There are certain patients who push your buttons and cause you to lose your cool. It’s up to you to anticipate these triggers and come up with a plan to manage their care with compassion and poise.
All my attempts to delve into the shallowness of epistemological relativism and to grasp objective and universal truths seem to have flopped. Viewing my fan mail versus hate mail, it is clear that the more down-to-earth suggestions are what people want. As one reader put it: “Don’t give me any crap by Bonhoeffer and Kant. Give me something that I can use in my next shift.”
To that end, I’d like to give you some techniques for recognizing when you have been either emotionally or intellectually hijacked and you are no longer in control in your own emergency department. Believe me, patients can play you like a violin, whether you like it or not.
Oh, you think it doesn’t happen to you. Yeah, right. The staff, the patients, even your own children are masters at twisting your emotions and responses. I tell people all the time to write down those incidences or activities which make them the maddest. Then whenever they see those things appear in the department, to be on their guard. You are set to be intellectually hijacked. You need to understand your own list of “hot buttons.” You need to know when you’re about to be captured, hauled off, sucked and blown out the other end of the emergency department.
In this world, there’s really only one thing we can hope to change, and that is ourselves – our own behavior. So let’s be aware of all the situations where a perfectly intelligent and caring emergency clinician can be made to do some really ridiculous things and lose control of the primary principles of decision making. Here are some hot button issues that we all confront, we all need to know about and we all should have a plan for managing.
The Drug Seeker
Drug-seeking behaviors either imagined or real is by far the greatest trap for emergency personnel. The reason we need to understand our feelings is not just for the patient but for ourselves. Too many “drug-seeking patients” can turn what otherwise would be a good shift into a nightmare. Know when you’re falling apart. The greatest contributor to this problem is the emergency staff itself. “That piece of crap is here again looking for a fix” has been said to me many times by the staff as I’m about to enter a well-known patient’s room.
Now you have two problems: Convincing the nursing staff that the patient deserves a proper evaluation and, if necessary, real treatment in which they feel you are “feeding the bears.” You need to focus yourself and get it right. Repeat headache patients, low back pain patients and all other chronic pain syndrome patients deserve a real evaluation just as if it was their first time. In headache patients, carbon monoxide poisoning, meningitis and subarachnoid hemorrhage are still in the list. In low back pain patients, perispinal abscesses, midline disks and aneurysms still need to be considered. Don’t be controlled by outside forces into giving half-assed medical care. Focus, focus.
Mr. 11/10 Pain
The next group of people who push your buttons as well as your limits are those who state: “Doctor, I have a high pain tolerance.” What does this mean? They are trying to impress you with the severity of their situation. The more irritating subset of this group of patients are those who state that on a scale of one of ten, their pain is an eleven. This often produces a mini lecture/scolding from the healthcare provider on the fact that there has never been an eleven. Let me just state that I hate pain scales. I don’t know who really invented them and I understand fully that no patient understands them. No one intrinsically knows what a seven or a five even is. If they need more pain medicine, I give it. The real danger is not the pain in the patient but the irritation in the providers. Stop it. Stop it now. Don’t lecture people on the pain scale. It isn’t their fault that it was invented by some deranged administrator. Emergency doctors tend to be tough guys and gals from the wooden ship, iron men school of personal commitment. And such wimp-like personalities tend to trigger negative responses in all of us. Just be aware.
A variant of the pain scale is the whiner. Everything to them is being done wrong. The nurse hurt them with the IV. “I’m cold. Can I have a sandwich? Can I smoke a cigarette?” Anything sound familiar yet? Steady the course. Respond as best you can. Sometimes when the patient knows you are taking them seriously, the level of complaints and confrontation actually descends.
I actually see emergency personnel say to the patient: “You get one, count them. One complaint, that’s it.” I know you want to say this but you can’t. They get to tell you whatever they want. It’s your job to prioritize what you’re going to do tonight with each one of these so-called problems. The corollary is the mixture of major and minor complaints and noncritical concerns. The fact that they have both the worst headache of their life and an itchy red spot on their left foot that they’ve known about for years do not really seem to us to go together. You may be the only doctor that they have ever felt comfortable in talking to about this problem.
Here’s the approach. At least look at it. Then you can talk about approaches for care which can be employed but not necessarily tonight. Offer to note it in the chart for the primary doctor and this at least provides a painless way to wrap up what otherwise could be a long story. Nonlife-threatening complaints are always difficult for emergency physicians (your own family understands this).
