How to deal with difficult families?

[greenbean]

Hi,
Im doing a prelim year in medicine, this is my first month on wards, i have a few pt's who have poor prognoses(from strokes, cancer, multiple mi's) and they also have very demanding, irritating families.

one family in particular .this pt had a stroke and can't talk as a result, she had hx of seizures but refused all care in house(meds, vital checks) and even though i explained the pt's condition to the family at least 3 times, the husband is insisting that 'we don't know whats going on'...how do i deal with some one as hardheaded as this? ive explained thing very clearly about sz's and meds like dilantin but he doesnt get it and thinks her dx is unknown, its making me angry and i get really annoyed when the nurse pages me to tell me to come up and explain whats going on the family. i think im going to end up screaming at them.

any advice?

green

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[snoopy brown]

even though i explained the pt's condition to the family at least 3 times, the husband is insisting that 'we don't know whats going on'...how do i deal with some one as hardheaded as this?

I just tell the nurse that I've already discussed everything with the family and tell her to relay that to the family. Being accomodating backfires when it comes to "demanding" families because they take advantage of that mentality. They will just have the nurse page you incessantly, complain of everything, and have more demands. At the end when they use you up they will then demand to speak to your senior and then the attending and so on. Dealing with the nurse is another issue in these instances because most nurses will just use you as the "safety valve." It's easier to tell the patient "the doc will come" than to deal with the issue, so they just pass the message along. If that is your problem, PM me and I'll give you the solution.

 

[greenbean]

well i have both problems, in one situation, the nurses use me as a safetyvalve(as you put it) and i usually just say 'look,im not gonna do it' or 'we've already met with them and theres nothing new to report'

but in this pts case, i went over the fact that she was having seizures, which was formally evaluated by a neurologist and fully worked up, i went over this at least 3 times with the husband(in an EXTREMELY slow, clear polite way) and also mentioned that she needed to take her dilantin to prevent this. but she kept refusing to take it, and every day the husband is like 'we don't know whats causing this', its so frustating, i mean is he stupid or something? finally , before we made the pt nonteaching ,and he again made that comment i said in a blunt, maybe not so nice way, that : we DO know whats going, we've always known whats going on,shes having seizures and she refusing her medication and all care, so she will continue to have seizures, she has a hx of seizure and she stopped taking her dilantin at home, why she did that, im dont know , but that is related to her current condition.. later i get a page from the nurse that the husband is feeling guilty and upset by what i said. later i hear from the attending that i need to be more 'sensitive' to my pts.and im at a total loss for words....or at my wits end,


thanks,
green

 

[NotAProgDirector]

Perhaps you are coming at this problem from the wrong point of view. What you are sensing as "hardheadedness" and is frustrating you is likely a combination of other factors:

1. The family's main emotion at this stage is likely fear. They are completely overwhelmed by this catastrophe. Or, the patient has had a slow steady decline and the family is in some denial, now challenged by her acute stroke. They probably are having a great deal of difficulty understanding all the information directed towards them, no matter how well meaning. They can't imagine taking care of this patient who cannot speak any longer. This can be difficult to see when you are the physician.

An example: Pretend that you have been accused of a serious crime. Imagine how you would feel if without any pre-trial preparation, you were put in a courtroom. A lawyer is with you, although you've never met him/her and never discussed the case. The trial starts immediately without any explanation. Your lawyer is trying to explain what's going on, trying to get your story, trying to listen to all the evidence all at the same time, and plan your defense. I could imagine feeling very panicked, wanting things explained multiple times, missing important points, etc. You keep asking your lawyer "What's going on?". Your lawyer is getting frustrated, since all these interruptions are interfering with their job. But you can't really stop.

This is similar to what your patient and their families are going through.

2. Most patients are able to understand their diagnosis, evaluation, and treatment at the sixth grade level. There have been multiple studies about this, demonstrating that in the outpatient clinic, patients often only understand/retain only about 25% of what they are told. I can only imagine how much more difficult this must be in the inpatient setting, where people are even sicker. It is very likely that your patient's family has understood almost nothing of what has happened so far.

