How to deal with difficult patients as a resident

[deleted1053216]

I am making this post because such patients always leave an impression on me.

Patient
In the ED or FM clinic, I have always had patients who twist my words or lie to my face or make demands that do not make sense. I have seen my attendings, nurses and consultants have such difficult patients, but they seem to brush them off, I however tend to get frazzled by this. It almost feels taboo as an intern to discuss such a problem with my seniors and felt it better to discuss this in a confidential setting such as this.

I will tell you my story with one such patient today in the ED, elderly female comes in by EMS to the clinic, patient has a hx of HTN and her BP was elevated, with some non-specific ekg changes and fatigue for the last two weeks that had PCP worried about possible ACS. It isn't unusual story and the workup I have down pat (L of Saline, Tropsx2, ekg, UA, CBC and CMP), I informed my attending after the workup was started and everything was going fine. Patient is hard of hearing, so I raise my voice in an effort to communicate with her and she asks me to remove my mask so she can perhaps articulate my words from my lips (I am assuming this is the meaning behind this odd request).

My attending drops in and sees the patient and comes back. He tells me, she reported that she has been feeling woozy lately, I should throw in a non-con Brain CT. I do that and in about 15 minute, the whole story takes a downwards turn. I have one of the ER nurses come to find me to tell me, the patient is angry, she is removing her IV and she wants to go home.

I go see the Patient, she tells me my attending said she could go home. I try to reason with her, that she gave my attending a history of dizziness and that plus her recent fatigue would be better for her to be evaluated with a CT scan. She is angry and not ready to listen. She denies having shared any such information, she tells me what she meant was she felt dizzy like a week back when this episode started. So I use that as a way to try and convince her for a CT scan. She refuses, patient is adamant. I go to my attending and inform him of the plan.

Attending says go ahead and discharge her. She changes her mind, begins asking me what was wrong with her, I tell her, she again request me to take off my mask. I am trying to convince her to stay, her BP is high, we can give her BP meds. She is still confrontational about dizziness and the Head CT, reports she should not need one now as she doesn't have any sxs. She is threatening to remove her IV and leave. in the meantime, I approach my attending several times about input and possible recommendations for the patient. Eventually, there is a shift change of nurses a new nurse comes in. I am grateful to her as she rescues me from this situation and convinces her to stay for the second set of troponin and the CT scan.

Such an interaction isn't new to me like I have said. As a fourth year, during my SUB-I I have observed several interns, residents and attendings with such patients.

-----

A day or so ago, I had another patient, for a infected panc. pseudocyst, I finished my workup and set everything up. However, the patient reports he wants to leave AMA and have the I&D procedure done at his Hometown hospital. I try to convince him, but, he is adamant and wants me to speak to his GI/Surgeon doctor.
I offer to do so, however,2 to covid, they are closed and not doing any procedures either. as he is still adamant to leave AMA, I have got that paperwork set up, he then asks me "Do you know what will happen to insurance payment? Will I have to pay more because I am leaving ama. I politely inform him that insurance payments in AMA situations isn't my expertise. I instruct him to call insurance company as they usually have someone available 24/7."

---

Such patients drain me emotionally, to the point I preserve over such interactions over and over. I spoke to my mother and the nurse about such experiences and they responded with that I should use them as a learning opportunity and an experience. I don't mean to whine either, I understand intern year has its challenges. However, if any with more experience can share how they emotionally get past such patients, much appreciated.

---

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[AMEHigh]

To be honest you just learn to deal with it. It doesn’t even sound like those patients were even super rude to you, just confused and wanted to leave. I honestly don’t give it a 2nd thought.

Now patients who are down right mean to me yelling and cursing then I usually tell them the behavior isn’t tolerated and leave to collect myself. I have cried a few times in private and got angry for a few minutes but then let it roll off my back.

I do try to sympathize with patients that being sick and navigating our confusing health system can be overwhelming but ultimately they shouldn’t treat me like a piece of poop and if they do I don’t take it personally and move about my day.

 

[smq123]

I am making this post because such patients always leave an impression on me.