The Unfixable Medical Problem
The unfixable medical problem is the natural predator of the emergency clinician’s soul and the sapper of his or her energy. The ambulance arrives from the nursing home. You pull the sheet back on a 92-year-old patient who is emaciated and in contractures, hasn’t spoken for two years and smells of feces and urine, to say nothing of the calcified Foley and feeding tubes. Your face drops. You feel weak. You keep wishing you’d gotten that dermatology residency. Before you seriously consider hemlock, define the goal: What’s the question on the table? Emergency people don’t like things they can’t fix, period. Before a minimum $20,000 workup is commenced, find the people, the players, also known as the family and find out what they actually want. Don’t assume they’re looking for everything to be done. Patience is key to solving this conundrum.
This is a country that doesn’t know how to die. Americans are the only people on the planet who believe that death is optional. Redefine success in these patients as having had an honest discussion with all the parties involves. Chronic, poorly-defined, ubiquitous medical problems are our new albatross. Your emotions at that time and how you deliver the message to the family will determine whether this will be a successful or unsuccessful interaction. Take pride in having delivered some honesty. We are in an age divorced from tradition, history and purpose. We are trained for usefulness and a market economy given to fulfill-ment through technology. This is the moment you realize science does not answer the big questions. You can at this moment do both this family and the wider society more good than you can ever imagine by being honest in our limitations as a profession.
The Patient with Poorly Defined Ailments
Next, we all confront patients who have complaints which are not easily translatable into medical-ese. Not everything has an ICD10 code. Poorly defined is too often synonymous with undefinable. Late at night you wish you had picked up the two-inch laceration chart as your last case to end the shift. Nondescript areas of “tingling” are the worst. They don’t fit a dermatome or a peripheral nerve distribution. They have no real periodicity or any particular action or inaction that provokes them. Like the patients, my family frequently has these types of complaints. When you admit you have no idea what it is, they are both angry and disappointed and conclude that you are an idiot of a doctor. Never open up with, ‘I don’t know.’ You know lots of things. You know they’re not about to die in the next ten seconds. You know it’s probably not total occlusion of the blood flow to the arm. Open up with something you know. That reassures the patient. I know now to use the term “irritative neuritis, probably of a viral nature.” How can you be wrong with cold compresses and reassurance?
My wife once inquired of me concerning a dysesthetic area on the back of her hand. After visual inspection, I made the unforgivable mistake of saying: “I don’t know.” She immediately impugned both my intelligence and medical skill: “What do you mean you don’t know? You give all those talks and write those books on neuro and you don’t know?”
“Well,” I said, “it’s cancer.”
“It’s not cancer,” she retorts.
“Then I don’t know.” Now she is really mad.
“If I were a patient, you would ask me questions.”
“Have you had this before?”
“Yes,” she said.
“Well, you’ve got it again.”
Clearly another mistake. Go with the nonspecific neuritis response – how wrong can you be?
The Patient Who Calls for Reinforcements
The last area which threatens the healthcare professional’s pride and raises ire are challenges to your direct competence. It may be subtle, even non-intended, but when they say: “Call my doctor,” all manner of negative thoughts can go through your mind. You are tempted to say: “I know that idiot and he won’t have a clue.” I know you’ve thought this because so have I many times. Instead, I take it now as a compliment that they want me to be more involved in their overall healthcare. It’s okay. I often on the phone renew an old acquaintance with a doctor I may not have spoken with in years. I can secure follow up and I win a friend for life when I tell the primary doctor that they don’t need to come in or admit the patient. Trust me, calling the patient’s doctor has its upsides.
A much tougher challenge to your authority and position on the healthcare team is when they say: “But how do you know, doctor?” Now you have to explain why the internet does not have all the information and certainly doesn’t know about you the patient who is sitting in front of the provider. All your diplomatic skills are required. It tends to be the more intelligent patients who ask questions. A little non-condescending conversation goes a long way in winning you a friend and admirer. We often forget that candor is appreciated by patients and their families. The internet suffers from too much information and way too much opinion and putting this in some perspective for the patient is definitely required. It is most required that we take this time when we are not going to do a test or not going to write for an antibiotic. Patients want to hear your thought process.
Sometimes with difficult patients just a compassionate interaction is more important than what is actually done. It’s like tourists in Times Square. It is not for the sake of a picture that a selfie is taken but for the sake of the taking. The desire is not for a captured image but for the captured self. They achieve through the lens what they cannot achieve through themselves: a moment in which the object penetrates both their body and soul and changes them in some way according to their value structure. It is this interaction, this magical laying on of hands that may be the most important part for the worried well in our society.
