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IN PRACTICE

Hi, I'm the doctor, and I won't be taking your order today

In theory, an office visit should be a doctor-patient partnership. But both sides can pull attitude.

January 19, 2009|Rahul K. Parikh | Parikh, a Walnut Creek physician, writes the Vital Signs medical column for Salon.com. www.rahulkparikh.com.

Sometimes, the minute you step into the room, you just know it's not going to go well -- as it didn't with the mother of this teenage girl.

Her daughter sat quietly on the exam table, coughing. Next to her was Mom, probably in her mid- to late 40s, but by her clothes seemingly clinging to her youth -- tight jeans, bright pink sweater; it looked as if she shopped at Forever 21 in her local mall. Her hat, a puffy billed urban thing, belonged on a hip-hop star's head instead of on her blond, well-to-do suburban one.

I'd barely had a chance to sit down when Mom started right in. She had a snooty tone, the kind that says, "I know exactly what's wrong with her," while she told me her kid's story. (Wasn't the kid old enough to tell me herself?)

"She's been coughing for two weeks. Nobody's sleeping at home, and now I'm getting it too. I've given her half a bottle of cough syrup, but it's not working. Her dad had it and his doctor gave him codeine cough syrup, and even though he's still coughing, he's sleeping better."

I cringed. I had been in this room less than two minutes, and in less than 30 seconds, I knew I didn't like this woman. My glare hardened and my lips curled in as I replied.

"If that's what you want, you won't be getting it from me," I told her sternly.

The cough syrup she wanted, promethazine with codeine, is no better than over-the-counter stuff, and the only reason it makes people sleep is because it contains a fair amount of alcohol.

I suggested the mother might as well buy her kid a drink before bedtime instead.

I know. I shouldn't have said it. I'm usually much better at talking to parents, even demanding ones, and negotiating some kind of agreement. I should have explained to her, professionally and courteously, that prescription cough medicines have not been shown to be any more effective or safe than over-the-counter ones, and that there have been reports of young people taking promethazine-and-codeine cough syrup and dying from respiratory failure.

I even could have told her how a few years ago, one mother in my practice kept calling and demanding the same medicine for her kids from me and my colleagues. She turned out to an alcoholic who was drinking bottles of the stuff herself.

But, irritated, I didn't do any of those things. I told her, basically, that she was out of luck. Her demand for medicine was not negotiable.

After all, who was I really here to see? The patient, who hadn't even spoken yet? Or Mom, who demanded that all of the racket in her house -- the coughing, sneezing and sniffling -- stop because she hasn't been sleeping? (She told me her daughter actually had been sleeping, despite her cough.) If it's sleeping pills Mom needed, then she ought to drive her luxury SUV over to her psychiatrist's office.

I moved on, turning my attention to my patient, still sitting there looking annoyed. (I didn't know whether it was with me or her mother.) I asked her a few cursory questions: Do you have any nasal congestion? Runny nose? Fever? Then I listened to her lungs with my stethoscope -- crystal clear.

I said that the girl's lungs sounded fine right now, but that the dry persistent cough could be caused by viral bronchitis. The best way to treat it wasn't with cough medicine, but with a couple of inhaled medicines that reduce inflammation and open the airways. "I think you'll see improvement in five to seven days," I said.

"But why did my husband get cough medicine, then? I'm just saying, he's sleeping better at night. Sure, he's still coughing, but he's starting to heal."

She went on. "And what's she supposed to do while we're waiting for the medicine to work? Is she just supposed to cough? That'll be another three to five days?"

I wasn't going to back down. "Look, based on what I've heard and my exam, this is the best way to go. But if you're not sure, we can do an X-ray, or you can get a second opinion with your regular doctor. But if you want to get to the root of her problem, this is probably the best way to go. What would you like to do?"

I expected her to walk out right there -- and complain to someone on the way out about her visit. (I probably deserved it.) That's when I heard the first complete sentence out of my patient, the girl sitting on the table whom I'd almost forgotten because the mother was so overbearing. "Mom, let's just try it."

Grudgingly, Mom took the prescription for inhalers. It would take a few days for her to see the earliest signs that her daughter was getting better. I was pretty confident she didn't have that kind of patience.

It wasn't my best moment as a physician. I was stubborn, blunt and dismissive. Doctors should work to serve patients whether we like them or not. It's best for both sides when that pact takes the form of a partnership, in which both work together to figure out what's best by combining science, instincts and heart.

That was not me. And I think it's because that partnership was lacking from the very beginning.

We all agree that patients don't like to be treated like children, talked down to or told to just "take two of these and call me later." But doctors don't like to be treated like waiters -- taking orders from a menu prepared by the patient.

In that sense, maybe we both deserved better from the encounter. She deserved more professionalism, empathy and reassurance from me, as well as a clear, calm explanation as to why there were better ways to handle her daughter's illness than with cough syrup. I deserved the chance to actually consult with my patient, this teenage girl, and have the time to take a better history, without having this mom bear down on me with her demands and expectations.

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