want or

> get the labs that I want/require....it goes on and on.

>

> There was a lot of tension when I saw her last. She basically

> said she wanted to be able to get her own insulin with

> out seeing a doctor and monitor herself at home.

> She did not understand why I wanted all these tests

> and why I even care despite me explaining things

> over and over agian. So much resistance! I mean the

> air was so thick with resistance. I mean we spend the

> atleast 50% of every visit processing this resistance.

> It s hard to accomplish anything.... and then she gets

> mad because I didn't cover all her issues. She admits

> she is difficult and I think she has implied she even

> feels sorry for me having to deal with her contrary

> nature.

>

> If I liked fighting I would have gone into boxing

> like those wild huge women on late night TV

> duking it out throwing each other over the

> ring into the audience.

>

> Amazing and not sure any of you know this but

> NPH and regular insulin is available WITHOUT

> a prescription.

>

> So we parted ways. I wish I could have made our relationship

> work somehow but the OCD part of me can't deal with a

> patient like this. I feel relieved and a tinge of guilt.

>

> She did tell me I'm the only doctor she will ever go to so

> essentially she will never see another doctor again.

> This sort of stabbed me through the heart.

>

> I think Joanne would have kept her. Joanne, you are

> amzing. Anyone get where I'm coming from?

> Help with the late night guilt here....

>

> I did the Joanne thing and did not accept any money

> from her as she sort of fumed out the door. It was

> a sad scene.

>

>

>

> Pamela

>

>

>

>

>

>

>

>

I feel bad about this but I have a gal who has out of control

insulin dependent diabetes. She is noncompliant and

doesn't like doctors. I spent the first 3 months just

trying to get her to the lab for a FBG/HgA1c etc..

Finally registered in at around 400. I feel for her

because of a lethal combination of denial and a good

dose of resistance mixed with an active dislike

for allopathic medical doctors. She wants to do things

her way and there is no way in the world she is

gonna come back at the intervals I would want or

get the labs that I want/require....it goes on and on.

There was a lot of tension when I saw her last. She basically

said she wanted to be able to get her own insulin with

out seeing a doctor and monitor herself at home.

She did not understand why I wanted all these tests

and why I even care despite me explaining things

over and over agian. So much resistance! I mean the

air was so thick with resistance. I mean we spend the

atleast 50% of every visit processing this resistance.

It s hard to accomplish anything.... and then she gets

mad because I didn't cover all her issues. She admits

she is difficult and I think she has implied she even

feels sorry for me having to deal with her contrary

nature.

If I liked fighting I would have gone into boxing

like those wild huge women on late night TV

duking it out throwing each other over the

ring into the audience.

Amazing and not sure any of you know this but

NPH and regular insulin is available WITHOUT

a prescription.

So we parted ways. I wish I could have made our relationship

work somehow but the OCD part of me can't deal with a

patient like this. I feel relieved and a tinge of guilt.

She did tell me I'm the only doctor she will ever go to so

essentially she will never see another doctor again.

This sort of stabbed me through the heart.

I think Joanne would have kept her. Joanne, you are

amzing. Anyone get where I'm coming from?

Help with the late night guilt here....

I did the Joanne thing and did not accept any money

from her as she sort of fumed out the door. It was

a sad scene.

Pamela

[Guest guest]

Thanks Marty and . Its the late night with the left coasters.

The gal actually has only been to 3 medical appointments in

her life before stumbling into my office at around age 50.

Was dxd with DM 10 years prior and did not see a doc since

until me and resisted me the entire time she was with me (1.5 yrs)

speaking out of both sides of her mouth. " I hate being here.

I love your practice. You must hate me. I don't want to

come in. I don't want labs. I don't want anything.... "

It was very unsettling. I think I helped her - at least she

started insulin and she can continue OTC even if she never

goes to another doc again. Still sad. Thanks for the support.

Honestly, it was her resistance that just wore me out

emotionally.

Pamela

P.S. I think your offlist attempt ended up on the list.

