The Real World: The really difficult patient

No Comments
Q.The really difficult patient
 I found out a patient I discharged yesterday died. I know I probably shouldn’t have discharged that patient, but I knew the internist would refuse the admission and the nurse was putting pressure on me. I feel trapped–and I feel awful. Do you have any tips on how to handle this in the future?
-JA, Atlanta, GA 

Dear JA,
I had a situation like this recently. A nurse wanted me to write a ‘medical clearance with no restrictions’ for a patient seen by another physician who had gone home. I flipped through the chart and saw an irregular heart beat and informed the nurse I’d have to see the patient myself. Perturbed, the nurse left. A few minutes later after shift change, another nurse aggressively made the same request. Then the charge nurse got involved and had the audacity to accuse me of lying about the first conversation.

Meanwhile there were numerous patients to be seen. The path of least resistance would have been to give a work clearance on the nurse‘s word without checking the chart too closely – but this would have meant contributing to this elderly truck driver possibly killing himself or others on the road or stroking out and being disabled. As it was I communicated with the patient’s cardiologist, we placed him on coumadin, and he was definitely not medically cleared with no restrictions. Interestingly, the nurse who wanted to ‘move things along’ had an empty pod at the time. And no, I didn’t get an apology…or a thanks.


Here’s the biggest take home message: Do what you think is right. Always. That is your shield. That will guide you around the many minefields in your way.  I’m reminded of the similarity of your situation to the Milgram Experiments documented in the book, “Obedience to Authority” in which 65% of the subjects, drawn from the community, were convinced by an authority figure in a white coat to administer, to a phony ‘subject’, increasingly stronger and eventually fatal (pretend) electrical shocks.

Don’t be afraid to be in the 35% who refused. Another recommendation: Get in communication with the nurse and doctor involved so that they have the information they need to adjust their behavior.

See next page for another Q & A with John Frey, MD
{mospagebreak title=next question}
 Q.This patient just won’t go away!
I had a patient who had long term vague symptoms, had been to multiple doctors who ‘didn’t do anything’, and wasn’t leaving until I found out what caused them. I ordered every test I could think of, yet the patient still wasn’t satisfied when they came back negative. I became very annoyed, and the patient wound up complaining to the CEO! What should I have done different?
-SB, Dayton, OH
Dear SB,
There are a number of tools at your disposal. Of course it will take some sensitivity and practice to utilize them to good effect. Sounding caring and interested is always good. Being defensive and accusatory never is. The main task is to get on the same side of the problem as the patient, the so called ‘therapeutic alliance’. Here are some phrases that will help you:


  1. Lower their expectations truthfully: “How long have you had these symptoms? And how many doctors have you seen? I sure hope we can help you, but it’s going to be hard in the short time we have. This is just the emergency room, and we’re set up to mainly deal with obvious emergency problems. You may need a lot of specialized tests that they don’t offer in the ER or even in the hospital”

  2. Show empathy: “Well your tests were all negative. That doesn’t mean that there is nothing wrong with you, just that we couldn’t find it. I sure wish I could wave a magic wand and make your symptoms go away, but I can’t.”

  3. Show compassion: “Can you think of any other way we can help you? Do you have a regular doctor? Are you going to be able to see your doctor? If anything gets worse, come back, ok? I wish we could have done more for you.”

These patients may just be anxious and have nothing, or may turn out to eventually have a occult, and real, illness. It’s very hard to predict, in a brief ER encounter, which camp your patient will fall into. There is no need to put yourself out on a limb.


John Frey, MD is the author of Secret Ingredients of the Ultimate ER and the developer of the SmartNotes documentation system.

Leave A Reply