Patient
In the ED or FM clinic, I have always had patients who twist my words or lie to my face or make demands that do not make sense. I have seen my attendings, nurses and consultants have such difficult patients, but they seem to brush them off, I however tend to get frazzled by this. It almost feels taboo as an intern to discuss such a problem with my seniors and felt it better to discuss this in a confidential setting such as this.

I will tell you my story with one such patient today in the ED, elderly female comes in by EMS to the clinic, patient has a hx of HTN and her BP was elevated, with some non-specific ekg changes and fatigue for the last two weeks that had PCP worried about possible ACS. It isn't unusual story and the workup I have down pat (L of Saline, Tropsx2, ekg, UA, CBC and CMP), I informed my attending after the workup was started and everything was going fine. Patient is hard of hearing, so I raise my voice in an effort to communicate with her and she asks me to remove my mask so she can perhaps articulate my words from my lips (I am assuming this is the meaning behind this odd request).

My attending drops in and sees the patient and comes back. He tells me, she reported that she has been feeling woozy lately, I should throw in a non-con Brain CT. I do that and in about 15 minute, the whole story takes a downwards turn. I have one of the ER nurses come to find me to tell me, the patient is angry, she is removing her IV and she wants to go home.

I go see the Patient, she tells me my attending said she could go home. I try to reason with her, that she gave my attending a history of dizziness and that plus her recent fatigue would be better for her to be evaluated with a CT scan. She is angry and not ready to listen. She denies having shared any such information, she tells me what she meant was she felt dizzy like a week back when this episode started. So I use that as a way to try and convince her for a CT scan. She refuses, patient is adamant. I go to my attending and inform him of the plan.

Attending says go ahead and discharge her. She changes her mind, begins asking me what was wrong with her, I tell her, she again request me to take off my mask. I am trying to convince her to stay, her BP is high, we can give her BP meds. She is still confrontational about dizziness and the Head CT, reports she should not need one now as she doesn't have any sxs. She is threatening to remove her IV and leave. in the meantime, I approach my attending several times about input and possible recommendations for the patient. Eventually, there is a shift change of nurses a new nurse comes in. I am grateful to her as she rescues me from this situation and convinces her to stay for the second set of troponin and the CT scan.

Such an interaction isn't new to me like I have said. As a fourth year, during my SUB-I I have observed several interns, residents and attendings with such patients.

-----

A day or so ago, I had another patient, for a infected panc. pseudocyst, I finished my workup and set everything up. However, the patient reports he wants to leave AMA and have the I&D procedure done at his Hometown hospital. I try to convince him, but, he is adamant and wants me to speak to his GI/Surgeon doctor.
I offer to do so, however,2 to covid, they are closed and not doing any procedures either. as he is still adamant to leave AMA, I have got that paperwork set up, he then asks me "Do you know what will happen to insurance payment? Will I have to pay more because I am leaving ama. I politely inform him that insurance payments in AMA situations isn't my expertise. I instruct him to call insurance company as they usually have someone available 24/7."

---

Such patients drain me emotionally, to the point I preserve over such interactions over and over. I spoke to my mother and the nurse about such experiences and they responded with that I should use them as a learning opportunity and an experience. I don't mean to whine either, I understand intern year has its challenges. However, if any with more experience can share how they emotionally get past such patients, much appreciated.

These patients get you emotionally worked up because they want to.

Some patients feed off of drama. They can't stand a quiet, calm interaction because that's not what they're used to (for whatever reason). And so they try to create discontent and chaos and anxiety, because that is the environment that they feel most comfortable in.

Try to develop a poker face. The calmer you are in response to their drama, the calmer you will feel internally as well.

Also, remember that these patients have their own reasons for being difficult, that have nothing to do with you. That's probably why you perseverate on these interactions - you probably feel like you caused them to be difficult, or if you had been more capable then they wouldn't be acting this way. That's not true - they would be acting this way no matter what you had done. Once you realize that, the less their behavior will bother you.

