A fellow came in yesterday to see me.  He had developed a small inguinal hernia that resulted as a consequence of imprudent lifting.  He did not know what this new and painful lump might be.  His general mood was wrathful – he seemed much more interested in determining whose fault it was, that the hernia had appeared.  He seemed to focus on the medical establishment as the tortfeasor of his own personal misery.  (And we wonder why our citizenry is mocked by others for vanity and disrespctfulness.)

Through our normative acceptance of bad schooling, poor instruction and even worse study habits, we habitually jettison any relevant and useful information, sleep through the class, and just hit the bright orange ON button and see where she goes. 

We throw away the assembly manuals from IKEA, ignore suggestions about breaking in new automobiles, sneer in general at any suggestions offering to inform us.  We dismiss them contemptuously, as though written in choppy Chinese prose.  We have the Force.  We just Know.

We know the best way to do things – tear up the rules and cut corners.  It keeps our emergency rooms busy.  Let ‘er rip, any old way and often buzzed, and race to the ER when we cause some minor but painful damage to ourselves.  All the while and loudly too, ignoring any useful advice from the ER staff, we blame our misery on the tool used, weather, cheap manufacturing, anything but what actually caused the injury.

I became snagged on my immature patient’s wrath when I began to stage and describe the hernia.  It was, I said and I still maintain, a SMALL hernia.  It protruded perhaps an inch at best, and did not descend from the inguinal foramen.  It lacked all of the parameters that gigantic hernias demonstrate – therefore, it was not gigantic.

My patient became increasingly angry that I should refer to it as a small hernia.  He was offended, insulted, by such a characterization, as though my attitude was shocking.  I gently explained the natural history of the pathology of inguinal hernias, and how they might progress.  I emphasized that small and large hernias can be equally painful; in fact, a small new hernia may well be more uncomfortable than a well-established large hernia.

He wasn’t buying it.  He battled back on all the descriptions of the various degrees of herniation, intent on demonstrating that my classification was ignorant and unsympathetic.  We battled over the topic of strangulation in a hernia in which the splanchnic contents, in fact, do not protrude beyond the abdominal wall.  He wouldn’t have any of that.  He argued that the risk of strangulation was no different in a large and small hernia, but that I was just being indifferent to his medical care.  I demurred.

I suggested a hernia belt, or truss.  He was deeply offended, as he knew intuitively that such care was old-fashioned and negligent.  He needed surgery, and proposed a mesh repair.  Not being a surgeon, I confessed uncertainty about whether that would be the best treatment, and deferred to a surgeon’s examination.  He pressed, trying to have me agree to a surgery before he should see the surgeon.

Of course, some prescription pain medication was expected as well.

Sadly, this is just the sort of fellow who gets a bad result in the long run, and the stairway of bad consequences usually leads to awful litigation.  If he dislikes the propensity of Homo sapiens to produce abdominal wall hernias, he should take it up with the Maker. 

Also, staging something’s severity is a common and dispassionate exercise of the physician’s diagnostic duties.  Super-Sizing a hernia does not mean a better hernia, or improved treatment.  Improper diagnosis or treatment under duress from the patient rarely leads to improved outcomes.

Nevertheless, it is sheer customer arrogance that many people sling wildly about the clinic, starting with the oafs and proles who people the front desk.  I do notice that young white males predominate in this pattern of presentation of their expectations.  Persons of all other shades and the broad rainbow of genders can be obnoxious, that’s a fact – but I have the impression that my own mirror-image, the Average American, enters with this pattern of impudence.

Our patient may well argue his way into surgery, and bull his way to getting a postage-stamp-sized mesh.  Then, he will likely be wrathful about the unwanted consequences of the unnecessary surgery.  Pain is a common result of surgery, and that does not imply that they surgery was shoddy.  The pain may be worse than that of the hernia untreated.  Mesh falls off, postoperative infections occur.  Those outcomes are not part of the fantasy which this fellow believes he can scream his way into receiving.

So many people believe in the magic OPEN SESAME! of rudeness and petulance, as though foul and offensive behavior can achieve the best results.  It never worked for the British Empire.  It does not work for us.

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