3. You are busy. You have 10-12 patients to see. You have duty hours. You have teaching rounds. How much time do you actually spend with the patient each day, where they see and interact with you? If it's anything like my training, it's not much. Much of the good work you do is behind the scenes, where your patient's don't see it.

Your patients don't understand any of this. As far as they are concerned, you are their doctor. They watch House, and think that you spend all day just thinking about them and only them. They have no idea how busy you are. It's not that they don't care, it's just so foreign to them that they don't understand.

So, what can you do?

Here are some ideas:

1. These types of issues are best addressed in a family meeting. Hold it in a quiet room, where everyone gets to sit down and be comfortable. Plan at least an hour, and try not to schedule anything directly afterwards in case it runs over. You should always have a faculty member or resident there, so all questions can be answered. Once the meeting is scheduled, you can simply inform the nurse (or the family) that you will answer all the questions at the meeting. The act of scheduling the meeting usually stops the questions. In the meeting you review the hospital course/diagnosis/etc, and most importantly you gently ask questions of the family members to assess their understanding.

For very involved/demanding families, schedule a followup meeting every 2-3 days, and/or choose one timepoint each day when you will be available to the patient's family. The latter is a very useful trick -- agree to be at the bedside at 2PM every day. Family members often get very nervous about "missing the doctor" -- i.e. they go for a quick walk/break and find out when they return that you stopped while they were out.

2. Choose a family spokesperson, if there are "too many cooks".

3. Take a deep breath. Remember the HoG rule that "the patient is the one with the disease". Imagine what these people are going through, and try to have patience and mercy.

4. Do not take your frustration out on the nurse, nor the patient, nor their family. This will only make things worse. Find an outlet for your frustrations away from work. There will be frustrations, no matter what your ultimate career path is.

Good luck!

 

[snoopy brown]

What you say is nice in theory, rotten in practice. Whenever a patient or family acts disagreeably, people quickly say, "well they are afraid of being in the hospital so that explains it all." It's nice because you can never say, "no that person is not afraid." Therefore, the patient is never at fault for their bad behavior.

Are doctors perfect? No. Absolutely not. But let's not pretend that there aren't patients/families that aren't difficult just because they are difficult people. Some physicians will spend literally hours with families only to keep getting paged for more and more things or to answer the same question monotonously. I've seen it, I've done it.

 

[greenbean]

i use 3rd grade language when i talk to patients and/or families, never use medical terminology(and if i do, i say that 'the medical/technical term for this is...")

the trial example im not sure is quite the greatest analogy to my example, my pt had a prior stroke (5 years ago) w/ residual aphasia and motor impairments, hx of sz since 20 years ago. stopped taking her dilantin 4 yrs ago b'c she didnt want to take it anymore, starting getting new sz's 1 week ago, went to another hospital where all w/up was negative and was admitted for 6 days there and d'c w/o a dx, was admitted the next day to my hospital for the same recurrent sx, and i went over all this many, many times with the son/daughter/husband/sister/husband/son/husband/husband.

if i were ever to be on trial for something, i would want to know whats going on, but i wouldnt always ask my lawyer what is happening. im in court too and i can hear,see for myself what is happening, when some1 is in the hospital, ppl cant listen/see all that we do(like you said, most of my work is unseen by them),but when i explain things repeatedly about why your relative is in the hospital and for that relative to continually insist that we don't know what is going on, after i just told them and gave opportunity for questions, is just crazy,

and this pt was continually refusing all care, so why is she still in the hospital? at that point, she should have left ama or attending should have addressed code status with the family

my only other option is to have the family talk to the attending directly who i feel is avoiding the topic for the same reasons i just described...and maybe in the future i will do just that

 

[snoopy brown]

aProgDirector's post is nice and bureaucratic. It's like when you're in medical school and they give you a scenario and ask "what did the doctor do wrong?" or "why did the patient act this way?" Then you sit around and brainstorm. What you get are very nice hypotheses like, "well the patient cursed out the doctor because they were afraid" or "the doctor wasn't compassionate enough." You can never ever say "gee, I dunno, seems like the doctor did everything he could" or "maybe the patient is just a jerk? Possibly?" I suppose you can just self-flagellate yourself all day, but it also doesn't solve problems.

