Changing How We Think about Difficult Patients

A Guide for Physicians and Healthcare Professionals

Joan Naidorf

• Publisher: American Association for Physician Leadership
• Year: 2022
• ISBN:
  9780996663229
• Edition: 1
• Topic: Medicina
• Subtopic: Teoría, práctica y referencia médicas

Physicians enter their professions with the highest of hopes and ideals for compassionate and efficient patient care. Along the way, however, recurring problems arise in their interactions with some patients that lead physicians to label them as "difficult." Some studies indicate that physicians identify 15% or more of their patients as "difficult." The negative feelings that physicians have toward these patients may lead to frustration, cynicism. and burnout.

Changing How We Think about Difficult Patients uses a multi-tiered approach to bring awareness to the difficult patient conundrum, then introduces simple, actionable tools that every physician, nurse, and caregiver can use to change their mindset about the patients who challenge them. Positive thoughts lead to more positive feelings and more effective treatments and results for patients. They also lead to more satisfaction and decreased feelings of burnout in healthcare professionals.

How does this book give you an advantage?

Caring for difficult patients poses a tremendous challenge for physicians, nurses, and clinical practitioners. It may contribute significantly to feelings of burnout, including feelings of exhaustion, cynicism, and lost sense of purpose. In response, Dr. Naidorf offers a pragmatic approach to accepting patients the way they are, then provides strategies for providers to find more happiness and satisfaction in their interactions with even the most challenging patients and families.

Here are just some of the topics the author discusses in detail:

• What Makes a "Good" Patient?
• The Four Core Ethical Principals of the Clinician-Patient Relationship
• The Four Models of the Physician-Patient Relationship
• What Challenges Anybody with Illness or Injury?
• How "Good" Patients Handle the Challenges of Illness and Injury
• Six Common Reactions to Illness and Hospitalization
• On "Taking Care of the Hateful Patient"
• Standards for Education in Medical Ethics
• De-escalation Strategies
• Cultural, Structural, and Language Issues
• Types of Patients Who Tend to Challenge Us
• The Think, Feel, Act Cycle
• Recognizing Our Preconceived Thoughts
• Three Common Thought DistortionsAbout Patients
• Asking Useful Questions
• Getting Out of the Victim Mentality
• Guiding our Thoughts Through a Common Scenario
• Show Compassion, Feel Compassion

If you're a healthcare provider or caregiver, Changing How We Think about Difficult Patients will give you the benefit of understanding your most challenging patients, and a roadmap to positively changing your mindset and actions to better deliver care and compassion for all.

Chapter 1

We Can’t Stand Some of Our Patients

Every physician, nurse, EMT, respiratory therapist, and clinician of every specialty has mused about how much better their workplace would be if they did not have to deal with difficult patients or demanding families. What a delightful fantasy!

We all know that sinking feeling we get when one particular name appears on our calendar or triage board in the emergency department. Some presenting problems on the list fill us with dread and apprehension. For some, it is another senior citizen who feels weak and dizzy. For me, it’s when the words “nosebleed” or “fish bone stuck in the throat” appeared in the triage note. Feelings of inadequacy and futility always manage to rear their ugly heads. I’ve always had trouble with these situations before. What if I can’t find that darn fishbone or stop that stubborn bleed?

Patients are problematic only when they evoke negative thoughts in the treating clinician — thoughts that create feelings of frustration, confusion, anxiety, sadness, and disgust. Those negative feelings can lead to undesirable actions such as arguing, snubbing, or prematurely discharging the patient. Those who entered the medical profession with the highest and noblest intentions do not want our actions to stem from feelings of anger, fear, and hatred. We are far better than that.

A study published in the Archives of Internal Medicine noted that physicians in an internal medicine practice rated approximately 15% of their patients as “difficult.”1 The study showed that difficult patients tended to have a depressive or anxiety disorder, poor functional status, unmet expectations, reduced satisfaction, and more frequent use of healthcare services. The physicians likely labeled these patients as difficult because they believed that the patients shouldn’t be acting anxious, depressed, or dissatisfied, or solicit so many healthcare services.