 

[SXMMD]

The longer you practice the easier this type of interaction gets. You learn to accept that people are allowed to make their own choices, including bad ones, and none of that is your fault (or frankly your business). Your job is only to educate, guide and assist your patient towards good health where you can, not take responsibility for their behavior or make decisions FOR them. This doesn't mean not to have empathy- rather your sense of empathy matures and you grow out of the martyr/savior complex. Time and practice will make these situations easier and we all go through this process, so take comfort in that.

practical tips to help move things along
1) Work on your communication. Communication is a 2 way street, but for physicians it starts with listening closely (and trying to understand what the patient is trying to convey, not just getting caught up in the specific word choice, for example) and paying attention to non verbal communication. I found our palliative care specialists to be absolutely fantastic at navigating difficult conversations and patients, and spent a lot of time studying how they approached things. Psych and therapists tend to be excellent at this too. Link up with some of these people or other trusted mentors who you've seen do well in these situations to work on this skill in a thoughtful way. Strong communication skills can help you better understand and work through the issues a difficult patient is having in a productive way.

2) Engage in self reflection. What specifically about these types of interactions got under your skin? Is there a pattern? When you can identify specifically what is bothering you, you can work on addressing the underlying issues. For myself, though I'm typically very comfortable with difficult patients/conversations, I get really worked up with alcoholics and struggled with them early on. I realized the helplessness I felt in dealing with these types of patients was what bothered me about them- not the management of withdrawal, cirrhosis/liver disease, etc- but the inability get these people to stop drinking themselves to death and leaving AMA to do so. With practice I learned not to take it personally and to be present and caring for my patient when they inevitably return in a few weeks drunk and sick. Do I still get annoyed with these patients now and then? Sure do, but I don't lose sleep anymore. I do the best I can for them and move on.

Your concern for patients is admirable, but don't take bad choices people make too hard. Everyone has a right to their own choices in life, including bad ones, and that's ok.

 

[VA Hopeful Dr]

You get used to it.

What works for me is remembering that my job is to advise. I figure out what I think is wrong and offer my recommendation for diagnosis/treatment. If the patient doesn't want to follow my recommendation that's on them. If I can alter my plan and still be safe, I will offer that. If not, I explain the possible consequences of not taking my advice, document as such, and more on.

This is obviously much easier said than done and when I was first out of medical school I had the exact same problems that you are having. With time it'll get better.

 

[deleted87716]

Agree with all of the above. Also, keep in mind that these people can sense fear and/or weakness. Be professional, and don't let your poker face slip. Remember, you're in charge of you, and they're in charge of them. You can't "make" them do anything, and vice versa. If they don't want to listen to reason, document their responses and move on. Patients generally think I'm a nice guy (there are exceptions, of course), but most would agree that I don't put up with any crap, either.

 

[FrustratedFamDoc]

All excellent responses. As time goes on, you will develop your own technique for dealing with unstable and more challenging patients. Treat your physical and emotional energy as currency and spend it wisely. With more experience, you'll get a sixth sense for encounters that are about to go sideways. You'll learn what to ask and what not to ask. You'll learn when to ask it and how. Don't let them take you down rabbit holes, and never surrender control of the interview. Be respectfully firm with redirection. You'll frequently encounter people whose entire life is in a tailspin and are desperately looking for someone to fix it. This person is not you. My favorite opening line "How can I help you today?" If you dare ask "what's going on?" sometimes you've dug your own grave. Only ask about things you're truly interested in. You don't really want to spend the next 10 minutes talking about their grandson's bad marriage, do you? Keep the small talk small. Asking about their trip to Alaska/new grandbaby/job/etc is fun, interesting, and can be diverted pretty quickly.

Again, as time goes on, you'll get better and more comfortable with this.

 

[Dr Tapatio]

I am making this post because such patients always leave an impression on me.

Patient
In the ED or FM clinic, I have always had patients who twist my words or lie to my face or make demands that do not make sense. I have seen my attendings, nurses and consultants have such difficult patients, but they seem to brush them off, I however tend to get frazzled by this. It almost feels taboo as an intern to discuss such a problem with my seniors and felt it better to discuss this in a confidential setting such as this.

I will tell you my story with one such patient today in the ED, elderly female comes in by EMS to the clinic, patient has a hx of HTN and her BP was elevated, with some non-specific ekg changes and fatigue for the last two weeks that had PCP worried about possible ACS. It isn't unusual story and the workup I have down pat (L of Saline, Tropsx2, ekg, UA, CBC and CMP), I informed my attending after the workup was started and everything was going fine. Patient is hard of hearing, so I raise my voice in an effort to communicate with her and she asks me to remove my mask so she can perhaps articulate my words from my lips (I am assuming this is the meaning behind this odd request).