 

[elwademd]

if the patient continues to refuse all treatment, then why do you (your team, not you personally) continue to keep her in the hospital. the diagnosis has been made, treatment is available, she and or the family don't want treatment... there's an impasse there to say the least.

patients have a right to refuse treatment. as long as you (your team) can show that the patient and/or surrogate(s) is/are capable of understanding what the diagnosis is, treatment, and the alternative therapies including no treatment, you document and move on. i.e. patients can refuse treatment and be discharged. in other words, patients and their families have the right to make decisions that seem... stupid. and if they are found to be capable of understanding and continue to refuse treatment, they can be medically discharged.

with that said, it seems as though the problem is with understanding. perhaps a case manager and/or social worker would be helpful in this case, in terms of laying things out from a different perspective.

i suppose another alternative would be an a.p.s. (adult protective services) report, though these can be hit or miss (largely miss in my experience). with an a.p.s. report, the appropriate authorities may look into the home situation if you think that's contributing to the picture.

also, you may want to ask the husband's understanding of the situation. he may completley floor you with "she was perfectly fine two weeks ago, but then all of this started and it's all new". or, he maybe he thinks the stroke is causing the seizures. or it might be something else.

in my experience with cases like these, i get case managers and social workers involved to help facilitate the process. documentation is also key as to what's been said and when it's been said. however, i'm at a small community hospital where these services are readily and easily available.

it sounds like the patient is no longer on your service (good for you, not so good for whomever picked her up), but the issue's likely to come up again. dialogue (early and often) seems to be the best answer.

 

[Annette]

I agree with the program director in having a family meeting. ONCE. Use what they call the "teach back method"- have the spokesperson in the family, pref the husband tell you in his own words what is wrong. Documenting that the POA or other reported understanding won't cut it anymore, unfortunately. The teach back also forces the POA to at least say the words they may not believe.

Limit the time. An hour is more than long enough. Arrange a page that you have to leave to answer. Have the nurse taking care of that patient there as well- this will help limit the pages as well. If the family continues to have more questions, have them write them down, and answer them when you round. This will also help limit pages.

If you have the diagnosis, treatment options have been explored and rejected, the next step is discharge. If the family insists the patient stays, they become responsible for the entire bill as insurances will not pay for unnecessary hospitalization.

If it goes beyond all this, it is about the family, not the patient. You are responsible for the patient, not the family.

As for being raked over the coals by the program director for not being sensitive enough, have her/him have a go with the family.

 

[snoopy brown]

I agree with Annette. To be clear, in my PM discussion with the OP I emphasized that an initial discussion with the family is important. Given that the OP stated that he/she already had lengthy discussions my posts are with that in context. Once you have done that and if you have been conscientious in your actions then you have no need to continue to wonder why you're such a rotten person or deficient in compassion. You have done your job. And I agree, if the attending or PD says you are not sensitive enough you simply need to ask them to deal with the situation. Watch them be compassionate it'll make you laugh.

 

[greenbean]

well i started to take care of this pt after she was admitted by the prev. intern, but after neurology said she was having seizures and wanted to increase her dilantin she started refusing all car, it took another 3 days for her to be made nonteaching,

part of the problem is the attending who wanted a psych eval for depression, as well as family's indecisiveness regarding placement, casemanager was meeting with them every day, but they wanted an MD to go over this with them in terms of prognosis. so when i did this, the husband and son apparently were not totally satisfied?im not really sure, but the attending saw the case manager's notes as well as mine and didn't really seem interested in acting on it but more in the psych consult, so while dragging her heels on that, i get creamed by family

rock<<me>>hard place

so now she's nonteaching, has been inhouse for another 2 d, while the attending is still figuring out god knows what, in any case, my philosophy is to keep pt's informed but not hold their hand, these are MATURE and GROWN ppl, i dont want to treat like little kids but i do want them to know whats going on so they can make informed decisions, i think this family wants that attending to have a oneto one/family mtg with said attg, which attg is trying to avoid/delay? in any case, its their problem now