>

> Hi Pamela -

>

> I'm answering off list, my preference.

>

> It sounds as though this patient is probably pretty PTSD from the medical

system and

also has a strong personality (i.e. borderline).

> How old was she when diagnosed? Probably teenaged. A few people with serious

chronic

disease seem to get locked into their emotional age at diagnosis pretty

dramatically.

You've already said that you are just not comfortable managing her without the

correct

labs, which is an appropriate assessment of your needs. She did have a choice to

keep you

by agreeing with what you needed, but that was unlikely to happen, as that would

have

changed the power balance.

> I do feel bad sometimes when patients like this separate, but that feeling is

part of the

push-pull interaction. Don't feel guilty about the " You're the only doctor " line

- that's why

she said it and probably not very accurate, frankly.

>

> When I work with patients that fight this hard, I sometimes remember an old

judo

teacher who translated a saying:

> " When they come, invite them, when they go, send them. " Not meant at all

literally, but

part of that wonderful emotional sense of working with the forces that are

presented to

you by the other person, keeping your own emotional forces separate and intact,

in that

" adult " way.

>

> If we didn't care about people like this and want to save them from

themselves, we

wouldn't be doctors.

>

>

>

> -------------- Original message ----------------------

>

> > I feel bad about this but I have a gal who has out of control

> > insulin dependent diabetes. She is noncompliant and

> > doesn't like doctors. I spent the first 3 months just

> > trying to get her to the lab for a FBG/HgA1c etc..

> > Finally registered in at around 400. I feel for her

> > because of a lethal combination of denial and a good

> > dose of resistance mixed with an active dislike

> > for allopathic medical doctors. She wants to do things

> > her way and there is no way in the world she is

> > gonna come back at the intervals I would want or

> > get the labs that I want/require....it goes on and on.

> >

> > There was a lot of tension when I saw her last. She basically

> > said she wanted to be able to get her own insulin with

> > out seeing a doctor and monitor herself at home.

> > She did not understand why I wanted all these tests

> > and why I even care despite me explaining things

> > over and over agian. So much resistance! I mean the

> > air was so thick with resistance. I mean we spend the

> > atleast 50% of every visit processing this resistance.

> > It s hard to accomplish anything.... and then she gets

> > mad because I didn't cover all her issues. She admits

> > she is difficult and I think she has implied she even

> > feels sorry for me having to deal with her contrary

> > nature.

> >

> > If I liked fighting I would have gone into boxing

> > like those wild huge women on late night TV

> > duking it out throwing each other over the

> > ring into the audience.

> >

> > Amazing and not sure any of you know this but

> > NPH and regular insulin is available WITHOUT

> > a prescription.

> >

> > So we parted ways. I wish I could have made our relationship

> > work somehow but the OCD part of me can't deal with a

> > patient like this. I feel relieved and a tinge of guilt.

> >

> > She did tell me I'm the only doctor she will ever go to so

> > essentially she will never see another doctor again.

> > This sort of stabbed me through the heart.

> >

> > I think Joanne would have kept her. Joanne, you are

> > amzing. Anyone get where I'm coming from?

> > Help with the late night guilt here....

> >

> > I did the Joanne thing and did not accept any money

> > from her as she sort of fumed out the door. It was

> > a sad scene.

> >

> >

> >

> > Pamela

> >

> >

> >

> >

> >

> >

> >

> >

>

[Guest guest]

Pamela,

She is an adult with adult onset DM?

She apparently had this opinion before the time of her diagnosis and being

diagnosed with a chronic incurable disease probably only reinforced her opinion

that doctors are worthless. If you are the only doctor she would see,

well then that is too bad for her. But if she has made up her mind about

things already you really can’t work with her. You can always leave

the door open, “when you are ready to accept the help you need, give me a

call.”

Kind of like handling an addict.

Some of them have to hit bottom before they will get help. Sounds like

her kind of personality. The good news is she is willing to try.