My attending drops in and sees the patient and comes back. He tells me, she reported that she has been feeling woozy lately, I should throw in a non-con Brain CT. I do that and in about 15 minute, the whole story takes a downwards turn. I have one of the ER nurses come to find me to tell me, the patient is angry, she is removing her IV and she wants to go home.

I go see the Patient, she tells me my attending said she could go home. I try to reason with her, that she gave my attending a history of dizziness and that plus her recent fatigue would be better for her to be evaluated with a CT scan. She is angry and not ready to listen. She denies having shared any such information, she tells me what she meant was she felt dizzy like a week back when this episode started. So I use that as a way to try and convince her for a CT scan. She refuses, patient is adamant. I go to my attending and inform him of the plan.

Attending says go ahead and discharge her. She changes her mind, begins asking me what was wrong with her, I tell her, she again request me to take off my mask. I am trying to convince her to stay, her BP is high, we can give her BP meds. She is still confrontational about dizziness and the Head CT, reports she should not need one now as she doesn't have any sxs. She is threatening to remove her IV and leave. in the meantime, I approach my attending several times about input and possible recommendations for the patient. Eventually, there is a shift change of nurses a new nurse comes in. I am grateful to her as she rescues me from this situation and convinces her to stay for the second set of troponin and the CT scan.

Such an interaction isn't new to me like I have said. As a fourth year, during my SUB-I I have observed several interns, residents and attendings with such patients.

-----

A day or so ago, I had another patient, for a infected panc. pseudocyst, I finished my workup and set everything up. However, the patient reports he wants to leave AMA and have the I&D procedure done at his Hometown hospital. I try to convince him, but, he is adamant and wants me to speak to his GI/Surgeon doctor.
I offer to do so, however,2 to covid, they are closed and not doing any procedures either. as he is still adamant to leave AMA, I have got that paperwork set up, he then asks me "Do you know what will happen to insurance payment? Will I have to pay more because I am leaving ama. I politely inform him that insurance payments in AMA situations isn't my expertise. I instruct him to call insurance company as they usually have someone available 24/7."

---

Such patients drain me emotionally, to the point I preserve over such interactions over and over. I spoke to my mother and the nurse about such experiences and they responded with that I should use them as a learning opportunity and an experience. I don't mean to whine either, I understand intern year has its challenges. However, if any with more experience can share how they emotionally get past such patients, much appreciated.

You need to grow a little bit of callous. Tell the patient "this is my plan for this reason. This is what I believe should be done. You have a right to refuse treatment, and if you wish to go, please ask the nurse for the form to leave AMA." People tend to respect those that put clear boundaries around them. You're not a med student anymore.

 

[Candidate2017]

In the ED or FM clinic, I have always had patients who twist my words or lie to my face or make demands that do not make sense. I have seen my attendings, nurses and consultants have such difficult patients, but they seem to brush them off, I however tend to get frazzled by this. It almost feels taboo as an intern to discuss such a problem with my seniors and felt it better to discuss this in a confidential setting such as this
---

Such patients drain me emotionally, to the point I preserve over such interactions over and over. I spoke to my mother and the nurse about such experiences and they responded with that I should use them as a learning opportunity and an experience.

Yes, your mother and the RN are correct. It's a positive thing that you perseverate. It means you want to get better, not just shrug your shoulders.

Few patients intentionally lie. They are confused, cannot explain symptoms, or do not feel comfortable sharing. What can you do to un-confuse them, make them trust you? The patients who regularly lie and make demands tend to be substance users/seekers. Even so, they are asking for help.

Every patient has a medical condition and a psychological condition. Ignore one or the other and you will have a difficult time. You are always treating at least 3 patients: the patient, the attending, yourself. Plus baggage in the attic. Ignore any of them and you will have a difficult time.

While there are mean patients, the two you describe seem normal.

