#23 Can We Do Anything About Difficult Patients?

The folks at the Inside the Match podcast and blog allowed me to post this guest blog:

Changing How we Think About Difficult Patients — Inside the Match

Their website starts with the premise that they offer “Everything you wanted to know about the residency match process — but were afraid to ask.” an impressive team of resident and attending physician bloggers offer up short posts about how to parent, keep pets, rank programs, and teach medical students. The advisory board is comprised of distinguished members of the medical education community from a variety of specialties.

People outside of our profession may not realize all the complexity that goes into the process by which medical students decide on potential specialties, interview for programs, and go through a computerized match process with the various training programs. The students rank order their selections and the residency programs rank order the candidates in the order that they want the students to enter their residencies. Students who are married can enter a special couples match. 

All the lists get entered into a computer and on Match Day (March 18th this year,) students are notified where they matched. Some people are elated, some are surprised, and some are heart-broken. Once upon a time, I was one of those people who was heartbroken, and I will share that experience in a future post.

The Inside the Match website, podcast and blog tries to cut through the mass of fiction, myth, and disinformation surrounding the match and life as a resident. I recommend that medical students, their families, and friends all have a look. Understanding what is involved will go a long way towards compassion for people going through the process.

Here is my post about a common challenge residents and students who take care of patients will inevitably have. One out of every four to five patients will be someone who seems to be difficult in some way. What can you do? A Lot:

 Changing How we Think About Difficult Patients

After I finished my residency in EM and started working as an attending physician, I realized I had a problem.  I believe a lot of you have the same problem. Some of our patients are so angry, oppositional, and non-compliant that we get angry and frustrated.  We become cynical as we start to think, “nothing I do can help this person.” We start to feel exhausted and burned-out. I researched the problem from the side of the patients and the physician. I read the literature. I wrote a lecture about it in which I suggested some solutions to to our residents in training. I expanded that lecture into a book that has just been published by the American Association for Physician Leadership.

You don’t have to change your job and you don’t have to leave the profession that you worked so hard to get into. You actually have to change the way that you think about your difficult patients. It sounds like wishful thinking, I know, but you can do it.

All of us have adopted a very negative attitude towards our patients. It’s not really our fault because human doctors naturally have a very suspicious and skeptical nature.  Our cave men ancestors had to be on the lookout about lions and bears lurking outside their caves. We are taught to be on the lookout for danger in the form of urgent Zebra diagnoses and dramatic deceptions.  On top of all that, we hear our senior residents and attendings loosely tossing about derogatory names for our patients like gomers or dirtballs. Everyone in the nurses’ stations and the breakrooms mocks their patients and tells stories to lighten the mood.

If our patients do not act the way we expect them to or comply with the treatment plan, they are labelled as “difficult” patients.  Once you believe a person is difficult, given the concept of confirmation bias, you will naturally look for (and find) evidence that supports that belief. Of course, we find ourselves avoiding difficult patients, cutting off their conversations, and quickly discharging those people we cannot stand.

Our patients go through some very predictable fears and responses to illness and injury. In turn, medical students and residents also think and respond with some thought distortions and misunderstandings about their patients and themselves. Armed with awareness and familiarity with the typical patterns, we learn more about what to expect. We anticipate when we will get push-back and we are better prepared to act calmly and confidently.

Additionally, we can get curious and ask better questions during those challenging interactions.  What else is true about that grumpy old man?  Is he someone’s father or grandfather? Could some of the patient’s behavior be a symptom of his disease? If we remember that, don’t those facts make the patient’s actions a lot more understandable? Is there another way to approach a problem to which you see only one solution? Can you reach some collaborative plan that satisfies both the patient and you?

With intention and practice, you can guide yourself towards better thoughts.  More optimistic thoughts lead to more positive feelings which lead to more effective actions and improved results. In addition, it just feels better as a professional to think, feel, and act with more kindness and empathy. What you think really matters and with a little guidance and repetition, you can find that you have no more difficult patients. Changing How we Think About Difficult Patients is available here and here.