“Thanks,” they say. “I feel better now.”
Editor’s Note: Dr. Greg Henry’s iconic column, Oh Henry, will conclude with a final essay in the December 2016 issue of Emergency Physicians Monthly. Want to send Dr. Henry a parting note about his column? Email [email protected] and we’ll pass it along. Look for a collection of Dr. Henry’s work to come out later this year.
While this post is not intrinsically about customer service one of the life lessons that has served me well is avoiding the over use of the phrase ,”it’s just.” Our intent may be to reassure the patient the their condition although annoying is not inherently dangerous. However, this phrase is often perceived by the patient as the physician being dismissive of their complaint or concern. Just sayin…
One of my mentors explained to me…the average drug seeking addict has an IQ higher than ours
Can you follow this up with six administrator triggers?
A great list. Can I add my personal “biggest” trigger: The functional patient. 100 different somatic complaints which are ultimately supratentorial in origin.
Subset of Unfixable Medical Problem: Ongoing nonspecific medical issue that has been seen by PCP as well as multiple other medical specialists. These drive me crazy as they really do want you to make a specific diagnosis even when multiple other providers with far more specialized knowledge have not made a diagnosis. Especially frustrating when workup is ongoing with a defined outpatient plan. Have asked what they want me to do today or tonight with minimal success. Usually a non-satisfactory interaction for both patient and provider.
Another that is very dangerous is the manipulative patient. Drug seeker is subset of manipulative patient. Drugs are not the only thing people manipulate for. An example is the patient that obviously needs admission coming to the free-standing ER across town so that they can try not to be admitted for their COPD, CHF or unstable angina etc. Very dangerous in that they push you outside of your comfort zone and try to convince you to do things you know are medically dangerous. Uninsured patients who ask you to not perform standard tests are another particularly dangerous patient. I have found the best approach is to practice the same no matter the location, insurance status or whatever the mitigating factor may be.
Should be whole separate trigger section for pts with “Chronic Fatigue” “Chronic Lyme Disease” and “Fibromyalgia” . Once you see that on the PMH you know you are going to be stuck in that room for at least 30 mins
So, do you not think patients could have other medical problems, if they are hurting? Ordering labs is a start and stop assuming what their problem is.
I recently heard a new term that resonated with me: The “medicine is a hobby” patient. These are the ones who seem to seek too much care, for too many benign complaints, and seem to enjoy the experience of being a patient a little too much. I had never quite heard the term before but it resonated with me and these are some of the most difficult people to interact with for me. There is a tendency to add a new test or a new medication, because that is what they want.
I had found the fibromyalgia patient the more difficult to treat and keep patient satisfied and to do or not to do a CT scan of head in the patient complaining of the worst headache of my life with no risk factors
My biggest trigger are patients who expect you to know things there’s no way you could know. They have a $1M work up at another hospital and expect you to have reviewed their entire chart prior to your going in to see them – or – the drunken driver from a roll-over MVC (unscathed of course) who insists you’re a liar because his “girlfriend” walks into the room silently then leaves all while you are auscultating so you think they are in the ED alone.
Great article…too bad I had to use a dictionary to get past the first sentence.
I work as an RN in a small but busy Australian emergency department.
My ‘favourite’ is the (typically older) female who says whilst still on the ambulance trolley, having just being wheeled into the dept and whilst I have barely started triaging says “how long am I going to be here for ??” or “Am I going to be admitted ??” or ” If I am staying, I want a single room !”
This is usually on a frantically busy night, when I have a queue of triages, there are only one or two vacant emergency beds and I don’t have the time or energy to pander to this behaviour.
The classic was a few years ago, when a for admission patient and relative wanted to argue endlessly about getting a single room because they had additional private insurance that said they were entitled to one, when the ONLY bed left in the entire hospital at 10pm was a bed in a 4 bed room. They just wouldn’t understand that they were getting the ONLY bed left, and wanted to make an issue of it, at which point I paged the supervisor and the supervisor took over the job of explaining to them.
other favourites include the ‘positive bag sign’ – the probably-doesn’t-need-admission patient who is hoping for an admission and packs a huge bag.
Or the ‘dying swan’ who wants something every time you walk past the bed, and maximum sympathy.
When I worked in sydney we used to have one frequent flyer elderly woman who when the back of the ambulance door went up, the TV and the large suitcase would come out first ….. the last time I triaged her she told me “your oxygen is so much nicer here than at the nursing home …”