Every physician, nurse, EMT, respiratory therapist, and clinician of every specialty has mused about how much better their workplace would be if they did not have to deal with difficult patients or demanding families. What a delightful fantasy!
A subtle shift in our thinking makes all the difference. If we think the problem is the patients who walk through the office door or arrive by ambulance, we’re out of luck. The psychiatric patients, concierge practice patients, substance abusers, hostile patients, demanding parents, chronic medical patients, non-English speakers — they are going to keep coming; there is no way for us to control when they present or how they behave. If we have to rely on those patients to change so we can feel better or have satisfying caregiver–patient relationships, we lose all our power.
We have the power to change what we think about those alcoholics, drug addicts, and demanding parents. Instead of labeling them as challenging, we could choose to think that we are challenged by them. Many of us chose the medical profession because it is challenging. Difficult patients are one of the many expected challenges that will enter the office or emergency department of every medical practitioner. When that sick or injured person arrives, we don’t have to recycle our habitual negative judgments of them. We can choose positive thoughts that lead to positive feelings. Positive emotions like excitement or compassion lead to more productive actions that will meet the challenge and solve the problem.
Although we may think it’s the arrival of the difficult patient that causes our negative thoughts, that is not true. It is our thoughts about the patients that determine how we feel, and not everybody has the same thoughts about every patient. Consider this example:
Two medical students are on their pediatric rotation. William wants to be a trauma surgeon. He loves the excitement and novelty of every shift. However, he dislikes having to see babies and toddlers. They can’t tell him what’s wrong, and they seem to cry whenever he walks into the room. He thinks kids don’t like him.
Sandra loves kids and might want to be a pediatrician. She thinks there is nothing better in the world than when that baby gives you a big smile after you tickle her stomach. Sandra thinks that she has a way with kids, and they like her.
A crying child is brought to the pediatric clinic by an anxious parent. William thinks with dread, “Oh no, not another fever work-up for me!” Sandra thinks with delight, “Yeah, cute little baby gurgles and smiles, coming up!” The same patient yields very different thoughts and emotions from her healthcare providers.
The labels and judgments you place on your patients are so habitual and ingrained that you may think you are just stating a fact:
All infants will cry.
We can never make that drug addict better.
Dr. Grant’s patients are all so demanding!
This dialysis patient always misses his dialysis sessions.
All drunks are nasty.
Sickle cell patients are drug-seekers.
You may believe you are simply making observations or reporting the facts of life in the office or emergency department. These are not facts; they are thoughts and opinions, and not all thoughts or opinions are true. You are thinking and re-thinking long-held beliefs or opinions about difficult patients. Everyone in the office or department may share these beliefs, but that simply means that they have all adopted the same negative mindset. Just because everyone believes something doesn’t make it true. Remember, at one time, everyone believed that the earth was flat.
The Think-Feel-Act Cycle
The notion that someone is a “horrible” patient does not serve us well. We can choose more positive thoughts that serve us better in moving people though the emergency department or clinical setting with accurate diagnoses, appropriate treatments, and minimal conflict.
If we do not act to control our thoughts and negative judgments, we can easily gravitate to negative, unacceptable, and unprofessional actions. Negative thoughts about challenging patients can cause, in otherwise capable clinicians, a sense of inadequacy and incompetence.
Psychologists often use Cognitive Behavioral Therapy to treat depression and help patients manage their thoughts and learn to act in intentional ways. To help people manage their minds and to live in a more intentional way, life coaches use the underlying sequence of human thought, emotions, and behavior. This is called the think-feel-act cycle. We can choose thoughts to create more useful feelings, actions, and results. Just as marketers use the concept to sell products, care providers can use it to improve their experiences with challenging patients (see Figure 1).
Figure 1. The think-feel-act cycle in the medical setting
Recognizing Our Preconceived Thoughts
For the purpose of this discussion about dealing with difficult people, the cycle begins with an event or an episode that is outside of the healthcare giver’s control. For example, a person registers at the medical clinic, is admitted to the hospital unit, or presents to the emergency department. The event or incident might be something that the patient or a family member says. Or, the event may be the presenting of a medical problem such as a dislocated shoulder or facial laceration. Each of these situations starts the think-feel-act cycle.
The patient presenting at the front door is neutral, neither bad nor good, until a healthcare worker has a thought about them. Remember the crying baby? One student thought it was great and one student thought it was terrible. The words spoken by a family member or patient are neutral until a clinician has a thought about the words, such as “How dare he question my judgment?” The shoulder dislocation and facial laceration are just medical problems until a medical practitioner thinks, “I can never reduce shoulders” or “I’m not very good at closing facial lacerations.”
Physicians and nurses have developed negative thoughts about some types of patients and situations throughout their training or prior experiences. You may have heard your senior residents or attending physicians refer to certain patients in a derogatory way. The other nurses in the break room may trade their horror stories. Your own prior experiences cause you to think that nothing that you can do for this type of person will ever make a difference. You may feel inadequate because this patient needs a procedure like an IV line or chest tube insertion that you have not yet mastered.
