Verbally abusive patients

[buffywannabe]

OK, totally understand this is going to happen so I want to ask you all how you handle it. Awhile back I had a patient yelling at me and I said you need to lower your voice or I will call security. i think this escalated things. Pts family got more mad and then I left and called security. I noted another doc with a different philosophy which I liked. He says "i understand you are upset. i'm going to step out and give you a moment to compose yourself." and then reenter saying "are you ready to talk now?" Any thoughts on how you handle this? It's really difficult not to get angry when being yelled at and I think some tips on how to handle it would be helpful. we definitely don't learn this in medical school or residency.

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[WilcoWorld]

Nobody can be perfect all the time. And there's no approach that will work with every encounter. I'll try to understand people's frustration, but if the patient is getting nasty I find it's usually effective to just reflect what they've said, or simply acknowledge their anger, but not comment on it. When someone's being totally unreasonable I'll say "I can see you're upset" and follow it with several seconds of silence. Usually I'll have to do that a couple of times, but eventually most people get sick of being flaccidly sympathized with and move on to either acquiescing with treatment or leaving AMA. I'm fine with either.

 

[Perrin]

A trick I use occasionally is the let them vent for a minute. I tell them I understand they are upset, "but let me take a quick listen to your chest again, because I may have heard something earlier." They usually get concerned a bit that the doc is wanting to check them again. I then do an extended lung exam with them taking numerous deep breaths. Most people stop talking when I put the stethoscope buds in and after a minute of deep breathing they are usually much calmer. That, and they want to know if you heard anything worrisome.

 

[GeneralVeers]

I don't have the time or energy to be yelled at, abused, or insulted. If they are not sick with an acute, or life-threatening issue, then I will simply excuse myself and discharge them. After that it's up to the nurses if they want to call security to escort them out. I'm not going to coddle them like children, or pretend that they are reasonable people.

 

[namethatsmell]

I don't have the time or energy to be yelled at, abused, or insulted. If they are not sick with an acute, or life-threatening issue, then I will simply excuse myself and discharge them. After that it's up to the nurses if they want to call security to escort them out. I'm not going to coddle them like children, or pretend that they are reasonable people.

Out of curiosity do you reference the patient's behavior in your mdm?

 

[UnderwaterDoc]

I'm with Veers. I do remain polite but I will not stand there and take the abuse, if there is no way to salvage the situation I will discharge immediately, with security called if needed. Sometimes I get the clinical manager involved and basically remove myself from the equation, you'd be surprised how well this works. I'm a night doc so this happens quite often at my shop, since the seekers come out of the woodwork at 3 AM.

And yes I absolutely reference the patient's behavior in the note, with as much detail as possible, because that's the patient that will call administration and complain and then I have to answer for it. Much easier to defend yourself when it is all laid out on the note.

 

[dotcb]

I try to be nice and professional. I try to acknowledge and address the patient's concern. I consider if there's a way I can make them happier without compromising what I feel is medically appropriate (oxycontin Rx, MRI back pain, demand admission, Etc.). If there's some way I can avoid the patient coming back and another provider having to deal with the same problem - I try to do that thing - social work, psych, housing, drug/etoh rehab, etc. I work in a public hospital w/ some very challenging patients - we have several who come to our ED 4 days a week.

I describe what happened and my reasoning in the medical record.

 

[Doctor Bob]

Out of curiosity do you reference the patient's behavior in your mdm?

Always. And I request that the nurses document it as well.

 

[WilcoWorld]

Whenever relevant (or especially humorous) I include direct quotes.

 

[Docinthetrenches]

If they are sick or altered, you deal with them. If they are not, you tell them once not to behave like that and if they continue, call security and have them removed. You simply don't have to deal with it when someone is not either a danger to themselves or others, psychotic, or under the influence of a substance causing them to not be able to control their actions. Basically, if they are rude and not sick, you have them escorted out. Alternatively if you don't want to go that far, have them speak to the nursig supervisor or the patient care representative.

