Helping Those Who Help Themselves

By Shaher T. El-Hadidy, MD

Dealing with human beings can sometimes be a challenging endeavor. The doctor-patient relationship is a fragile entity that is ideally based on mutual respect and trust. I still remember a challenging case I faced in one of my out patients where a women in her early forties presented with an ache on the tip of her right index finger, below the nail. There was no night pain or cold sensitivity. This woman, who dressed and behaved in the manner of people from the affluent level of society, had approached me after getting multiple opinions from an array of doctors concerning her pain and was given creams and NSAIDs with no improvement. As a hand surgeon and a man of science, I expect that patients would listen to reason, I respectfully informed the patient that to examine her finger I would need to remove the nail polish she had on. Before I even had a chance to explain why, the patient got very angry. She said that I have no right to request this of her and she left the consultation room in anger. I respected the patient’s right to refuse treatment and documented my account of the consultation. 

A month later the patient requested another consultation, which I gladly provided and on this occasion she presented without nail polish. On examination, there was a bluish hue at the vicinity of the lunula of the index finger. I used the tip of a paper clip as a hammer and she flinched as this caused her localized pain. My impression at this point is that she has a glomus tumor and I explained she needed an X-ray AP and AP magnified and the same with the lateral and an MRI. She became very agitated by the word tumor and started crying. I comforted her that it is unlikely that it is a cancer we were looking at and, even though I explained the situation thoroughly, she refused to go through an MRI and for the second time left the consultation room in a distraught manner.

Sadly, a few years later, she returned with a deformity of the nail coupled with enlargement of the distal segment. I wish she had listened initially and we might have evaded the deformity she ended up with. The treatment and course of her disease was explained but the patient did not want my advice or help, she wanted a magic pill to make her better, which, in this case, unfortunately does not exist.

In hindsight, I should have showed her evidence of what her finger might develop into. I have now started to adopt this approach with my patients as it gives them insight into their ailment. I have also started providing my patients with links to trustworthy websites which give access to peer reviewed search engines so that my patients can be more informed about their disease. 

Furthermore, I also kindly request from my patients to remove nail polish prior to attending, given in this case is a potential hindrance to the clinical examination of the hand. It is moments like these that stay with me.

We have sworn an oath to help the sick and do no harm, however, the fact remains that we can only help people who want to help themselves. Given that the patient had capacity I respected her decision. I have found over the years that the hardest part of being a physician is treating a patient you know you can help but they choose not to heed the advice.