We wrote such beautiful essays and personal statements on our medical school and  residency applications. But, over time, our mission to heal and justly distribute the  bounty of our medical skills somehow devolved into mocking patients in the breakroom and roasting them mercilessly in online closed social media forums. We resent many of the patients for coming to the emergency department and we blame them for their illness or injuries. Then we justify those thoughts and beliefs by saying that everybody thinks and vents to each other in this way.

We define patients as “difficult” when they do not hew to the imagined rule book we have created for “good” patients. I have written that, “… good patients are actually people who reflect what the physician views in herself as desirable characteristics. Treatment of these patients leads to congenial, effective, mutually rewarding interactions.”¹

The patients and their families who don’t follow the rules get labeled as “difficult.” Interacting with them makes the physician feel uncomfortable, inadequate, or frustrated. Those sour interactions follow us home, drive us to the breakroom for a glazed doughnut or send us home at the end of our day to a few glasses of wine. We scan our email for alternate job offerings and dream about our escape route from clinical medicine. What can be done about these burdensome interactions with difficult patients?

The first thing to realize—and this might be the hardest—is that the problem lies with you. Passing judgement on what makes a good patient and believing non-compliers are “difficult” are some of the most toxic and unhelpful thoughts you can have. And those thoughts are entirely optional. You can set them aside and find more useful and accepting thoughts about even your most challenging patients.

How Can Any of Us Change Our Very Negative Thoughts and Beliefs?

Primarily, we must realize that we have a negativity bias. This is a very human tendency that probably developed when our cavemen ancestors had to scan the horizon for constant threats. Our brains go naturally to find what might be dangerous or going wrong. In medical school and residency, we are subconsciously taught to mock and degrade our patients by judgingly speaking about drunks and druggies and labeling our patients as diabetics and sicklers. We frame our physician group-think as “the truth.” Everybody talks this way so we don’t even consciously hear how terrible it sounds. It becomes habit.

The feelings physicians have about patients are useful clues that we have about how we are thinking and invariably, find their way into the results we obtain. Psychiatrist James Groves, MD, writes about this issue in his landmark article, “Taking Care of the Hateful Patient.” He writes, “Emotional reactions to patients cannot simply be wished away, nor is it good medicine to pretend that they do not exist…When the patient creates feelings in the doctor that are disowned or denied, errors in diagnosis and treatment are more likely to occur.”1

If we could somehow manage the negative thoughts that come up, not only will we feel better in our day-to-day practice, but we will also get better results with individual patients. Can we find some middle ground with demanding patients or family members so that we can build a mutually agreeable plan? Could you be wrong about the specific approach you set out to address the patient’s problem? What else is true about this human being lying before me with a high blood alcohol level? Is he a veteran? Is he someone’s son? Can I remember that getting checked out in the emergency department is the best place for him and not the bottom of some ditch?

If I can think of that person as someone’s son, I can generate much more compassion for the fellow. I have two sons and if one of them showed up in the emergency department, I would want him treated with empathy and given the benefit of the doubt. When I empathize with the mother of my patient, I look more closely for occult injuries, clean him up, and make sure he has a ride home. When I do the medical evaluation to rule out subdural hematoma, I accept that as part of my job as an emergency physician. I accept reality and I appreciate that my staff and I did everything that we are supposed to do for a human in that condition.

When we become aware of our frustration or anger, we can pause before overreacting or mirroring hostility. Our patients have the autonomy to question or to reject any of our suggestions or treatment plans. We can remember that our patients have their own fears, beliefs, limitations, and obligations that affect their ability to comply with the plan. Their thoughts, feelings, and actions have nothing to do with your ability or judgment as a physician.

When encountering challenging people, we can train ourselves to ask better questions. We can find better solutions by taking responsibility for our thoughts, feelings, and actions during the encounters. We can only do that by believing in our own training and feeling confident in our beneficent actions towards our patients.

Recognize that anger and frustration are normal and unavoidable human emotions that patients, nurses, and physicians have in the emergency department. Nothing has gone wrong here. Thinking that something has gone wrong or it shouldn’t be this way only makes us miserable. We can learn how to respond more effectively to intense emotions; we can’t eliminate them. Most of our patient interactions are lovely and mutually rewarding. Look for something good in them. Armed with more insight into the behavior patterns of our most difficult patients, perhaps we can actually change our negative perceptions of them.

Dr. Naidorf is an emergency physician, speaker, and author based in Alexandria, VA. She trained at Albert Einstein Medical Center in Philadelphia and is board-certified in EM. Her book Changing How we Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals was published in January 2022 with the American Association for Physician Leadership.

References

1. Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-887.