We all have them — patients who require a lot of our time and energy, not necessarily because they are sick but because they are hypochondriacal, needy, or entitled. The latter are the worst kind. They want what they want when they want it. They call with urgent demands and show up without an appointment. They belittle staff, and they feel they are different from everyone else so rules don't apply to them. They are pushy and, quite frankly, drive me nuts.

Susan was such a patient. She was married to William, another patient of mine who was also high maintenance and an enabler. Together they were hard to take and frequently called in for tests or medications without being seen. This time the call came from William, who wanted a referral for Susan to an endocrinologist. I knew she was on a lot of hormones — none of which I had prescribed for her. They went to a holistic practitioner who took care of her numerous meds and tests, half of which I rarely used or had never heard of before. Unfortunately, that practitioner had retired so I was called for the referral, which she wanted stat. She knew which endocrinologist she wanted to see, so — not wanting to be bothered with why — I had Dalia, my office manager, make the referral. For some reason it didn't go through, and Susan showed up at our door distraught and caused a scene in front of other patients. Susan later apologized by phone for this behavior, but when the second faxed referral apparently wasn't received by the endocrinologist's office, I got an email from William saying Dalia had treated Susan in a profoundly irresponsible manner, causing her and their family a great deal of emotional stress. He went on to say that Susan had attempted to contact me to inform me directly of the many incidents, but Dalia was intercepting the calls. My reply to him was succinct:

“I am sorry to hear that you are having a hard time with our office and Dalia. In all the years she has worked for me, I have never had one complaint about her, only praise. She is the best, most efficient office manager I have had, and after 40-plus years in practice, I have had quite a few. Regarding the referral, I have seen the record of the fax she sent last week and I personally observed her resending it today. I don't know why they didn't get it; perhaps the problem was on their end. In any event, we do the best we can for our patients and hope that will be good enough for you both.”

It was good enough for a time, but not for the endocrinologist who, quite correctly, wanted to know the reason for the referral. I had let my frustration with this patient get in the way of good medical judgment. Why did she need to see this specialist? “Susan's testosterone level was 520 when she was no longer using testosterone,” William informed me in a subsequent telephone call. “She asked my prostate doctor about it during my last visit, and he said she could have polycystic ovary syndrome and might need a pelvic ultrasound. That freaked her out!”

“When did she stop using testosterone?” I asked him, knowing that lab test was three months old because I had been asked to order it.

“About four or five months ago,” William said.

“Well, maybe it hadn't gotten out of her system yet,” I said. “Perhaps we should repeat the test before getting the scan. Why don't you and Susan come in tomorrow so we can talk about it?”

It turned out that Susan already had had an endovaginal pelvic ultrasound for lower abdominal cramps a year before ordered by a colleague during my absence, and it was negative. With all the testing Susan had had, she didn't recollect it, but when I showed her the report she was relieved. I offered to repeat the blood test and told her that if her testosterone was normal, we would forget the whole thing; if not, she would get her referral. She agreed, and they left seemingly satisfied with this plan, but I couldn't help but wonder what they would ask me for next. I vowed to be better prepared, to not let their sense of urgency get in the way of my diligence, and to confidently say no to inappropriate demands.