 

[elwademd]

Documenting that the POA or other reported understanding won't cut it anymore, unfortunately. The teach back also forces the POA to at least say the words they may not believe.

i'm not sure if this was directed towards my comment about documenting, or just a comment about documenting in general, but i think it's important to document that a conversation occurred... i suppose whether or not there was understanding is something else! lol. but in all seriousness, documenting a conversation will at least let anyone else know between whom the conversation was had.

i've had the experience of talking to "the daughter" and got one story... and the attending talked to the "daughter" and got a different story... it wasn't until we (the attending and i) spoke about the differences that we realized there were two different daughters, each with her own opinion on the matter (home w assistance versus nursing home).

with all of that said, greenbean, be prepared for more cases like this throughout the year. learn from each one and apply it to the next.

 

[NotAProgDirector]

What you say is nice in theory, rotten in practice. Whenever a patient or family acts disagreeably, people quickly say, "well they are afraid of being in the hospital so that explains it all." It's nice because you can never say, "no that person is not afraid." Therefore, the patient is never at fault for their bad behavior.

Are doctors perfect? No. Absolutely not. But let's not pretend that there aren't patients/families that aren't difficult just because they are difficult people. Some physicians will spend literally hours with families only to keep getting paged for more and more things or to answer the same question monotonously. I've seen it, I've done it.

aProgDirector's post is nice and bureaucratic. It's like when you're in medical school and they give you a scenario and ask "what did the doctor do wrong?" or "why did the patient act this way?" Then you sit around and brainstorm. What you get are very nice hypotheses like, "well the patient cursed out the doctor because they were afraid" or "the doctor wasn't compassionate enough." You can never ever say "gee, I dunno, seems like the doctor did everything he could" or "maybe the patient is just a jerk? Possibly?" I suppose you can just self-flagellate yourself all day, but it also doesn't solve problems.

There is no question that patients and families can be angry, frustrating, annoying, unreasonable, etc. Often, the engine behind this is a serious problem itself -- psychiatric disease / personality disorders in families, memory loss, etc. I guess I see it this way -- even if the patient is being unreasonable, "a jerk", mistreating me, etc, I still feel it is my responsibility to try to deliver the care that they need. In my experience, with clear limit setting (i.e. one meeting a day, no more than 30 minutes, etc) most "demanding" families can be addressed. What the OP was going through is completely unreasonable. As I was trying to point out, if I've scheduled a meeting at 2PM daily with the family and questions arise at 4PM, they can be deferred to the 2PM meeting the next day, and usually by the nurse. The nurse is paging you because he/she has no idea what to do with the demanding family -- give the nurse a viable plan, and (usually) things get better. Will this work for every single patient? Of course not. However, I was struck by the OP's suggestion that he had a "few" patients like this on his/her first month. Truely "impossible" patients are rare.

I should add that although I will allow patients to "abuse" me, I will not allow them to abuse nurses, students, residents, etc. The most common reason for me to terminate a patient in my outpatient clinic is abusing my nurses.

However, I should point out that I am probably a bit more flexible than many of my peers in my practice. I have a few patients that no one else will follow any longer -- I figure that if I don't put up with them, no one will. However, I also have the "honor" of being the "hard ass of narcotics". The nurses know that if they schedule a difficult narcotic patient in my panel, they either shape up or ship out. So we all have our limits.

the trial example im not sure is quite the greatest analogy to my example

I agree. I was tired. Still, I think (and most studies suggest) that many patients have great difficulty, or are perhaps unable to understand their condition and their treatment options. Given the new details in your example this seems less likely the cause.

my only other option is to have the family talk to the attending directly who i feel is avoiding the topic for the same reasons i just described...and maybe in the future i will do just that

Totally agree. However, some day soon you will be the attending, and there will be no one to "turf" the patient to.

 

[snoopy brown]

There is no question that patients and families can be angry, frustrating, annoying, unreasonable, etc. Often, the engine behind this is a serious problem itself -- psychiatric disease / personality disorders in families, memory loss, etc. I guess I see it this way -- even if the patient is being unreasonable, "a jerk", mistreating me, etc, I still feel it is my responsibility to try to deliver the care that they need.