 

[Birdstrike]

This is another reason Patient Satisfaction Centered Medicine is a bad thing as applied to Emergency Medicine. A patient or family can be verbally and physically abusive to you, yet the fact that you were abused by the patient and family, by itself, does not invalidate their patient satisfaction rating of you and your hospital, nor do your bosses consider them any less a "customer" that you need to please.

If a patient verbally or physically abuses an outpatient doctor in their own practice, any complaint goes back to that doctor himself. It's discarded as invalid, as it should be. They same cannot be said for hospital-based medicine.

Patients verbally and physically abusive to Emergency Department personnel are common, unfortunately. The law (Emtala) requires you to take the abuse. Patient Centered Medicine as pushed by the government (HCAHPS, Medicare, Federal Government) and the businessmen (hospital administrators in bed with patient satisfaction survey companies) force you to encourage more by "satisfying" such "customers" and threaten your job and/or contract if you don't comply. And you're required to see the same person again, and "satisfy" them. Again.

This needs to be changed. There needs to be different rules regarding EMTALA-based settings and other settings. EDs don't function like boutiques, and therefore should not be judged by the same rules that boutiques are. The same goes for Addiction Medicine and Pain Medicine settings. Not having separate rules, fine tuned for these special settings, is disastrous.

 

[LaBusqueda]

This is another reason Patient Satisfaction Centered Medicine is a bad thing as applied to Emergency Medicine. A patient or family can be verbally and physically abusive to you, yet the fact that you were abused by the patient and family, by itself, does not invalidate their patient satisfaction rating of you and your hospital, nor do your bosses consider them any less a "customer" that you need to please.

If a patient verbally or physically abuses an outpatient doctor in their own practice, any complaint goes back to that doctor himself. It's discarded as invalid, as it should be. They same cannot be said for hospital-based medicine.

Patients verbally and physically abusive to Emergency Department personnel are common, unfortunately. The law (Emtala) requires you to take the abuse. Patient Centered Medicine as pushed by the government (HCAHPS, Medicare, Federal Government) and the businessmen (hospital administrators in bed with patient satisfaction survey companies) force you to encourage more by "satisfying" such "customers" and threaten your job and/or contract if you don't comply. And you're required to see the same person again, and "satisfy" them. Again.

This needs to be changed. There needs to be different rules regarding EMTALA-based settings and other settings. EDs don't function like boutiques, and therefore should not be judged by the same rules that boutiques are. The same goes for Addiction Medicine and Pain Medicine settings. Not having separate rules, fine tuned for these special settings, is disastrous.

 

[Birdstrike]

Did you just beam 1,000 likes onto my post with your Death Star-liker-laser?

 

[LaBusqueda]

Like, I did. Hmmmmmm

 

[Psai]

This is another reason Patient Satisfaction Centered Medicine is a bad thing as applied to Emergency Medicine. A patient or family can be verbally and physically abusive to you, yet the fact that you were abused by the patient and family, by itself, does not invalidate their patient satisfaction rating of you and your hospital, nor do your bosses consider them any less a "customer" that you need to please.

If a patient verbally or physically abuses an outpatient doctor in their own practice, any complaint goes back to that doctor himself. It's discarded as invalid, as it should be. They same cannot be said for hospital-based medicine.

Patients verbally and physically abusive to Emergency Department personnel are common, unfortunately. The law (Emtala) requires you to take the abuse. Patient Centered Medicine as pushed by the government (HCAHPS, Medicare, Federal Government) and the businessmen (hospital administrators in bed with patient satisfaction survey companies) force you to encourage more by "satisfying" such "customers" and threaten your job and/or contract if you don't comply. And you're required to see the same person again, and "satisfy" them. Again.

This needs to be changed. There needs to be different rules regarding EMTALA-based settings and other settings. EDs don't function like boutiques, and therefore should not be judged by the same rules that boutiques are. The same goes for Addiction Medicine and Pain Medicine settings. Not having separate rules, fine tuned for these special settings, is disastrous.

