When a patient threatens to shoot, how does a doctor respond?
Difficult patients — those who are angry, abusive, or rude — may not get the best medical care, according to a pair of studies published Monday in BMJ Quality and Safety.
As a medical student, I’ve seen firsthand how a patient’s attitude might affect a clinician’s judgement.
As part of an internal medicine rotation during my third year, I accompanied a nurse for a day on home health visits in the rural community of Abingdon, Va. That morning, I arrived at the patient’s home before the nurse did. I waited in my car for more than an hour so we could enter the patient’s home together.
Upon entering the home, I shook the patient’s hand and introduced myself as a medical student working with his home health team.
“I was going to shoot you,” he said to me, unapologetically.
“Why would he shoot me?” I thought. “Is it because I’m black?”
I slowly withdrew my hand from the man’s leathery but feeble grip and let out a nervous laugh.
“You don’t look like you are from around here, and that’s what happens when you hang around people’s property,” he said.
I participated in visits like this one to understand the delivery of care in the home setting and to better appreciate how patients manage chronic conditions like diabetes, heart disease, and chronic obstructive pulmonary disease. This patient’s attitude, however, made it challenging for me to focus on that task.
Instead, I was preoccupied with imagining a scenario in which I was gunned down for nothing. My crisp white coat from the University of Virginia would not protect me from my patient’s assumption that I was up to no good. Rather than learning how to help this patient, I was distracted by fear.
I wasn’t responsible for making any diagnoses or recommending any treatments that day. I’d like to believe that if I had been, I would have been able to care for this patient as if he was the one who first inspired me to pursue a career in medicine. But as I’ve progressed through medical school and become a bit more jaded by difficult doctor-patient interactions, that experience and others have made me wonder if my feelings toward a patient would compromise my ability to be a good doctor.
That’s the question the two BMJ studies set out to explore. Both were conducted by the same research team in the Netherlands. In one study, doctors were presented with clinical vignettes that described patients with medical conditions of varying complexity. Each vignette described the patient as either neutral or difficult. For both straightforward and complex medical conditions, the doctors were more likely to misdiagnose the difficult patients.
In a follow-up study, the researchers explored why these mistakes happened. They concluded that dealing with a disagreeable patient saps the mental energy doctors need to make an accurate clinical judgement.
Most doctors believe they can rise above negative emotions stirred up by difficult patients, whether they are manipulative, hot-tempered, or just plain rude. But it isn’t easy, and simply brushing off difficult behavior may not be enough. As the researchers concluded, “difficult patients trigger reactions that may intrude with reasoning, adversely affect judgements, and cause errors.”
Both in and out of clinical settings, as a black American female, I’ve grown accustomed to ignorance and insensitivity toward people who look like me, or who identify as minorities in other ways. While my trigger-happy patient made me feel heartbroken and horrified at the same time, medical school has taught me to shake off jarring comments from patients and do my best to care for them, anyway. It’s a resilient behavior I’ve learned from other minority physicians, a quiet refusal to be defined by anything other than my own effort and accomplishment.
An editorial accompanying the two studies highlights several strategies to help optimize the care of difficult patients. One approach suggests that patients themselves simply behave better. Recognizing the improbability of that medical miracle, the editorialists suggest that doctors take a step back to reassess the clinical situation when they recognize that a patient may be rubbing them the wrong way. Such awareness could prompt a physician to exercise what’s called metacognitive debiasing, essentially using a mind trick that allows him or her to reimagine a difficult patient with a more pleasant personality.
Other strategies to minimize the potential for diagnostic error include providing diligent follow-up appointments, or asking colleagues for advice or a second opinion.
Without discounting the complex emotional and social realities of medical practice or invalidating my experience as a black female medical student, these studies empower me to uphold my promise to “do no harm,” even unintentionally. While I intend to continue relying on the resilience I’ve developed, as a new newly minted physician I can employ greater self-awareness to make sure that I give my patients, no matter how difficult they may be, the best care possible.