COMMENTARY

The Smelly Patient: Some Fresh Air From Your Peers

Brandon Cohen

Disclosures

April 02, 2012

During an all-physician group discussion on Medscape's Physician Connect concerning unpleasant patients, a psychiatrist posed a question: "I had a patient who smelled so bad that no one could sit in the waiting room or office with them. How would you handle that?" Several colleagues chimed in with suggestions and stories about this delicate topic.

Some reported simple solutions to simple problems. "The [foul-smelling] lady was morbidly obese, and very poor," wrote a general practitioner. "She had 2 nice kids. I didn't want to discharge the family, so I called the mom and privately explained the situation. She took it quite well and thereafter wasn't a problem."

"I had a situation similar to this," added a pediatrician. "The mother of one of my patients smelled so bad that I literally could not breathe when in the small exam room [with her]. After the third visit, I calmly and apologetically told her. She did not get offended (not outwardly). I thought that she would not return but she did, bathed and deodorized. I never mentioned it again nor alluded to it, and our relationship continued for a number of years."

A child psychiatrist broke it down into greater detail when describing a malodorous patient: "Brief, direct to the point, corrective sentences are effective, if you want to be listened to and heard at the same time. A single educational session can work. Just as the patient entered my office, the said odor greeted me. After a brief social greeting, I apologized and asked to be excused so I could open all the windows in my office. I then sat down, and I asked whether she had noticed that I did exactly what her therapist had been doing every time she was in session. She was curious, and asked why. When simply told that she emanated a very foul odor, she was flustered and said she noticed that her coworkers didn't want to be near her as well." The psychiatrist advised the patient to "Buy 5 different deodorants, use a different deodorant each day after a shower or bath. This worked wonders."

Some situations proved trickier. A psychiatrist whose new patient had extremely poor hygiene wrote that "I tolerated it for the consultation and picked up on the patient's low self-esteem. Starting that way would have been impossible if I had not also detected intelligence masked as rough, elemental speech and a fierce need for connection with someone. This patient continued to smell for months; people wondered why my window was open in January. In brief, analysis lasted 7 years, and I helped him develop the appropriate level of self-regard and functioning."

Another doctor wrote of a more disappointing outcome: "I supervise a very-low-calorie-diet weight loss clinic. We had a fellow [with] such poor hygiene that we had people leave the waiting room, and one lady actually threw up. I felt sorry for him because he only had a bathtub and was so heavy, and had knees so bad, he couldn't get into it. We all had several discussions with the patient. Finally, [we] came upon what we thought was a solution. We made it mandatory for him to stop by the HealthPlex at the hospital (included in the weight-loss program) and shower prior to his weight loss visit. When this failed, we sent a discharge letter. Now, I think maybe I should have sent him for a psych evaluation because he was at least passive-aggressive and maybe [had] a personality disorder."

Some doctors saw the odor as a symptom: "Test for trimethylaminuria," a general practitioner advised.

Picking up on this idea, a psychiatrist wrote, "Years ago, a female patient presented for a psychiatric appointment with such a bad smell that the odor was apparent long before she actually got to my office. It turned out this poor lady had advanced breast cancer with a lesion that was eating through the breast and oozing foul-smelling necrotic gunk! She was too psychotic to know what was happening. Fast-forward to after surgery and on antipsychotic meds: No more odor, no more craziness. So, it's always good to go back to basics: Don't assume something has a psychological cause until you've ruled out medical causes!"

Finally, a general practitioner from rural Missouri managed to take the problem and turn it into an opportunity for community-based action: "[The patient] mentioned that she had been asked to leave church the previous Sunday because of her odor. I became curious, and asked her why she thought they said that to her. Surprisingly, she admitted she knew she smelled bad. She continued, adding that she had no running water in her trailer, and therefore no way to bathe. So, my kind office manager took her into my private office and allowed her to use my shower. Knowing this to be only a temporary fix, my office manager looked for a more permanent solution. She came up with the idea to hold a fundraiser to raise enough money to clean out the patient's old water well and get it working again." After rallying the community to raise several thousand dollars, the physician realized, "This is why I became a physician -- to make a real difference in people's lives!"

View this and other discussions in Physician Connect. Note, this is open to physicians only.

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