And yes, syringes and needles have never

required a prescription. But I think you sign for them which is why

addicts won’t just buy them. I know that beef and pork insulin are

not prescription items either. There was a Long Island murder case that

revolved around that I think, her name was Bunny or something. Left in a

coma. The new, fancy insulins are only available by prescription (Lantus,

Humulog, Novolog, Levemir, and all the various mixes.) And of course

glucometers, strips etc don’t require an RX. Having them paid by

insurance does require an Rx now that insurance is required to pay for this

stuff.

Kathy Saradarian, MD

Branchville, NJ

Solo low-staff practice since

4/03

In practice since 9/90

Practice Partner User since 5/03

[Guest guest]

From Drain: Heavens, Pamela, you don't need the fighting patient. You are overfull with people who want to see an MD. She clearly did not want to see you at all. You tried. One of my older Vet friends used to say that 20% of your patients should reject what you offer, because otherwise it means you are not offering enough. Of course, those were dogs. Yes, if I didn't lose my temper at her attitude, I might have kept that patient for acute illnesses, with an agreement that we would disagree and that I had to keep offering these things and she would just keep rejecting them, Mostly, the patients I see who act like that don't come in except for their pneumonia or their neuropathy some years later. Most of my Drainites are not so subtle that they try to torture the physician by saying in clinic things that imply they will

just go out and die rather than talk to another MD. I wonder if your patient would have shown the characteristic diabetic calcifications in her brain on MRI... one of my long term diabetic men with a very bad attitude also has that change in his MRI, (or at least that was what the neurologist said those little funny spots were.) There can be some triumphs using a process based system of allowing the patient to come to terms with their disease over time. I just got one of my known heavy drinking Barrett's esophagus patients to see a followup gastroenterology guy for the repeat endoscopy and to start counseling for drinking cessation. He was fully admitted to being up front in DENIAL-----he said so himself. I told him I figured he told me that he was in denial so that I could continue to confront him and try to save his life. It took three months of him making jokes about it

whenever I saw him in the store or on the street, but he gets the endoscopy in one week and will see me to confirm his alcohol management progress monthly. I get some real "Whee!" moments here in Drain... Joanne, the MD in Drain, Oregon roxywible wrote: I feel bad about this but I have a gal who has out of

controlinsulin dependent diabetes. She is noncompliant and doesn't like doctors. I spent the first 3 months justtrying to get her to the lab for a FBG/HgA1c etc..Finally registered in at around 400. I feel for her because of a lethal combination of denial and a gooddose of resistance mixed with an active dislikefor allopathic medical doctors. She wants to do thingsher way and there is no way in the world she isgonna come back at the intervals I would want orget the labs that I want/require....it goes on and on.There was a lot of tension when I saw her last. She basicallysaid she wanted to be able to get her own insulin without seeing a doctor and monitor herself at home.She did not understand why I wanted all these testsand why I even care despite me explaining things over and over agian. So much resistance! I mean theair was so thick with resistance. I mean we spend the atleast 50% of every

visit processing this resistance.It s hard to accomplish anything.... and then she getsmad because I didn't cover all her issues. She admitsshe is difficult and I think she has implied she even feels sorry for me having to deal with her contrarynature.If I liked fighting I would have gone into boxinglike those wild huge women on late night TVduking it out throwing each other over thering into the audience.Amazing and not sure any of you know this butNPH and regular insulin is available WITHOUTa prescription. So we parted ways. I wish I could have made our relationship work somehow but the OCD part of me can't deal with apatient like this. I feel relieved and a tinge of guilt.She did tell me I'm the only doctor she will ever go to soessentially she will never see another doctor again.This sort of stabbed me through the heart.I think Joanne would have kept her. Joanne, you are

amzing. Anyone get where I'm coming from?Help with the late night guilt here....I did the Joanne thing and did not accept any moneyfrom her as she sort of fumed out the door. It was a sad scene.Pamela

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[Guest guest]

Dear Pamela,

It sounds to me like you did a superhuman job with her for as long as you did. Don't beat yourself up about letting her go. You were very good to her. The comments about not seeing another doctor ever again, while perhaps meant as a compliment to you, were a low blow and very manipulative. She has made her choices up to now to take very poor care of herself, and that's not your fault. It's not your fault if she chooses to continue in this pattern as well.

