Practitioner Question of the Month – September 2017

Napapat T. says

I have a question about your recommendation; “Have a snack when waking and see if this helps with your sleep.”
May you explain how this helps with sleep problems?

Thank you

Happy to answer this question, because it is a key concept to understand. When people have a tendency toward low blood sugar, they will often exhibit the following symptoms:

1. During the day: fatigue, brain fog, shakiness, or irritability if missing a meal
2. At nighttime: insomnia

Both of these can indicate low or unstable blood sugar; termed loosely, you could say hypoglycemia.

These patients will often do well with frequent meals during the day. They may also respond well to adrenal support. Foundationally, it is important to determine where any ‘stress’ is coming from that could be causing this (blood sugar is partially mediated by the HPA axis and chronic stress can cause dysregulation). The stress might be obvious (examples: diet, sleep, emotional stress) or less apparent (examples: inflammation, true hypothyroid, GI imbalance).

When low blood sugar occurs nocturnally, it can lead to the release of stress hormones to bring up blood sugar, and this can interfere with sleep. So, just like someone here does better with frequent meals during the day, they may need to get some ‘fuel in the tank’ before bed to prevent a blood sugar low and/or have a snack when waking to help keep blood sugar up. This will not fix the problem, but it can provide immediate aid in many. Fixing the problem will be achieved by addressing the source of ‘stress.’ Adrenal support will not fix the problem either, but it can provide relief and may decrease time to recovery.

What they eat does not matter, so have them experiment with anything allowed within whatever diet they are on. If this is the right approach for someone, they should notice a difference immediately. If they don’t, move on.

When to kindly send volatile patients elsewhere.

Some people are unhappy no matter what you do, and this also applies to patients. Some can be rude, demanding, and, despite your best efforts to help them and meet their demands, leave a nasty review about your clinic. This can be a challenging issue to navigate for many clinicians because we all want to help people and we are also likely empathetic to the fact that someone may be acting rude or mean because they are not well.

I believe in being empathetic and working with people, but over the years (and after being taken advantage of), I have come to draw one non-negotiable distinction. If people are not polite and respectful, they have no place in my office. I can tolerate someone who is needy, emotionally draining, requires extra time, and things like this, but not someone who is rude, mean, or disrespectful.

Eventually you develop an intuition and will hear that voice in your head say ‘be careful with this person’ or ‘this person seems off’ or something similar. I used to work with these people out of the desire to help them, but every time I did not listen to that voice in my head I ended up getting screwed. Screwed most often meaning people left bad reviews (even when I bent over backwards to help them). There were also a few times when we decided to allow someone to pay at a later date after they made an emotional plea that they desperately wanted help but just needed to get some funds together, and then…they vanished.

When working in the insurance model, word of mouth isn’t supremely important because the insurance system provides a stream of patients to your office. However, when working in a hybrid or cash office, word of mouth and reputation are much more important, thus these malicious patients are exponentially more damaging. This is why, at least in my experience, it is important to have screening processes in place, and when high-risk patients are identified, refer them elsewhere. Here is what we do in my office:

1. Filter with initial paperwork
2. If established during first visit – refund, apologize/explain and refer
3. If established during follow-up visit – no charge  for that visit, apologize/explain and refer

First, we can get a hint based upon the initial paperwork. If our medical assistant sees any of the early warning signs, she may inform the prospective patient that our office might not be the right fit.

Second, if I get a bad feeling during our initial visit, I may apologize to the patient and explain that I am not the right provider for him/her. We will also refund them for their visit and provide a few suggested providers if we know of any who might be the right fit.

Finally, if we miss this initially, then during a follow-up visit I may apologize to the patient and explain that I am not the right provider for him/her. We will also refund them for that day’s visit and provide a few suggested providers if we know of any who might be the right fit.

Essentially, you are looking for anything that is out of the ordinary:

• They are complaining about price, paperwork, wait time, your tie (joking), an office policy, etc.…that is outside of what you normally hear.
• They make demands that seem unreasonable. ‘I need to talk with the doctor,’ or ‘Dr. X should do this because blank…’
• They come off as generally unappreciative and have an air of anger or resentment.

It is hard to send someone away. It can be socially awkward and sometimes just easier to ignore the issue. However, and as I stated earlier, every time I have done this, it blew up in my face. One thing that has been very helpful for me is to use whatever their complaint or objection is as the reason for me not being a good fit. If they complain that ‘they can’t email you directly and that they don’t agree with your fee structure,’ then you can say ‘you’re right and I understand your concern, and while I’d love to help you, I think someone who has more email availability and a different price structure might be best suited to work with you.’ In truth, that is likely the case. Now, as soon as you say this, most people will immediately forget about their complaints and say that it’s OK and that they still want to work with you. This is where you have to be strong and stand your ground.

I wish issues like this never came up in the clinic, but unfortunately they do. I wish I could just help everyone and ‘turn the other cheek,’ but unfortunately these same people will often defame you and the good reputation you are trying to build. We have all worked hard and sacrificed a lot to become clinicians, and it is just not worth working with malicious patients who can partially jeopardize that. Be honest, fair, operate with your patient’s best interest in mind, and always work to treat people like family. If you do this and still get someone who feels malicious, mean, or ungrateful, then it’s best for you to kindly refer them elsewhere.

I’d like to hear your thoughts or questions regarding any of the above information. Please leave comments or questions below – it might become our next practitioner question of the month.