Yes but this is my point. This is like an exercise to brainstorm anything possible to excuse a behavior. For example say a patient throws a book at you, doesn't hurt you but throws a book at you. Let's just say there's a certain personality in medicine who will then say, "hey what could be behind that behavior ...what do you think the patient is feeling." And then everyone gets together and goes around in a circle and it goes something like "I bet the patient is scared!" "Frustrated!" "Alone!" "Tired! No, wait, I mean confused!" And then everyone says "see how those emotions can cause that reaction? So how can we work to make the patient less scared/frustrated/etc?"

The point is that you could brainstorm an excuse for any behavior if you really wanted to. You can always say "the patient is frustrated! That led to their screaming at you! And also when they stabbed you!" It's just a touchy-feely way of saying "couldn't you be a better physician? And who is opposed to being a better physician?" Guess who acts like this? Generally it's the people who don't have to deal intimately with that patient.

 

[jennyboo]

What I did on the wards:

Let your attending deal with it during your first month of wards (assuming you have an attending who actually sees the patients). You've got enough notes to write and labs to check without wasting an hour of time talking to the family. They want to hear it straight from the horse's mouth anyway. This is your time to learn the hospital system and learn to handle your patient load. Seriously, you're scrambling to get all your work done at this time of year -- don't feel bad about avoiding the big family meeting to finish calling your consults and following up your tests!

When the nurse calls, tell him/her that your team will update the patient's health care proxy ONCE per day. Give an approximate time for when you think you'll be coming. You do NOT have to run to the bedside now. "Once a day" does not mean "now." It can mean 6 hours from now, as long as you can provide an approximate time frame for the family. And of course it's August and you will probably be an hour later than you think -- that's part of hospital culture, they will have to deal with it.

If cross-covering someone else's patient on night float or long call, and the nurse calls saying the family wants an update and to know what's going on, you do NOT have to run, read the chart and update the family! You can tell the nurse that you are cross-covering, you do not know the patient, and the family should wait until the primary team returns the next day.

If you get suckered into seeing a cross-cover patient's family, I've always done okay telling the family, "I am not the main doctor and I do not know the patient's treatment plan. I am here to cover for EMERGENCIES ONLY and the patient's doctors will be back the next day." What the hell are they doing asking for the doctor's update at 2am anyway? Where were they during the day? Guess it doesn't occur to them that people, ummm, go home. 😛

 

[AmoryBlaine]

Interesting discussion. aProgDirector had some great suggestions earlier, I really like the "family spokesperson" idea and I plan to incorporate that.

We had a situation on one of my medicine months where a guy had been in the hospital for about 2 months and the wife (who was basically a nice person) declared herself an amature physician. This meant that she would demand to know every lab result, every day. So instead of talking about her husband's rehab and impending G-tube placement she would want a short lecture on interpretation of bicarb. She wanted copies of all the cultures and sensitivities and so would view multiple infections with S. aureus as proof that we were not doing our job (pt was neutropenic).

My poor intern was at her wits end, a little knowledge is a terrible thing.

 

[snoopy brown]

This meant that she would demand to know every lab result, every day. She wanted copies of all the cultures and sensitivities

Refer her to medical records.

 

[deleted87716]

I just wanted to support what aProgDirector has said so far. This is a situation where tact, diplomacy, and "people skills" are put to the test. Don't be too quick to dismiss his answers as "bureaucratic." This is real-world stuff, and you can learn a lot from people who have been there, done that. 👍

 

[snoopy brown]

Don't be too quick to dismiss his answers as "bureaucratic." This is real-world stuff, and you can learn a lot from people who have been there, done that.

Surely but I think there is also an area of hypocrisy in this regard. I've noticed that often when people say "turn one cheek and then turn the other and then find a third cheek to turn ...etc" it's directed towards a resident. Meanwhile the attending himself will either avoid the patient or go in to see them on rounds briefly and then when things get hairy they'll volunteer "the resident will be back to continue things." I've also seen attendings who demand soft-shoe techniques and kid-glove treatment go in and be very tough with patients and they'll say "I've dealt with this patient for years" as an excuse.