Just have to go around satisfying everyone I suppose

 

[Mighty Mouse]

depends on context....

1) altered, delerious, or suggestive of medical/psych pathology....deal with it, sedate if necessary, and find out what's wrong

2) if they are legit upset about something...recognize that the yelling/frustration is their primitive way of showing some other unmet need. take an emotional step back, let them vent, and figure out how to fix the problem. if it doesn't work, then document in a way that makes you look awesome and them not so much. important to acknowledge at least a medical screening exam that demonstrates they had no acute medical emergency before they were escorted out.

3) verbally abusive or potentially violent towards you or staff just because they are bad people -- you do not for a single second have to tolerate verbal or physical violence in your work place. we do not have to tolerate anything that would get the cops called at any other place. if you are the attending (resident a little harder) you get to decide when the encounter will end and whether that cost/benefit is worth it. and I have no problem saying, "you don't get to act like this in here, and you don't get to treat my staff this way. security is going to see you out now." usually freaks them out because they're not accustomed to having someone actually stand up to them. again, important to document a MSE and anything that makes you look awesome and them not so much.

 

[Angry Birds]

Karate chop to the head.

 

[namethatsmell]

Always. And I request that the nurses document it as well.

Thanks, I asked because one attending who I greatly respect has been sued for a case involving a patient who was verbally abusive (thankfully case was meritless and was dropped). His counsel told him that the way he documented a patient's activity--something akin to "patient in no apparent distress texting comfortably on phone and eating mcdonalds"--could be viewed as minimizing and possibly mocking the patient in court. Since hearing this I've been way more self-conscious about charting on these types of patients. As much as possible I just try to put their statements in quotes.

 

[RuralEDDoc]

I don't have the time or energy to be yelled at, abused, or insulted. If they are not sick with an acute, or life-threatening issue, then I will simply excuse myself and discharge them. After that it's up to the nurses if they want to call security to escort them out. I'm not going to coddle them like children, or pretend that they are reasonable people.

I agree with your approach in principle, but am curious about how this plays out. Do you get more patient complaints than the average doc in your group? I fully agree that we shouldn't have to put up with bull****, but the modern practice of emergency medicine involves a great deal of customer service. Plus, there's the additional aspect of leaving the uncomfortable act of discharging the abusive patient to the nurse; do you get nursing complaints? This is not criticism of your approach, I am curious how this affects you.

 

[TooMuchResearch]

I agree with your approach in principle, but am curious about how this plays out. Do you get more patient complaints than the average doc in your group? I fully agree that we shouldn't have to put up with bull****, but the modern practice of emergency medicine involves a great deal of customer service. Plus, there's the additional aspect of leaving the uncomfortable act of discharging the abusive patient to the nurse; do you get nursing complaints? This is not criticism of your approach, I am curious how this affects you.

Veers doesn't have a group.

 

[GeneralVeers]

I agree with your approach in principle, but am curious about how this plays out. Do you get more patient complaints than the average doc in your group? I fully agree that we shouldn't have to put up with bull****, but the modern practice of emergency medicine involves a great deal of customer service. Plus, there's the additional aspect of leaving the uncomfortable act of discharging the abusive patient to the nurse; do you get nursing complaints? This is not criticism of your approach, I am curious how this affects you.

I used to work for a group, and would definitely had more complaints. Most of my complaints were regarding not giving narcotics to people, and other complaints were rare. Generally if a patient complains about not giving narcotics, hospital admin and the group don't take them too seriously. 90% of my fights with patients are due to not giving shots of narcotics, or prescriptions. I have a pretty hard line on narcotics, and the nice thing about TX is that we don't have the state-mandated triplicates, and as a result can't write for anything stronger than Tramadol or Tylenol #3. This has really cut down on complaints and confrontations as most drug seekers realize now that they're not going to get Percs or even hydros from the ED.

