That's Doctor Evil, I didn't go to six years of evil medical school to be called miss, thank-you very much...

I've had my share of difficult patients but one in particular stands out...

This patient was an older man who was referred from the occupational health clinic at his place of employment. He was in the public transport industry. He was HIV positive with a CD4 count of 186 and had recently completed a full 6 month course of TB treatment. The referring sister had sent him for ARV treatment.

This was his second visit and one of my colleagues had seen him previously, repeated the CD4 and taken some other baseline blood tests. He had also prescribed some vitamins and sent him for an adherence class to prepare him for starting ARV's. I now had his blood results before me. His CD4 count had gone up to 258 - not really surprising since the CD4 count fluctuates anyway, but more because it tends to go down when a patient has an opportunistic infection such as TB an goes up again once it's been treated. I conveyed this information to him. He understood English but didn't speak it very well so he spoke to my assistant in Swazi and she translated for me. He said that he did not want to start ARV's as he didn't need them now since his CD4 had gone up. That's reasonable I thought. The cutoff for ARV's in our country is 200, even though the WHO recommends 350 in countries such as ours where TB is rife. We tend to start at higher CD4's than the state clinic's so he could still have started ARV's then if he wanted to but it was also ok to wait a while.

But I had also noticed that his blood pressure was very high. I checked my colleague's notes and saw that it had been high at the previous visit as well. It was so high that lifestyle changes alone would not good be enough. I explained to him what it meant, about end organ damage and that we needed to start him on anti-hypertensives.

His response was simply that his blood pressure was not high.

I explained that it was in fact high. Again he told me that it was not. Just like that.

I was a bit stunned and didn't quite know how to respond to this. I've seen patients who were in denial about TB or HIV before but never one who was in denial about Hypertension! I was also quite insulted that this uneducated man simply disregarded my medical education and clinical skills and simply told me that I was wrong.

I took a deep breath. I had visions of him transporting a load of people and having a stroke or heart attack behind the wheel, crashing and leaving a bunch of dead people scattered all over the tarmac.

I remained calm. I told him that I was not doing guess work, that this was a physical parameter and that I had measured it and it was, despite his expert input, high and needed treatment. I tried to convey to him that he was responsible for the people he transported and that with a blood pressure that high, a stroke was a high likelihood.

At this point he got aggressive. He told the interpreter that there was in fact nothing wrong with him, he did not have high blood pressure, he did not even have HIV, he did have TB but that had been treated, so there was actually nothing wrong with him now. He said that we were wasting his time and that the last time he'd been there, he'd flushed the tablets we'd given him down the toilet. I must admit I found that a bit amusing. Why did he even bother to take the tablets then? I pictured him standing over the toilet cursing and angrily flushing the tablets away, mumbling about how he was in perfect health and we were all deluded. He said that the only reason he was attending was because he had been referred to us by his occupational health nurse and because his employer was paying for it and had money to throw away.

I developed an acute case of compassion fatigue.

I sent him on his not so merry way, didn't bother to give him a follow up date and sent a letter to his occupational health nurse by email asking for him to be boarded him until his blood pressure was under control. I then called her to make sure she had received my letter and discuss the case with her. She shed some light on the matter saying that very high blood pressure was considered an occupational hazard and that he knew this, which was probably why he had behaved the way he had.

I had little sympathy for him. It was a problem that was easily solved, but he was not interested. If he didn't want treatment, that was his problem, but I was not about to let him put innocent people at risk.