Difficult patients raise the gamut of negative feelings within the clinician toward not only the patients but also toward themselves. Some patients and their illnesses make the clinician feel helpless and inadequate, unable to help the difficult patients. Feelings of anxiety or inadequacy may stem from the lack of confidence in performing a needed procedure. For example, if a resident thinks he is not well-trained in doing lumbar punctures, he will try to avoid doing that procedure, risking failure to detect a subarachnoid hemorrhage or case of meningitis.

Perhaps clinicians feel threatened by the specter of a malpractice suit or complaint filed in the event of a bad outcome from the encounter. Some difficult patients and their families use intimidation to get what they want. Patients and their families have more power than ever to lodge complaints, report practitioners, and file legal action when they are dissatisfied with their care. Anonymous comments posted online can be detrimental to our reputations, but we have no recourse. Healthcare providers feel a real threat to their livelihoods, which may cause them to over-test, over-treat, and over-consult to diffuse responsibility.

Negative Think

We see the narrative of the difficult patient playing out during every shift. Everyone in the dialysis center may agree that Mrs. Berman is a cranky, demanding old lady. We all believe that Mrs. Berman will always make a new demand and will never be satisfied. Just because everyone in the center agrees that this is true, however, does not make it true. Difficult patients have not read the instruction booklet for how a good patient is supposed to behave. The truth is that everyone in the dialysis unit has adopted the same negative attitude about Mrs. Berman.

Mrs. Berman is not simply a thorn in the side. She is a mother and a wife. She is human, and sometimes humans complain. The only problems with Mrs. Berman and the similarly difficult patients are those you have conjured up based on your beliefs and judgments about them. You resent Mrs. Berman because she returns with more symptoms and rejects your advice. If she were a good patient, you think, she would get better and profess gratitude. We will discuss more about what clinicians expect from good patients in Chapter 2.

The Hidden Curriculum

You may not even realize the negative thoughts that you have accrued about certain patients and specific behaviors. These thoughts may have sprung from the attitudes of the mentors and senior house staff who trained you. One of my professors referred to the alcoholic patients on his service as TOADs: totally obnoxious alcoholic derelicts. Unfortunately, adopting his worldview was a natural part of the academic curriculum. Many of our negative thoughts about difficult patients are deeply ingrained habits that spring from the hidden curriculum of medicine.

In medical training, the hidden curriculum refers to the lessons that medical trainees receive behind the scenes and in “the real world.” Some of these lessons stand in stark contrast to the high ideals of humanism and professionalism proclaimed in medicine’s codes of ethics and echoed during the first day of medical or nursing school orientation. I will come back to the negative feelings we develop toward patients later, in Chapter 3.

As our senior residents and mentors complain and blame the system, we learn a pattern of victim mentality, blaming addicts, alcoholics, chronic pain patients, and other “undesirable” people for making life difficult for us. Conscious and unconscious biases exist against specific genders and racial and ethnic groups whom we treat on a regular basis. The implicit biases and arbitrary assumptions that play into many of our thoughts and feelings about patients will be discussed in Chapter 9.

Our human brains seek efficiency by regularly recycling old patterns of thinking. Our habitually negative thoughts directed toward problematic patients in the clinical setting have a protective origin. We must be on the lookout for the most dangerous diagnoses that may be lurking behind a seemingly innocent complaint.

What seems to be a placidly sleeping drunk on an emergency department gurney can be hiding an occult fracture or brain injury. We can’t miss a dissecting aortic aneurysm or pulmonary embolism, or other lurking zebras in our patients with chest pain. Our negative thoughts and inquisitiveness trend toward curiosity with a large dose of suspicion.

