Healthcare providers have a responsibility to care for all of their patients equally, but not all doctors and nurses like their patients. In a recent article for The Washington Post, Dr. Joan Naidorf discussed what it feels like to take care of a difficult or unruly patient and how these negative feelings can be detrimental for both patients and providers.
Naidorf recalled being asked to treat a female patient with severe pain that she had already seen twice before.
“She was always crying out in agony. She would inject drugs into her legs leading to multiple deep infections. There was poor intravenous access, and once we established an IV, she accepted some medications and signed out against medical advice. I resented that she did not fill any prescriptions and did not see a primary care physician outside the ER,” the physician wrote.
Naidorf explained that the patient was struggling with substance abuse and an undiagnosed psychiatric disorder, which couldn’t be adequately addressed in an ER setting.
“It seemed to me like she was purposely making herself sicker while frustrating me and our nurses further,” she noted.
According to a study in the Archives of Internal Medicine, internal medicine physicians find around 15% of their patients to be “difficult.” Interactions with these patients can leave providers feeling frustrated, resentful, defeated or inadequate.
If a physician sees around 25 patients a day, they will likely encounter these feelings between three to four times per shift.
Naidorf argues that many providers ignore these feelings, believing them to be contrary to the oaths they took to provide the best possible care to all patients.
Psychiatrist James E. Groves addressed these concerns in his article, “Taking Care of the Hateful Patient.”
“When the patient creates in the doctor feelings that are disowned or denied, errors in diagnosis and treatment are more likely to occur,” he wrote.
Groves found that providers caring for “hateful” patients were more likely to feel helpless, to unconsciously punish the patient, to punish themselves, to inappropriately confront the patient, or to avoid or remove them from the clinical setting.
If the patient believes their provider is unconsciously judging or punishing them, any sense of trust quickly breaks down. A study in the British Journal of Medicine found that patients who believed their doctor had compassion for their plight were more likely to take their medication, follow through with treatments, experience better outcomes, rate their physicians higher, and file fewer malpractice lawsuits, even when a mistake was made.
Rana Awdish, medical director of Care Experience for the Henry Ford Health System in Detroit, recently wrote about the problem with branding patients as difficult in her memoir, “In Shock: My Journey From Death to Recovery and the Redemptive Power of Hope,” after one of her nurses labeled her as “difficult” while she was being treated for a critical disease.
“We label patients. We label them as cooperative, or drug-seeking, realistic, or difficult,” Awdish wrote. “It functioned as an abridged report to our colleagues of what to expect. ‘Difficult’ was shorthand for ‘The patient is not going along with the plan. I have a good solid plan, and they weren’t on board.’ … We insisted on creating a dynamic in which one person wins and the other loses.”
Naidorf argued that medical providers are just as susceptible to “negativity bias” as other human beings. We all have a tendency to judge one another. It’s an instinct our ancestors used to detect and avoid imminent danger.
Medical providers are also trained to look for what’s wrong in any given situation, even if it means blaming the patient for their life decisions.
Naidorf wrote that she heard plenty of teachers and colleagues using derogatory language toward patients that were seen as difficult, disagreeable, or just non-compliant. They referred to patients that return to the ER regularly as “frequent fliers” and “drug seekers”, but she believes providers don’t have enough information about their patients to make such sweeping generalizations.
“We generally do not have all the information we need to formulate an accurate assessment. Because of confirmation bias, we tend to interpret new information as being supportive of the opinions we already hold. We search for things in the world that support the negative beliefs we already have. We also ignore evidence that disagrees with or does not confirm our preconceived beliefs,” she wrote.
When it comes to combating negative bias, Naidorf encouraged providers to imagine what their patients are going through, including how terrifying it would be to have a symptom or disease they don’t yet understand.
She also suggested that providers should look for common truths about the patient. For example, is this patient someone’s son or daughter? Are they suffering from an undiagnosed mental health disorder that may be contributing to their difficult or combative behavior? Providers should think about what may be causing this behavior and whether they should give the patient the benefit of the doubt.
Every provider knows what it feels like to care for a difficult patient, but these labels often do more harm than good. Keep these ideas in mind to avoid the trap of confirmation bias.