{"id":36378,"date":"2016-03-22T15:52:36","date_gmt":"2016-03-22T14:52:36","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=36378"},"modified":"2016-03-22T15:52:36","modified_gmt":"2016-03-22T14:52:36","slug":"suzanne-gordon-on-the-difficult-patient","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2016\/03\/22\/suzanne-gordon-on-the-difficult-patient\/","title":{"rendered":"Suzanne Gordon on the difficult patient"},"content":{"rendered":"<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2015\/04\/suzanne_gordon.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-thumbnail wp-image-33921\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2015\/04\/suzanne_gordon-150x150.jpg\" alt=\"suzanne_gordon\" width=\"150\" height=\"150\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2015\/04\/suzanne_gordon-150x150.jpg 150w, https:\/\/blogs.bmj.com\/bmj\/files\/2015\/04\/suzanne_gordon.jpg 160w\" sizes=\"auto, (max-width: 150px) 100vw, 150px\" \/><\/a>Today it\u2019s hard to find a healthcare professional who doesn\u2019t want to \u201cput the patient first,\u201d practise \u201cpatient centered care,\u201d or make the patient \u201cpart\u201d or even \u201cthe centre\u201d of\u00a0the healthcare team. When you discuss any potential or actual bureaucratic, governmental, insurance company, or even internet interference in clinical practice, clinicians complain that non-healthcare professionals fail to understand the sacred trust that exists between clinician and patient and the duty to \u201cfirst do no harm,\u201d and protect the patient.\u00a0<!--more--><\/p>\n<p>When, however, the conversation moves from the abstract patient to the real life patient whom clinicians meet in their daily practice, it\u2019s amazing how quickly we, as patients, can slip off our sacred perch and be categorized as \u00a0\u201cdifficult.\u201d\u00a0 The rapidity of our descent into difficultness has always intrigued me. Who exactly is \u201cthe difficult\u201d patient?\u00a0 What exactly do you have to do to move from worthy to difficult? Call the physician at home every couple of hours? \u00a0Scream at nurses in the hospital or sit on the call bell? Be, god forbid, \u201cnon-compliant?\u201d<\/p>\n<p>When I talk to ER docs, or surgeons, or even primary care physicians (the ones who are supposed to be extra-special caring) I also hear many complaints about their \u201cdifficult patients.\u201d \u201cYou see a patient whose chart is the size of a dictionary, and you run in the other direction,\u201d one internist told me recently.\u00a0 (I cringed when I heard this. What happens when I\u2019m 80 and my medical chart is as thick as my wrinkles are deeply etched?) Another ER doc (like so many ER nurses) complained about all the \u201cfrequent flyers\u201d\u2014patients who repeatedly visit the ER, often with chronic conditions\u2014coming to his institution. OMG! I thought, would that be how they talk about me if I had sickle cell anemia, or repeated falls from dementia, or some other chronic physical or mental problem?\u00a0 I\u2019ve heard nurses complain about patients who are simply anxious about a procedure, or ring the call bell once too often.\u00a0 Comparing them to patients who are much worse off, they wonder what this person has to complain about.<\/p>\n<p>Most non-healthcare professionals would heartily agree that screaming, using abusive language, punching, and other violent behavior falls into the category of \u201cdifficult.\u201d But it\u2019s a bit frightening to hear <a href=\"http:\/\/content.healthaffairs.org\/content\/31\/5\/1030.abstract\">healthcare professionals label patients as \u201cdifficult\u201d<\/a> only because they are anxious and terrified at being in an alien land\u2014i.e. a hospital; ask too many questions when the nurse or doc is busy; ring the call bell because illness has reduced them to the status of an infant who can\u2019t do anything for herself; or express a slight doubt about treatment.<\/p>\n<p>I understand that many healthcare professionals may lack empathy because they are overworked, exhausted, hungry, and perhaps even depressed and anxious themselves. Some would also insist that they are caring with their patients no matter how \u201cdifficult,\u201d these patients prove to be. Nonetheless, I worry that using the term \u201cdifficult\u201d establishes a framing effect\u2014a cognitive bias\u2014that may result in poor communication and tense patient-clinician relationships. Well-intentioned healthcare professionals may convey their feelings about so-called difficult patients to those patients and to other people who will care for those them. This will color the behavior of other caregivers and turn the patient record into a kind of rap sheet\u2014the proverbial gift that keeps on giving. (Just say the word \u201cdifficult patient\u201d to yourself and consider how you would respond to that person. Does your stomach clench, your blood pressure rise, and your mind race to the most negative image when you contemplate interacting with that person?\u00a0 Then think about how a \u00a0nurse, told by her manager that she is about to care for a \u201cdifficult patient and family\u201d has been set up to approach them? Framing patients as \u201cdifficult\u201d can lead practitioners to convey subtle signs of impatience, lack of sympathy, negative judgments about the patient or his or her behavior, among other things.\u00a0 As Dominck Frosch and his colleagues have documented in <a href=\"http:\/\/content.healthaffairs.org\/content\/31\/5\/1030.abstract\">a study in Health Affairs,<\/a> this can, in turn, lead patients to fear asking questions of, discussing concerns about treatment with, or even concealing critical information from their caregivers.<\/p>\n<p>The potential to create unproductive and unsafe relationships could, perhaps, be reduced if the terms used to describe patients changed: if clinicians talked about the \u201cdifficulty\u201d they had dealing with a particular patient or situation rather than characterizing the patient as \u201cdifficult.\u201d Such a reframing might make it more possible to search for options, alternatives, and solutions to those \u201cdifficulties.\u201d Conceptualizing the patient as difficult, on the other hand, makes that process very hard once the problem is almost defined as someone else\u2019s character rather than one\u2019s own response to a challenge or individual.<\/p>\n<p>The point here is that words matter. If we can shift the clinical and relational terrain by adding a y, or ies to the word difficult, isn\u2019t it worth a try?<\/p>\n<p><em><strong>Suzanne Gordon<\/strong> is a healthcare journalist and co-editor of <\/em>The Culture and Politics of Healthcare Work Series<em> at Cornell University Press. Her latest book is <\/em>Collaborative Caring: Stories and Reflections on Teamwork in Healthcare<em>, which she co-edited and she is co-author of Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety. Most importantly she is a patient.<\/em><\/p>\n<p><strong>Competing interests:<\/strong> None declared.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Today it\u2019s hard to find a healthcare professional who doesn\u2019t want to \u201cput the patient first,\u201d practise \u201cpatient centered care,\u201d or make the patient \u201cpart\u201d or even \u201cthe centre\u201d of\u00a0the [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2016\/03\/22\/suzanne-gordon-on-the-difficult-patient\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5749],"tags":[],"class_list":["post-36378","post","type-post","status-publish","format-standard","hentry","category-patient-perspectives"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Suzanne Gordon on the difficult patient - 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