Good job.

Lonna

Re: Patient predicament with (?) happy ending - maybe...

Thanks Marty and . Its the late night with the left coasters.The gal actually has only been to 3 medical appointments inher life before stumbling into my office at around age 50.Was dxd with DM 10 years prior and did not see a doc sinceuntil me and resisted me the entire time she was with me (1.5 yrs)speaking out of both sides of her mouth. "I hate being here.I love your practice. You must hate me. I don't want to come in. I don't want labs. I don't want anything.... "It was very unsettling. I think I helped her - at least shestarted insulin and she can continue OTC even if she nevergoes to another doc again. Still sad. Thanks for the support.Honestly, it was her resistance that just wore me out emotionally.PamelaP.S. I think your offlist attempt ended up on the list.>> Hi Pamela -> > I'm answering off list, my preference.> > It sounds as though this patient is probably pretty PTSD from the medical system and also has a strong personality (i.e. borderline). > How old was she when diagnosed? Probably teenaged. A few people with serious chronic disease seem to get locked into their emotional age at diagnosis pretty dramatically. You've already said that you are just not comfortable managing her without the correct labs, which is an appropriate assessment of your needs. She did have a choice to keep you by agreeing with what you needed, but that was unlikely to happen, as that would have changed the power balance. > I do feel bad sometimes when patients like this separate, but that feeling is part of the push-pull interaction. Don't feel guilty about the "You're the only doctor" line - that's why she said it and probably

not very accurate, frankly. > > When I work with patients that fight this hard, I sometimes remember an old judo teacher who translated a saying:> "When they come, invite them, when they go, send them." Not meant at all literally, but part of that wonderful emotional sense of working with the forces that are presented to you by the other person, keeping your own emotional forces separate and intact, in that "adult" way.> > If we didn't care about people like this and want to save them from themselves, we wouldn't be doctors. > > > > ------------ -- Original message ------------ --------- -> From: "roxywible" <roxywible@. ..>> > I feel bad about this but I have a gal who has out of control> > insulin dependent diabetes. She is noncompliant and > > doesn't like doctors. I spent the first 3 months just> > trying to get her to the lab for

a FBG/HgA1c etc..> > Finally registered in at around 400. I feel for her > > because of a lethal combination of denial and a good> > dose of resistance mixed with an active dislike> > for allopathic medical doctors. She wants to do things> > her way and there is no way in the world she is> > gonna come back at the intervals I would want or> > get the labs that I want/require. ...it goes on and on.> > > > There was a lot of tension when I saw her last. She basically> > said she wanted to be able to get her own insulin with> > out seeing a doctor and monitor herself at home.> > She did not understand why I wanted all these tests> > and why I even care despite me explaining things > > over and over agian. So much resistance! I mean the> > air was so thick with resistance. I mean we spend the > > atleast 50% of every

visit processing this resistance.> > It s hard to accomplish anything.... and then she gets> > mad because I didn't cover all her issues. She admits> > she is difficult and I think she has implied she even > > feels sorry for me having to deal with her contrary> > nature.> > > > If I liked fighting I would have gone into boxing> > like those wild huge women on late night TV> > duking it out throwing each other over the> > ring into the audience.> > > > Amazing and not sure any of you know this but> > NPH and regular insulin is available WITHOUT> > a prescription. > > > > So we parted ways. I wish I could have made our relationship > > work somehow but the OCD part of me can't deal with a> > patient like this. I feel relieved and a tinge of guilt.> > > > She did tell me I'm the

only doctor she will ever go to so> > essentially she will never see another doctor again.> > This sort of stabbed me through the heart.> > > > I think Joanne would have kept her. Joanne, you are > > amzing. Anyone get where I'm coming from?> > Help with the late night guilt here....> > > > I did the Joanne thing and did not accept any money> > from her as she sort of fumed out the door. It was > > a sad scene.> > > > > > > > Pamela> > > > > > > > > > > > > > > >>

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[Guest guest]

Thanks! What a wise group we have here. Pamela

> >

> > Hi Pamela -

> >

> > I'm answering off list, my preference.