 

[Tired]

Sometimes I have found it helpful to write down the diagnosis, pronosis, treatment plan, and (after running it through the team) giving it to the patient and family. This lets me be very deliberate in what I am trying to explain, and it gives the family time to ponder it.

Also, later when they claim to not know what's going on, I can break out the written explanation and ask, "Exactly which part was unclear to you?" This helps me distinguish pretty quickly who really is confused, and who is just trying to f*ck with me.

 

[deleted87716]

Surely but I think there is also an area of hypocrisy in this regard. I've noticed that often when people say "turn one cheek and then turn the other and then find a third cheek to turn ...etc" it's directed towards a resident.

I'm a firm believer in "tough love," and have found that you can satisfy somebody without necessarily giving them what they are asking for. Clearly, that's what's called for in this case.

That being said, I was also placed in situations as a resident where the attending clearly didn't want to deal with the situation. I took that as implied consent to do things my way. 😉

 

[Otto Octavius]

My advice for dealing with difficult families (although not politically correct) is this:
remember that the unhappy family member/patient is the person that sues. This has been shown time and time again in study after study. It's not the medical errors that end you in court, it's the patients who thought that you were a jerk. If you can bend over backwards, an extra 10-20 minutes a day reassuring a family member can save you years of legal headaches/stress in the future. When you can't please that family member (I've had family members come right out and say in front of me "somebody's going to pay!" and yell at me and do all the same things that you were describing for their family member having a stroke in the hospital), remember that your documentation should be pristine and your care (I know that this is wrong) should be conservative.

 

[snoopy brown]

I was also placed in situations as a resident where the attending clearly didn't want to deal with the situation. I took that as implied consent to do things my way. 😉

Then we are on the same page. 😉 But that's not what I took from aProgDirector's post, which is why I took exception. If that's what he meant then I apologize. Definitely I'm into not just being a mindless appeaser of patient demands.

 

[snoopy brown]

My advice for dealing with difficult families (although not politically correct) is this:
remember that the unhappy family member/patient is the person that sues. This has been shown time and time again in study after study. It's not the medical errors that end you in court, it's the patients who thought that you were a jerk.

Listen, everyone brings this up and then we as a community cower under a rock somewhere. If patients are going to hold us hostage for not doing wrong medically but just because they don't like you that's lame. Where else can I sue someone just because we didn't get along? Can I sue a restaurant? A judge? My lawyer? Nope. But somehow it's right because it's medicine. The solution is to just be extremely dilligent medically and then countersue a lot. Either that or just get everyone to pack up and leave the state, which happens.

 

[deleted87716]

Where else can I sue someone just because we didn't get along? Can I sue a restaurant? A judge? My lawyer? Nope.

Actually, you can sue anyone for anything. Successfully...? That's something else. Still, a lawsuit sucks, even an unsuccessful one. They're best avoided, and a little communication goes a long way towards doing that.

 

[snoopy brown]

Yeah but even an unsuccessful lawsuit against a physician is damaging on so many levels, why not in any of those other instances? I'm not talking about reputation even or malpractice rates. I mean the cost of defending it can even run into the hundreds of thousands whereas if I randomly sued a lawyer it would be like one day and thrown out. It's total B.S.

 

[deleted87716]

if I randomly sued a lawyer it would be like one day and thrown out. It's total B.S.

You can't sue a lawyer, because you'll never find another lawyer to take the case.

Old joke:

Q: Why didn't the shark eat the lawyer?
A: Professional courtesy. 😉

 

[greenbean]

lawyers sue lawyers all the time, or did u mean doctors cant sue lawyers?
this thread exploded but thanks for all the responses, i like hearing all the different perspectives

my new approach will be explain clearly to pt and if family is there, thereby kill two birds with one stone,and just keeping updating them about pt's progress.
if my gut is telling me theirs a problem with understanding despite my efforts,(ie the little greenbean inside me is sensing something afoot), i will deflect all requests for info to the attending.

i agree with aprog director that when im an attending i wont be able to do this, but at that point i would support my residents and not accuse them of being insensitive after all that talking, i swear that still feels like a slap in the face

peace,
greenbean

 

[DarksideAllstar]

B52's all around.

