January 20, 2018
One cannot ignore the potential for conflictive behavior as a potential in medical patient-physician relationships (and indeed associated with other individuals in the medical system interacting with patients and patients interacting with them.) This behavior can be disruptive to attain important professional relationships and effective diagnosis and treatment.
The following is a brief analysis of the dynamics associated with such behavior and hopefully toward resolution as researched and written by a first year medical student. The obvious goal, hopefully, is resolution of potential conflicts to promote a therapeutically effective doctor-patient relationship. My visitors' views on this issue are welcome. ...Maurice.
DIFFICULT PATIENT VS DIFFICULT DOCTOR
First Year Medical Student
A doctor’s worst nightmare? A patient that is impatient, inattentive, rude, and demanding. A patient’s worst nightmare? A doctor that is impatient, inattentive, rude, and demanding. A so-called “difficult patient” or “difficult doctor” represent two sides of the same coin, with similar behavioral and communicative factors causing conflict. Occasionally, the difficult relationship may culminate in a
messy outburst – as recently seen in a violent altercation between a Gainesville doctor and patient
The duality of the patient-physician relationship allows us to examine (from both perspectives) what underlying actions and issues initiate the conflict – and eventually focus on mediation and resolution. Addressing the “difficult” nature of these parties is a vital first step towards creating positive patient-physician relationships and health outcomes.
You may hear the phrase “difficult patient” offhandedly thrown around in a physician’s lounge – a blanket term like “problem child” or “one of those
” that draws universal understanding but little clarity on the specifics of the interaction. Physicians characterize 15-20% of all patients as “difficult.”2,3
Such encounters point to a strong association between the “difficult” characterization and patient mental disorder – namely, depression, panic disorder, and anxiety.2,3
Doctors note these patients are either 1) not interested in a medical opinion whatsoever, or 2) have repetitive, non-specific complaints.
However, it was also noted that difficult patients are hard to describe and characterize as a group.4
Mental health does not preclude a difficult interaction. In a series of interviews, physicians described “difficult” as conversational issues such as patients
being “violent, demanding, aggressive, rude and [seeking] secondary gain.”5
Physicians describe their primary motivations as the desire to solve medical problems and help others – and anything that stymies this process sadly draws the label “difficult.”
The onus is not completely on the patient, however. One study points out that the difficulty may stem from the doctor’s work style, belief system, and/or cultural barriers.5 The more experienced a family medicine physician is, the less likely he/she is to characterize a patient as “difficult” – suggesting that there is a burden on the doctor to develop the interpersonal skills to handle the interaction. Collectively, physicians that report high frustration with patients are those that are younger, work longer hours, and have symptoms of depression, anxiety, and stress.6 While physicians often characterize patients as difficult, patients are less likely to describe their physician as so. In most studies, patients are evaluated for their “satisfaction,” which includes many aspects of their medical care, including perceived expectations, the underlying medical condition, and other members of the healthcare team. This may also reflect the power dynamic between patient and physician. Patient complaints may be dismissed, once again, as the patient being “difficult” - leaving the physician immune to criticism.
The difficult patient-physician relationship involves both behavioral (mental disorders, stress) and communicative (rude and aggressive language) factors from both parties. Ultimately, cooperative relationships stem from respect, empathy, and patience. As one physician stated in his interview, “First of all, what I have learned with the years is being empathetic toward [patients].” Taking the time to understand another’s perspective can go a long way in making the difficult into easy.5
1. Bever, Lindsey. (2017). A doctor shouted at a sick mother to 'get the hell out.' Now he's under criminal investigation. Washington Post.
2. Hahn, S. R., Kroenke, K., Spitzer, R. L., Brody, D., Williams, J. B., Linzer, M., & Verloin deGruy, F. (1996). The difficult patient. Journal of general internal medicine, 11(1), 1-8.
3. Jackson, J. L., & Kroenke, K. (1999). Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Archives of Internal Medicine, 159(10), 1069-1075.
4. Koekkoek, B., van Meijel, B., & Hutschemaekers, G. (2006). " Difficult patients" in mental health care: a review. Psychiatric Services, 57(6), 795-802.
5. Steinmetz, D., & Tabenkin, H. (2001). The ‘difficult patient' as perceived by family physicians. Family practice, 18(5), 495-500.
6. Krebs, E. E., Garrett, J. M., & Konrad, T. R. (2006). The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data. BMC health services research, 6(1), 128.
GRAPHIC: From Google Images.
January 18, 2018
|By Tarris Rosell, PhD, DMin|
Fifteen years ago in the aftermath of 9/11, I was invited to respond as an Ethics panelist to a new, self-published book, The Fundamentals of Extremism
(Blaker, et al., New Boston Books, Inc., 2003). The authors aimed to expose “the Christian Right” as a danger to democracy. While I sympathized with chief editor Kimberly Blaker’s agenda, the book itself struck me as taking much the same rhetorical tack as the religious fundamentalists that she and her co-authors vociferously critiqued.
My invitation to a book-signing event came with the expectation that I, a progressive clergyman ethicist, would be an enthusiastic proponent who might also help sell a few books. While preparing remarks, I was challenged with the dilemma of not wanting to disappoint a young author with worthy aims, while also engaging in truth-telling as I saw it. Most importantly, I wished not to support or practice the very thing we both condemned: divisive, speculative, paranoid, demonizing fundamentalist—or even anti-fundamentalist—rhetoric. Unfortunately, to my Ethics eyes, The Fundamentals of Extremism
was pretty much what it denounced.
So, for my panel presentation, I resorted to writing poetry, or possibly doggerel - an Ethics response in rhyme.
It seemed to me then, and now, that our ideological divisions are ameliorated best by civil discourse laced with mutual respect and a dose of good humor. This is difficult, and especially so when the stakes appear high, as they did back then, and now. Yet, if we who disagree with political or religious extremism engage in the same sort of rhetoric and behaviors as those we oppose, if our own claims are factually challenged anecdotes and innuendo, we only foster more schism and less democracy.
This is the poem I wrote (with minor edits). I think it still works in the partisan era of Trump.
An Anti-Fundamentalist Confession
© 2003, 2018
I’m fundamentally opposed to fundamentalism,
And separate myself from those who foster any schism.
I feel an obligation to expose the boorish Right
And other such extremists whom the rest of us must fight.
I fear their chief ambition is to slay democracy;
Their paranoia leads them to engage conspiracy.
They’d have us all subservient to Fundie* ways of being,
Dichotomize and simplify our thinking and our seeing.
Black and white, or good and bad, on absolutist values
Strikes me as absolutely wrong, as I’m compelled to tell you.
Yet, in my strident anti-fundamentalist critique,
Another thought has struck me, and has left me feeling meek.
One problem with Conservatives in all their stridency
Is one that tempts both Right and Left as human tendency.
While exorcism of their demonizing fits the facts,
Sometimes I look into the mirror and see “Them” looking back.
The rhetoric we choose to use, the labels we assign,
The latitude we grant to those across the picket line,
Our attitude of hubris, or of apt humility—
All these demark the difference between Us and Them
* A pejorative slang abbreviation that refers to religious fundamentalists of any religion or denomination.Dr. Rosell is the Rosemary Flanigan Chair at the Center for Practical Bioethics. He is also Professor of Pastoral Theology at Central Baptist Theological Seminary, Clinical Professor, History and Philosophy of Medicine at the University of Kansas Medical Center, School of Medicine, and Chair of the Department of Bioethics at Kansas City University of Medicine and Biosciences.