Choosing Our Thoughts with Think-Feel-Act

Human behavior has been described in the literature of psychology in terms of the motivational triad and the think-feel-act cycle. Human beings at their most basic level are motivated to seek pleasure, avoid pain, and minimize effort. Our thoughts cause us to feel a certain way and act — or not act — accordingly. Marketers use this principle to get us to buy their products. They tell us that a product will give us thicker hair (thought). Because we desire thicker hair (feel), we buy the product (act).

We can apply this think-feel-act triad to our clinician-patient relationships. Once we accept that our own thoughts and beliefs create our emotions and cause us to act — not the words, emotions, and actions of others — we can obtain better results for our patients and for us. If a “problem” exists only in our minds, we can solve the problem by changing how we think.

The think-feel-act cycle begins with a situation or event that occurs outside of us and beyond our control. For example, a thunderstorm is a natural event outside of our control. It is a neutral occurrence until someone has a thought about it. A wedding couple are upset because it rains during their ceremony. A gardener is happy because her tomato plants get more water. The thunderstorm doesn’t cause people to become upset or happy— people’s thoughts about the thunderstorm cause their feelings. This is a subtle difference. Outside events or circumstances don’t cause our feelings; our thoughts about the event or situation cause our feelings.

For the context of this book, the arrival of a patient in an office, on the hospital floor, at the urgent care center, or in the emergency department presents a situation or event over which we have no control. The situation is neutral until a physician or nurse has a thought about the patient. The generous thoughts of the healthcare professionals cause emotions like compassion or concern that drive the actions that determine the results. If the arrival of the patient results in negative thoughts reflecting resentment or disgust, a far different set of emotions, actions, and results occur.

Every action is driven by a thought and an emotion that occurs so swiftly that we don’t realize that a thought preceded the action or caused the emotion. Most of us are unaware of the thought that causes a particular feeling without further introspection. Our feelings drive the actions or responses we initiate with our patients and give us an outcome that always relates in some way to our original thought about the situation. In Chapter 4, I will review the think-feel-act cycle and how it applies to the patients who present in the clinical setting.

Choosing Our Thoughts with Intention

Recognizing that our own thoughts cause negative emotions can positively change everything. It is possible to change what you think by replacing that thought with a new thought. Chapter 13 reviews tools and questions to ask ourselves to change our beliefs regarding our challenging patients and their families.

You can question any of your long-held beliefs and decide to change them. You can actually choose to think thoughts that will serve both you and your patients better. The first issue related to changing your thoughts is realizing a random sentence in your mind is just a thought. When a PA thinks, “I’m not very good at draining paronychial infections,” he thinks he is stating the truth. Yet, that thought is just that — a thought. Because of that thought, he may avoid seeing patients who present with that common problem. The PA can instead choose a thought that better serves him and his next patient: “Every time I treat a person with paronychia, I get better at doing it.” With this thought, he can build self-confidence and feel proud of...

Table of contents

• Introduction and Guide
• Chapter 1
• We Can’t Stand Some of Our Patients
• Chapter 2
• What Makes a “Good” Patient?
• Chapter 3
• What Challenges Anybody with Illness or Injury?
• Chapter 4
• How Do Sick and Injured People Feel and Act?
• Chapter 5
• On “Taking Care of the Hateful Patient”
• Chapter 6
• Responding to Dr. Groves: An Evolving Understanding
• Chapter 7
• Our Least Favorite Patients
• Chapter 8
• How to Manage Our Thoughts
• Chapter 9
• Three Common Thought Distortions About Patients
• Chapter 10
• What We Think:Two Common Thought Distortions
• Chapter 11
• Working Against Ourselves
• Chapter 12
• How We React
• Chapter 13
• Turning It Around
• Chapter 14
• Getting Out of Our Own Way
• Chapter 15
• How It Works
• Chapter 16
• Why Does It Matter?
• Chapter 17
• No More Difficult Patients