Today I was rounding with one of our nurse managers. Our first stop was a unit that has been treating a difficult patient—someone who has challenged our ability to provide care.
Staff told me how they have attempted to meet the patient’s needs, only to be rebuffed and even worse. They were aware that satisfying this patient was like boiling the ocean or walking to the moon. That didn’t mean they had stopped trying to do so, but it did mean that they were discouraged, frustrated, and sometimes just plain scared. I was impressed by our staff’s openness in talking about the situation and the ways that they supported each other.
Pushing your button
Dealing with difficult patients is one of the great challenges of health care. It’s one for which we are not well prepared. After all, in our personal lives, we try to avoid people who “push our buttons” or at least minimize our interactions with them. But when someone becomes a patient at CPMC, we have a responsibility to care for them—avoidance is not an option.
Some advice
Most of us receive very little training in this area. I was lucky. When I was a medical resident in the primary care clinic at San Francisco General Hospital, I had a preceptor who was a psychiatrist. He was there to help us address patients’ psychological issues, as well as our own limitations in caring for difficult patients. I learned a few lessons: to pay attention to my buttons so they’d be harder to push (easier said than done, believe me); to be aware of patients trying to split the health care team (“You’re really nice, but that Dr. So-and-so is a jerk”); and to ask for help when I was in over my head, rather than just toughing it out.
Hospitals are often places of last resort for those who have fallen through the cracks in our society. Most of the time, patients are deeply grateful that we’re here. But not always.
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July 14, 2010 at 2:50 p07
Steven P Reidbord MD
Great post Dr. B.
It’s important to remember that hospitalized patients are often in pain, scared, hugely stressed — basically at their worst. When stressed, we all fall back to our oldest, most familiar coping mechanisms. Psychiatrists call this normal process “regression.” Emotional people tend to get more emotional, detail-oriented types more detail-oriented, suspicious folks more suspicious, and so forth.
Difficult patients do this too, but with regressive coping that says, “the best defense is a strong offense.” By lashing out against caretakers, making impossible demands, and setting health care teams against each other, the scared, threatened patient gains a temporary sense of control and power. Unfortunately, this behavior is counter-productive, as it pushes away the very people who can help.
As Dr. Browner says, dealing with difficult patients is one of the great challenges of health care. It is hard work — heroic at times — to stay engaged with a difficult patient, and yet good patient care requires it. Staff who can do this with the most difficult patients are special people indeed.