Difficult patients

The previous two posts raised the issue of ‘difficult patients’. As I am likely to be one, I thought I should read up on what medics say about me.  Indeed, the internet is full of advice how to deal with ‘difficult patients’. I’d like to offer some comment.

Who are the ‘difficult patients’? Well, a recent piece suggested

You know who they are: patients who are angry, disrespectful, and rude; patients who demand specific drugs or tests, even when they’re not indicated; and patients who growl at everyone, act suggestively to the nurses, or ask you to submit a fraudulent bill so the insurer will cover the cost of treatment.

Gosh, I thought, the nasty shits didn’t even read up on what drugs or tests are indicated in their conditions. Is it unacceptable or is it unacceptable?!

The advice how to deal with ‘us’ (even though I plead guilty only to being angry, I espouse the label) is fairly obvious – you remain calm or engage in conversation etc. To be fair, most texts I found try to understand the ‘difficult patients’, writing about brevity of consultations, emotional difficulties and some such like. You’re very quickly lulled into thinking it’s all nice and understanding. But I still think it’s a bit off.

Let me show you a BMJ article, which in contrast to others, doesn’t even talk about ‘difficult patients’, it talks about ‘challenging interactions’. How cool is that? And you immediately think – well, finally someone was thoughtful enough to stop putting all of us into one category. You know, I might be disrespectful, but I am never rude. In fact, I think that well-placed sarcasm can be much more effective that shouting at a doctor.  Though, I must admit, shouting also works.

And still there was something off….So, let’s have a look at how the author writes about patients:

Patients can be uncooperative, hostile, demanding, disruptive, and unpleasant (although it is important to remember that patients may think that doctors also show some of these same characteristics). They might have unrealistic expectations or be unwilling to take responsibility for their health. All these factors can contribute to making an interaction with such a patient a challenging experience.

And now have a look how she writes about doctors:

Interactions can be more difficult if the doctor is hungry, angry, late, or tired (HALT). Personal factors could be a distraction for some doctors, and in other cases the doctor’s personality traits could clash with those of the patient. In addition, it can be easy to stereotype or label certain patients or their behaviours, which might influence the doctor’s perception of the difficulty of the consultation.

I started looking at the differences and it suddenly struck me. Patients are nasty, doctors are overworked. Look at the adjectives:

Patients: uncooperative, hostile, demanding, disruptive, and unpleasant

Doctors: hungry, angry, late, or tired

The difference cannot be starker, I think. The patient wrecks things, the doctor cannot keep up with things. Yes, being angry in reference to the doctor doesn’t fit very well, still, it’s placed in a context – between hungry and late. How can you not be angry? Patients are different. The adjectives are not placed in any social context – patients (not all, obviously) are simply disruptive and unpleasant – just like that. That’s the way patients are.

Consider also that all these things could be rendered by verbs. Patients could be said to disrupt, demand, not cooperate (yes, hostility and unpleasantness would be difficult to render by verbs).  And yet, instead of verbs, the author choses adjectives. Why? Well, because they remove the context – it’s not about interactions, it’s about the way patients are. And no, this argument doesn’t apply to doctors. ‘Hungry’ doesn’t describe you generally.

Ha ha, you might say, have you not noticed that the author wrote:

although it is important to remember that patients may think that doctors also show some of these same characteristics?

I have. But have you noticed how it is put? The author doesn’t actually say that the doctors are like that. Oh, no. It’s the patients who think that. In fact, doctors are not responsible for anything. The author shifts focus from doctors to their ‘personality traits’ (we don’t get to hear what they might be) which clash with patients’. Finally, again, it’s not the doctor who stereotypes, no, no, their perception is influenced. What can you do?

And here we come to the main point of this post. The article appears to put doctors and patients on a par. Both are responsible for making interactions ‘challenging’. And yet it’s done in a very different way. Patients are described very directly, difficult patients are simply nasty. Doctors are anything but. After describing them as overworked, they’re not referred to directly. Despite appearances, patients are constructed as different from doctors. I would go as far as saying that the article is pernicious in pretending to construct doctors’ responsibility, while at the same time a divide is being constructed.

The divide, however, is used for one more reason, I think. What really irritates me is that the source of disruption which comes from the patients is locates in them. There is no context, there is no reason for the disruption. It just happens. We, patients, cannot get angry because the doctor said something, did something. Oh no, we simply disrupt things, while the poor doctor, tired and late, is trying to do the best for us.

Look, finally, at the case studies. The first one describes the patient like that:

She was poorly compliant with the nurse led review clinics and the monitoring of her conditions. However, she would regularly demand emergency appointments to see a general practitioner at which she would inevitably request new prescriptions, claiming to have lost or run out of her inhalers and pills. She would be rude to reception staff and refuse to leave the consulting room until she got what she wanted.

The patient simply did these things. Just like that. Out of spite, malice or simply boredom or personality?  Is it not possible, just possible, however unlikely, that her doctor had been responsible for some of what she did? Instead, the case study simply constructs the patient as a child who had to be disciplined. For pity’s sake – I mean, do you really not reflect occasionally on what you write?

Yes, we, patients, can mess up, sometimes big time, but sometimes, just sometimes, it’s because you messed up doctor. In a nutshell, we cannot possibly understand each other without you acknowledging that you are actually human. Just like me.

 

3 Comments
  1. Dariusz Galasinski

    It’s a very good point. The issue of whether asking a question makes you difficult is a very pertinent one.

  2. Very well put! I’m always polite at doctor’s office – but, on the other hand, I’m polite everywhere wher some level of formality is required. And it kills me, that I’m labeled “difficult” in the moment I dare to ask some questions. Like: “why did you give me antibiotics on my tonsillitis? Is’n that bacterial desease?”. Or: “so what this medicine actually do to my body?”. I understand that doctors can be overworked, overwhelmed by patients and responsibility… but isn’t it a case in every people-related job? Why do we tread doctors like nobility? Nobody will say that rude guy in complaint departament is just hungry or tired. And he really has to deal with angry people. But noooo, there are angels who heal and demons who demand to be treated.

  3. Great piece Darek! Fundamental Attrib Error and Actor-Observer effect at play here.

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