 

[littlejuan]

Thanks, I asked because one attending who I greatly respect has been sued for a case involving a patient who was verbally abusive (thankfully case was meritless and was dropped). His counsel told him that the way he documented a patient's activity--something akin to "patient in no apparent distress texting comfortably on phone and eating mcdonalds"--could be viewed as minimizing and possibly mocking the patient in court. Since hearing this I've been way more self-conscious about charting on these types of patients. As much as possible I just try to put their statements in quotes.

Wait, so how are we supposed to document when a patient comes in with a severe (insert complaint here) and is doing ridiculous crap like that? 'Patient in no apparent distress' does not always convey just how comfortable they look.

 

[namethatsmell]

Wait, so how are we supposed to document when a patient comes in with a severe (insert complaint here) and is doing ridiculous crap like that? 'Patient in no apparent distress' does not always convey just how comfortable they look.

So my attending was told by the lawyer that simply charting "patient in no apparent distress" is sufficient for the chart and less likely to engender ill feelings with the jury.

Obviously charting their specific behavior is more in line with how many of us document.

I'm not saying it's the "right" way to chart, and am definitely curious to hear what others think.

 

[da8s0859q]

I'm curious too. I'm also a detailed charter -- texting, laughing, joking in conversation with friend at bedside, asking for something to eat with 10/10 pain, etc. I try to leave it to my MDM (and, often, ordered labs/imaging) to explain that/how/why I did not blow someone off.

 

[GeneralVeers]

I always document what the patient is doing. "No acute distress" opens you up to a lot of questions from the Plaintiff's attorney about what consitutes distress and the medical definition of distress. If you paint the picture for the attorneys and the jury by describing specific behaviors, it's better and simpler. On balance I'd rather describe the behaviors than leave it vague.

 

[Vandalia]

So my attending was told by the lawyer that simply charting "patient in no apparent distress" is sufficient for the chart and less likely to engender ill feelings with the jury.

Obviously charting their specific behavior is more in line with how many of us document.

I'm not saying it's the "right" way to chart, and am definitely curious to hear what others think.

I am not an attorney, do not play one on TV, nor have I stayed in a Holiday Inn Express recently.

However, I have been around for awhile and if there is a problem it is more likely with the first part than the last part. One can reasonably question a physicians interpretation of a patients internal state. "The patient is not in pain" could very well lead a rational person to ask, "Well, how do you know?" The line "The patient is in no apparent distress" while much more defensible still involves a matter of judgement which someone might argue is not objective.

However, facts are facts. "Just the facts, ma'am." It is pretty much impossible to make light of this line of documentation. If the patient is eating and complains of severe nausea and anorexia, something is amiss. If someone comes into the ED, it is reasonable to assume that there is a decent chance that they might need some sort of anesthesia at some point for which knowledge of food intake is important. Also there is a difference between eating one french fry and a double quarterpounder. If the patient claims not to be able to keep their eyes open, but is using a Smartphone, that is relevant documentation.

Anyone can make an issue out of anything, however, documenting the facts will almost never get you into trouble. Documenting objective facts is about the safest thing you can do.

 

[Hair Police]

So my attending was told by the lawyer that simply charting "patient in no apparent distress" is sufficient for the chart and less likely to engender ill feelings with the jury.

Obviously charting their specific behavior is more in line with how many of us document.

I'm not saying it's the "right" way to chart, and am definitely curious to hear what others think.

Yeah, I don't know if I would follow that advice. I have a better picture of the patient with your attending's initial note. You never want to make personal judgements in the note, but you can and should provide details to show how good a person looks.

On the flip side, of course always document the finding or history that made you go for the extra test.

 

[Birdstrike]

You absolutely should document abusive patient behavior, verbal or otherwise. Just don't fall into name calling yourself. Just document facts:

Patient said, "...."

Patient did, "...."

Don't use pejoratives out of anger. This is likely what the lawyer mentioned above, was cautioning against.

Stick to facts.

 

[namethatsmell]

Thanks all for the comments!