When Patients Disagree and Don’t Believe You

Unlike some of my colleagues, I know that both an overactive and an underactive thyroid can cause blood pressure elevations. But the other day a patient with erratic pulse and blood pressure didn’t believe that he needed a heart monitor and a 24 hour urine for the various stress hormones that can cause his symptoms. He thought a small change in thyroid function was the only reasonable explanation and that an adjustment of his levothyroxine dose would do the trick. He was unsure about how soon this change might be effective, because the TSH blood test takes 4-6 weeks after a dose adjustment to reflect the new steady state. Of course I know that symptoms usually change much quicker than that after a dose change.

In this case, my strategy was to say that a primary arrhythmia, like paroxysmal atrial fibrillation, or cortisol excess or even a pheochromocytoma were things worth considering, so why not widen our exploration to also include them in our differential diagnosis while we waited to see the effect of his medication adjustment. He agreed and we are working together instead of butting heads.

Both because I’ve seen a lot in my many years of practice and because I trained in another country on another continent (Sweden), I am well aware that there are many ways to approach any given clinical situation. I have seen new drugs and new diseases come and go, so who am I to be completely dogmatic or unwilling to include my patient’s beliefs in my differential diagnosis or treatment strategy?

My mother was very opinionated and not always right and I have had bosses who thought they knew better than the doctors they supervised, so perhaps I have a little extra experience in getting along with people who don’t believe me.

So my strategy is to avoid direct confrontation about beliefs, but to be inclusive, to pursue two alternate strategies at the same time if at all possible. If the patient’s and my theories are mutually exclusive, I sometimes say “we couldn’t possibly do both things at the same time, so which do you want to try first?”

If I believe my patient wants to try something dangerous or doesn’t believe me when I try to convince them that not following my advice could cause them harm, I say just that, plain and simple. In those cases, parting ways may be the only way to go, but I frame that as the patient leaving my care by choice.

But don’t lock horns with headstrong people unless you are willing to be fired.