Dear Diary,
Some patient’s are @$$holes.
I’ve read multiple articles about dealing with difficult patients (this one is probably one of my favorites) and sometimes I take pride in how well I can calm a disgruntled patient myself. Yet, I’ve also noticed, more and more, that when we promise to “do no harm” to patients, that favor isn’t exactly returned. In my previous post “Thank You” Goes a Long Way I mentioned how very few times we are actually thanked for doing our job. Gone are the days of paternalistic medicine and blind trust in one’s physician. For the most part, that’s a good thing. However, patient autonomy seems to becoming the ultimate desire at the expense of physician/healthcare worker autonomy and even safety in some aspects.
Observations:
A large number of patients trust their Google search over the clinical acumen/experience/knowledge of their physician(s). Annoying, AF.
In some areas, a majority of patients direct their own care–demanding needless labs, radiology tests, and even invasive procedures that are not evidence based nor beneficial.. (I’ve even been told once to consider the “community standard” rather than just the “standard of practice” when treating a patient. And honestly, I simply don’t agree and feel like that’s a very slippery slope.)
Patients and family members are increasingly hostile toward healthcare workers (nurses, techs, PAs/NPs, cRNAs, physicians, administrators, everyone). Not only do they lack the manners to express simple gratitude, they argue, belittle, harass, curse, and sometimes physically threaten those providing their care. Hell, they even MURDER them.
In a medical world managed by administrators with little clinical experience, hospital systems that are more concerned about their bottom line and scores on HCAHPS surveys, the relationship between administrators and healthcare providers is bordering antagonistic. I.e. when a patient is difficult, it’s often the physician’s/nurse’s fault. It’s a he-said/she-said circumstance that sometimes feels like a no-win situation for us.
It’s extremely cumbersome to “fire a patient” or excuse oneself from the care of a patient that is deemed verbally abusive or exhibiting inappropriate behavior. Not only does one have to prove that their medical condition is not causing them to act in such a way, one must continue to provide care to a patient (especially if they are in extremis) despite their ongoing behavior. It is up to the provider to identify how to safely care for that patient/create a safe environment in which to do so. (Last I checked, if you were acting inappropriately at a restaurant, you could easily be asked to leave, and the waiter/hostess/manager has no responsibility to find you an alternative.)
Solutions:
There is no taking away the internet or social media or fake news or bad sources or ill-advised friends that convince patients of their maladies. The medical world needs to come to terms with the fact that we will constantly be competing against Dr. Google and WebMD with misinformed eyes. We have to remain competitive in our knowledge and astute to what our patients find, and teach them how to apply that data to their own health situation. We have to be smarter, more compassionate, and simply more human than the robots (or eventual AI) that are trying to provide patient care. We have to make it more convenient to be seen–hence, why telemedicine is a growing field that will be worth multiple billions in the coming years. In today’s society, convenience often takes precedence over quality (AmazonPrime anyone?). But we must also allow for work-life balance among healthcare professionals as well.
Physicians and other providers must stop giving in to the “community standard” and uneducated demands of their patients. Why establish “standards of care” if we are not going to follow them? Why tout evidence-based medicine if the demands of a patient don’t agree? We’ve spent the last century bettering medicine, doing more research, publishing more articles, and putting more money into healthcare than every before. A simple Google search should not trump our vast community of knowledge when caring for a patient. I’m not sure I know the answer to how to better explain this to patients. However, I think if we less often acquiesce to needless demands, we can bring down healthcare costs and provide better care overall.
Healthcare workers should be better protected in the workplace. Yes, if someone is dying, we need to be available to provide care. However, if someone is in that sort of extremis, there is a darn good chance they don’t have the physical reserves to be abusive or even difficult. When a nurse is sexually harassed by a patient, he/she should have every right to request NOT to care for that patient without repercussions or judgement. When a physician is belittled/cursed, we should be able to easily excuse ourselves from being required to round on that patient every day (or ever again). Patients should take more ownership of their behavior and then be expected to find their own replacements. In the outpatient setting, a physician shouldn’t have to subject herself to ongoing inappropriate behavior for another 30 days while initiating the process of “firing the patient”. If other workers in other fields are to be protected and we have laws asking them to be so, why not healthcare workers?
Hospital administrators need to befriend those that provide the care/bring in the business. Screw HCAHPS and JACHO, etc. Our duty is to our patients and to those providing a clean environment for others to provide excellent healthcare. Our duty is not to surveys and suits. When physicians feel protected, we are more productive and our job is better aligned with our values. When we are subjected to punitive committees, defensive letter writing, and other bureaucracy, the individual initiative to keep going is markedly diminished. (Recipe for burnout.) If more physicians, rather than MBA, MPH, and non-medical trained professionals, were among the highest ranks in hospital administrations, then perhaps physician satisfaction would improve due to a sympathetic ear among them. Perhaps this would lead to better working environments and more compassionate relationships that provide for the reestablishment of trust between physicians and patients.
It should be far easier to be removed from a patient’s care. We shouldn’t have to consult ethics committees, wait for 30 days and send registered mail, and we shouldn’t have to provide our own alternatives for a difficult patient’s care. I don’t want to refer a difficult patient to a colleague. In some environments (rural care), it is extremely difficult to find alternatives, and I understand that. However, in other environments, this is simply not the case. Patients need to take responsibility for their actions, especially as adults–whether its the vasculopath that refuses to stop smoking or the jerk that refuses to stop harassing female providers–there must be consequences.
All in all, I think most human interactions are less benevolent than they once were. We are all more empowered and more entitled than we were before the days of depending on the internet. We are less patient yet more knowledgeable than ever before. Although we have the world at our fingertips, we can’t assume we are experts and can simply ignore what others are saying. I think one solution to all of the observations is mentioned in the last paragraph–taking responsibility for ourselves. We have to care for ourselves and care for others. When we fail to do either one, we must face the consequences. Also, especially for healthcare providers, we must foster a community of acceptance, non-judgement, and empathy for our own. Medicine shouldn’t be a dog eat dog world and the pyramidal training of the past has led us to be vicious to those below us. That simply needs to stop. We need to care for those ahead of us, with us, and behind us.
These are obviously all points of debate, and I’d love to know your take. Leave a comment with your observations and/or solutions to some of medical practice’s current issues!
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