 

[Transvaal]

Interesting discussion. aProgDirector had some great suggestions earlier, I really like the "family spokesperson" idea and I plan to incorporate that.

This is standard at our hospital, though this message doesn't always come across. And then three or four them all demand you to inform them on the condition of the patient. EVERY DAY. Luckily the nurses are able to sort things out with those people, though it can be tricky if there's some kind of family break-up involved.

 

[NotAProgDirector]

Surely but I think there is also an area of hypocrisy in this regard. I've noticed that often when people say "turn one cheek and then turn the other and then find a third cheek to turn ...etc" it's directed towards a resident. Meanwhile the attending himself will either avoid the patient or go in to see them on rounds briefly and then when things get hairy they'll volunteer "the resident will be back to continue things."

This is completely unacceptable behavior on the part of the faculty member. Residents should not EVER be "a shield" between a patient and the faculty. Faculty should model the behaviors that they want their residents to learn. As faculty, we need to be sure to allow residents to "fly on their own" as tolerated -- hence residents should get first contact at this, if problems then supervised by faculty, with faculty taking full responsibility for the problem if needed. I can totally see how burned out this could make you if it was just dumped in your lap without help.

Implicit in my answer above was limit setting -- addressing the patient/family concerns while simultaneously setting limits to keep it all reasonable -- i.e. the single meeting daily, not reviewing each lab with the family member (but allowing them access to the medical records, as mentioned above), etc. Sometimes this balance is impossible, but most of the time it works.

I've also seen attendings who demand soft-shoe techniques and kid-glove treatment go in and be very tough with patients and they'll say "I've dealt with this patient for years" as an excuse.

This is equally wrong, although if you have a long term relationship with a patient it is easier to use a "bad cop" technique.

So, I think we agree -- if faculty demand that you "address" this and "be nice", etc, yet give you little/no support when the going gets tough and simply deflect all of this badness your direction, that is wrong and it's all psychobabble. If they practice what they preach, back you up when needed, and help you see how it's done, then it can be a valuable tool. Like all tools, it only works when you know how to use it safely and only for the right problems.

 

[snoopy brown]

This is completely unacceptable behavior on the part of the faculty member. Residents should not EVER be "a shield" between a patient and the faculty. Faculty should model the behaviors that they want their residents to learn.

That's right but you know that this happens. See this is my thing with your post and I'm just trying to explain where I'm coming from and not trying to insult you or anything. People in positions such as yours always act shocked like they don't know this stuff happens. Like if you tell them some resident was just insulted or berated by an attending they act like they were totally unaware this happens in their institution when in fact they probably are well aware of it or else there's a bigger problem that they were completely oblivious to it.

You and I agree on what should occur. Where we differ is on the response to what does occur. In an ideal world where the attendings are always very involved in discussions with all of their patients and supportive of their residents and good models for behavior, yes, I'd do everything you said. Absolutely. Since it's not like that I'll go with KentW's "implied consent to do it my way."

 

[PeepshowJohnny]

Even though I'm just a lame medical student, I'm really interested in how to handle cases like this.

Denial is the most common defense mechanism used by patients... unfortunately it's like my personal pet peeve and drives me up the wall.

Nothing is so frustrating as to spend a time with a patients family explaining everything about their disease at a grade school level and our treatment plan only to come back the next day and find the patient, or the spouse, or the child assault us for "Not telling us anything about what's wrong with [the patient] or how we're going to fix it".

I think it stems from one of the first patients I was following in second year as part of our schools "transition" into clinical years. I was following an FP doc who asked me to see his patient at the hospital each morning before clinic. I think one was their for a total of four days with the typical problems of an older person who didn't take care of themselves: Diabetes into renal failure, COPD, CHF. And every single day she would start crying, and ask me "Why can't they just figure out what's wrong with me?" despite our long discussion the previous day about exactly why she was wrong, but as soon as she found out there was no miracle cure for the manifestations of these chronic conditions everything we talked about flew out the window.