Pt 1: elderly, deaf, confused why her PCP wants her to go to ED, frustrated with ED wait. Why do think it's odd she wants your mask off? Yes logically, COVID. Emotionally, strangers with masks are terrifying. There is plenty of room here to improve.
Pt 2: also frustrated, confused and scared, away from home, afraid of out of network costs. He has the right to leave. I would have educated him on the severity of his situation, why he needs to be treated now. If he chooses not now, then he needs to call his own GI/insurance/local hospital ASAP to be treated.
Also, don't forget there is you: intern, frustrated and scared, insecure, tired, afraid of looking stupid to the patient and attending, mother is a physician? etc etc.

 

[Splenda88]

These are what I would consider 'normal' patient interactions...

 

[Bacchus]

These patients get you emotionally worked up because they want to.

Some patients feed off of drama. They can't stand a quiet, calm interaction because that's not what they're used to (for whatever reason). And so they try to create discontent and chaos and anxiety, because that is the environment that they feel most comfortable in.

Try to develop a poker face. The calmer you are in response to their drama, the calmer you will feel internally as well.

Also, remember that these patients have their own reasons for being difficult, that have nothing to do with you. That's probably why you perseverate on these interactions - you probably feel like you caused them to be difficult, or if you had been more capable then they wouldn't be acting this way. That's not true - they would be acting this way no matter what you had done. Once you realize that, the less their behavior will bother you.

If these couldn’t be truer words came from my mouth, for the OP, it would be do as I say, not as I do. Still trying to perfect 4 years out from training.

OP, being a PGY1, seven years behind me I’m not surprised by your concern over the situations. If you didn’t have concern or get riled up, I’d have more questions

 

[deleted480308]

I have a huge autonomous streak. I am in control of my actions and the consequences. The patient (if having capacity) is solely responsible for their choices and consequences. I am a paid advisor. They give me information and I create advice about next steps, if they agree we do those steps. If they don’t I write down what they told me and they leave.

their life, not mine. It isn’t lack of caring, it’s respect for their autonomy

 

[Sardonix]

Only a couple weeks in and I have also seen patients pull some silly, frustrating things.

So long as they have decision making capacity, that's their choice. So long as I do my job well and in good faith, make a sincere effort to inform them and help them, their choices are on them. The only other option is torturing myself and trying to mother adults into making decisions I decide are best for them. That's not a practical option.

 

[Splenda88]

Only a couple weeks in and I have also seen patients pull some silly, frustrating things.

So long as they have decision making capacity, that's their choice. So long as I do my job well and in good faith, make a sincere effort to inform them and help them, their choices are on them. The only other option is torturing myself and trying to mother adults into making decisions I decide are best for them. That's not a practical option.

The sooner you understand that, the better you residency experience will be. It took me a whole year to realize that I can't save some people from themselves..

 

[Sardonix]

The sooner you understand that, the better you residency experience will be. It took me a whole year to realize that I can't save some people from themselves..

Right now I know it objectively, but let's see how well I actually put it into practice, ha.

 

[wysdoc]

I am making this post because such patients always leave an impression on me.

Patient
In the ED or FM clinic, I have always had patients who twist my words or lie to my face or make demands that do not make sense. I have seen my attendings, nurses and consultants have such difficult patients, but they seem to brush them off, I however tend to get frazzled by this. It almost feels taboo as an intern to discuss such a problem with my seniors and felt it better to discuss this in a confidential setting such as this.

I will tell you my story with one such patient today in the ED, elderly female comes in by EMS to the clinic, patient has a hx of HTN and her BP was elevated, with some non-specific ekg changes and fatigue for the last two weeks that had PCP worried about possible ACS. It isn't unusual story and the workup I have down pat (L of Saline, Tropsx2, ekg, UA, CBC and CMP), I informed my attending after the workup was started and everything was going fine. Patient is hard of hearing, so I raise my voice in an effort to communicate with her and she asks me to remove my mask so she can perhaps articulate my words from my lips (I am assuming this is the meaning behind this odd request).

My attending drops in and sees the patient and comes back. He tells me, she reported that she has been feeling woozy lately, I should throw in a non-con Brain CT. I do that and in about 15 minute, the whole story takes a downwards turn. I have one of the ER nurses come to find me to tell me, the patient is angry, she is removing her IV and she wants to go home.

