I took a deep breath and entered the exam room where Mary was waiting. Her weight was up more than 10 pounds in the past month, and she reported dyspnea on exertion. She had told the nurses she was only taking half her furosemide dose. I asked her why.

“I can't take that dose, doc. It makes me pee too much,” she said.

“But you need it, Mary,” I said. “Your kidneys don't work as well as they used to.”

“They work just fine!” she insisted. “I pee all the time. I don't want to use the public toilet or get up in the middle of the night!”

What is a conscientious physician to do in a situation like this?

Many physicians have a mental template of a “good” patient. They follow our advice, take their prescriptions, call us only when appropriate, and know when they should go to the emergency department. Most of our doctor-patient relationships fall into this category, but the ones that don't seem to keep us up at night. Some studies show that primary care doctors describe patients as “difficult” in 15–20% of visits.¹ This description usually stems from patients not adhering to the plan laid out by the physician. Some patients neglect screening exams, reject vaccines, or do not take medications as prescribed. Others are unwilling or unable to cease cigarette smoking, substance abuse, or unhealthy eating. Still others are chronic no-shows, have long lists of complaints, or are “frequent fliers.” (Note that I'm not talking about patients who are verbally or physically abusive here. That behavior is beyond “difficult” and should never be tolerated.)