> >

> > It sounds as though this patient is probably pretty PTSD from the medical

system and

> also has a strong personality (i.e. borderline).

> > How old was she when diagnosed? Probably teenaged. A few people with serious

chronic

> disease seem to get locked into their emotional age at diagnosis pretty

dramatically.

> You've already said that you are just not comfortable managing her without the

correct

> labs, which is an appropriate assessment of your needs. She did have a choice

to keep

you

> by agreeing with what you needed, but that was unlikely to happen, as that

would have

> changed the power balance.

> > I do feel bad sometimes when patients like this separate, but that feeling

is part of the

> push-pull interaction. Don't feel guilty about the " You're the only doctor "

line - that's

why

> she said it and probably not very accurate, frankly.

> >

> > When I work with patients that fight this hard, I sometimes remember an old

judo

> teacher who translated a saying:

> > " When they come, invite them, when they go, send them. " Not meant at all

literally,

but

> part of that wonderful emotional sense of working with the forces that are

presented to

> you by the other person, keeping your own emotional forces separate and

intact, in that

> " adult " way.

> >

> > If we didn't care about people like this and want to save them from

themselves, we

> wouldn't be doctors.

> >

> >

> >

> > ------------ -- Original message ------------ --------- -

> > From: " roxywible " <roxywible@ ..>

> > > I feel bad about this but I have a gal who has out of control

> > > insulin dependent diabetes. She is noncompliant and

> > > doesn't like doctors. I spent the first 3 months just

> > > trying to get her to the lab for a FBG/HgA1c etc..

> > > Finally registered in at around 400. I feel for her

> > > because of a lethal combination of denial and a good

> > > dose of resistance mixed with an active dislike

> > > for allopathic medical doctors. She wants to do things

> > > her way and there is no way in the world she is

> > > gonna come back at the intervals I would want or

> > > get the labs that I want/require. ...it goes on and on.

> > >

> > > There was a lot of tension when I saw her last. She basically

> > > said she wanted to be able to get her own insulin with

> > > out seeing a doctor and monitor herself at home.

> > > She did not understand why I wanted all these tests

> > > and why I even care despite me explaining things

> > > over and over agian. So much resistance! I mean the

> > > air was so thick with resistance. I mean we spend the

> > > atleast 50% of every visit processing this resistance.

> > > It s hard to accomplish anything.... and then she gets

> > > mad because I didn't cover all her issues. She admits

> > > she is difficult and I think she has implied she even

> > > feels sorry for me having to deal with her contrary

> > > nature.

> > >

> > > If I liked fighting I would have gone into boxing

> > > like those wild huge women on late night TV

> > > duking it out throwing each other over the

> > > ring into the audience.

> > >

> > > Amazing and not sure any of you know this but

> > > NPH and regular insulin is available WITHOUT

> > > a prescription.

> > >

> > > So we parted ways. I wish I could have made our relationship

> > > work somehow but the OCD part of me can't deal with a

> > > patient like this. I feel relieved and a tinge of guilt.

> > >

> > > She did tell me I'm the only doctor she will ever go to so

> > > essentially she will never see another doctor again.

> > > This sort of stabbed me through the heart.

> > >

> > > I think Joanne would have kept her. Joanne, you are

> > > amzing. Anyone get where I'm coming from?

> > > Help with the late night guilt here....

> > >

> > > I did the Joanne thing and did not accept any money

> > > from her as she sort of fumed out the door. It was

> > > a sad scene.

> > >

> > >

> > >

> > > Pamela

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> >

>

>

>

>

>

>

>

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