I go see the Patient, she tells me my attending said she could go home. I try to reason with her, that she gave my attending a history of dizziness and that plus her recent fatigue would be better for her to be evaluated with a CT scan. She is angry and not ready to listen. She denies having shared any such information, she tells me what she meant was she felt dizzy like a week back when this episode started. So I use that as a way to try and convince her for a CT scan. She refuses, patient is adamant. I go to my attending and inform him of the plan.

Attending says go ahead and discharge her. She changes her mind, begins asking me what was wrong with her, I tell her, she again request me to take off my mask. I am trying to convince her to stay, her BP is high, we can give her BP meds. She is still confrontational about dizziness and the Head CT, reports she should not need one now as she doesn't have any sxs. She is threatening to remove her IV and leave. in the meantime, I approach my attending several times about input and possible recommendations for the patient. Eventually, there is a shift change of nurses a new nurse comes in. I am grateful to her as she rescues me from this situation and convinces her to stay for the second set of troponin and the CT scan.

Such an interaction isn't new to me like I have said. As a fourth year, during my SUB-I I have observed several interns, residents and attendings with such patients.

-----

A day or so ago, I had another patient, for a infected panc. pseudocyst, I finished my workup and set everything up. However, the patient reports he wants to leave AMA and have the I&D procedure done at his Hometown hospital. I try to convince him, but, he is adamant and wants me to speak to his GI/Surgeon doctor.
I offer to do so, however,2 to covid, they are closed and not doing any procedures either. as he is still adamant to leave AMA, I have got that paperwork set up, he then asks me "Do you know what will happen to insurance payment? Will I have to pay more because I am leaving ama. I politely inform him that insurance payments in AMA situations isn't my expertise. I instruct him to call insurance company as they usually have someone available 24/7."

---

Such patients drain me emotionally, to the point I preserve over such interactions over and over. I spoke to my mother and the nurse about such experiences and they responded with that I should use them as a learning opportunity and an experience. I don't mean to whine either, I understand intern year has its challenges. However, if any with more experience can share how they emotionally get past such patients, much appreciated.

Your first patient: don't forget that in these "hard of hearing" situations you can write your question on a piece of paper and listen to her answer
It takes a lot for some elderly +/- senile individuals to come to an ER. They really don't want to be there, are worried and fearful, and when frustrated by it all they just want to go home. You will gain experience in these things but remember they are scared and confused.

 

[Fatalis]

The sooner you understand that, the better you residency experience will be. It took me a whole year to realize that I can't save some people from themselves..

And also realize that a lot of them do it to themselves and don’t really care what you say/ tell them. As someone said above, your job is to advise

 

[hallowmann]

And also realize that a lot of them do it to themselves and don’t really care what you say/ tell them. As someone said above, your job is to advise

While I generally agree with the sentiment that you cannot at times save people from themselves, I will say that I often see this argument used as an excuse not to put the time or effort in to properly explain the situation to patients or try to understand why they are apprehensive about treatment. It usually ends in opting to just not deal with the "difficult" patient and just give them ultimatums. We often take for granted how little some people understand about medicine/healthcare and how rightfully mistrustful many marginalized populations are.

Again, to be clear, some people will not listen no matter how hard you try, and ultimately that's their right, but we should all try to relay the necessary info and reasoning to them so they can make truly informed decisions. Something I have to remind myself of often, and it bears repeating here.

 

[Fatalis]

While I generally agree with the sentiment that you cannot at times save people from themselves, I will say that I often see this argument used as an excuse not to put the time or effort in to properly explain the situation to patients or try to understand why they are apprehensive about treatment. It usually ends in opting to just not deal with the "difficult" patient and just give them ultimatums. We often take for granted how little some people understand about medicine/healthcare and how rightfully mistrustful many marginalized populations are.

Again, to be clear, some people will not listen no matter how hard you try, and ultimately that's their right, but we should all try to relay the necessary info and reasoning to them so they can make truly informed decisions. Something I have to remind myself of often, and it bears repeating here.

Oh I agree 110%, there’s a fine line between patients that don’t understand and are not educated in the treatment or disease and there are the ones that just don’t give a ****