Our thoughts cause us to have certain emotions or feelings. If you are excited to see a sick child, you have a thought that elicits that emotion. If you dread seeing an old lady who doesn’t speak English, you may have a negative thought about the communication gap making the interaction more difficult. We create our feelings about our patients based on our thoughts about them. The patients don’t cause our feelings directly. Simultaneous thoughts about our patients can cause us to have simultaneous feelings about them.
Some of the negative thoughts we have about some patients have become so unconscious they are like bad habits. Just as we can train ourselves to break bad behavioral habits, we can retrain our brains to change poor thoughts. James E. Groves, author of the landmark 1978 NEJM article “Taking Care of the Hateful Patient,” noted that we should not ignore our feelings about “hateful” patients. The negative feelings give us valuable clues as to what we think and believe. It is high time all clinicians re-examined and questioned many of their beliefs — or judgments — about their patients.
Throughout our training, we develop strong judgments about what should happen or what shouldn’t be said, or what ought to occur. We sometimes justify our judgments by saying that we have high standards. With curiosity and practice concerning their judgmental thoughts, clinicians who encounter challenging patients — and that would be ALL clinicians — can feel positive about the experience and get better results.
What we were taught or have come to believe about ourselves and others is important because of what we know about confirmation bias. Confirmation bias is people’s tendency to seek information that confirms or strengthens their beliefs or values and is difficult to dislodge once affirmed. Confirmation bias is an example of a cognitive bias; we keep looking for evidence to support a belief that we already have.
When we think that our skill in closing facial lacerations is inadequate, we search for and find evidence to confirm that belief. Even when we do a terrific job at repairing a laceration, we nit-pick and find something about our work that is not quite perfect, we maintain our perception of our weakness and do not allow ourselves to feel pride in our work.
This is why it is so important to choose thoughts intentionally that will serve our goals. If we keep criticizing and judging ourselves for some perceived flaw, we actually find or create it.
Actions That Move Us Toward Better Outcomes
The next part of the think-feel-act cycle is the action piece. Our actions are what we do or don’t do for our patients, our conversations, our instructions. We have been trained to respond or act in a certain way or maneuver to fix various medical problems or start the healing process.
In the example of the dislocated shoulder, we have been trained to provide pain relievers, image the joint with X-rays, and use a technique to reduce the dislocation. I was taught the traction-counter-traction technique during my residency that involved two people with a lot of brute force. Then an orthopedic surgeon taught me the elegant technique of the external rotation method that I could do by myself, with minimal effort, at the patient’s bedside. I changed my thoughts about which technique would be my go-to when presented with an anterior shoulder dislocation. I used a different action, got better at the technique, and the result was a reduced shoulder dislocation.
Our feelings dictate what actions or inactions we take. The student, Sandra, who enjoys pediatric cases, will shove someone out of the way to get at that adorable patient. A PA who dreads the old lady who can’t speak English suddenly has to go to the locker room to retrieve something from his locker. When he ends up seeing her anyway, he feels resentment toward her.
The actions or inactions that we take in response to a feeling lead to a result. The result naturally reinforces the original thought that we had about the situation. Treating the sick child leads to satisfied parents and a happy gurgling baby, reinforcing Sandra’s original thought that treating children is fun. The student treating the old lady struggles with the translator and orders the tests and treatment he can only guess that she needs. He tries to give a diagnosis she will understand. His original thought that he can’t stand non-English speakers is emphatically reinforced.
The ultimate result clinicians seek is an improvement or cure for their patients’ symptoms or a plan to begin treatment for the cure. For some of our patients, the correct course is to make the end of their lives more comfortable. Being with a grieving family and having our feelings of sadness are entirely appropriate in many situations. Happiness and sadness are exquisitely part of the human condition.
There is good news about leveraging the think-feel-act cycle to experience better interactions with difficult patients. The negative thoughts that we have about difficult patients are OPTIONAL. We can choose to think the thoughts that serve our patients and us better. We can question many of the default negative thoughts that we have learned. Our brain likes to be efficient, so it recycles all the well-known and familiar thoughts repeatedly. Better thoughts will produce more positive actions and then more positive results.
Awareness of Negative Thoughts
The first step in changing our negative thoughts in the clinical setting is recognizing that we have them. The primitive part of our brain focuses on what it perceives as “not right,” interpreting it as a threat or danger. This is basic human nature.
Negative thoughts commonly color and distort our thinking and cause negative feelings as we interact with our patients. We are trained to look for the worst possible diagnosis, after all. Our negative thoughts usually focus on a particular problem patient, but we may focus on ourselves or other external circumstances as well. Our judgments about ourselves can make us feel inadequate or unworthy. These self-critical emotions generally don’t lead us to act confidently in the care of our patients.
When you tune into the negative thoughts you have about a difficult patient, you become aware of them and can choose to replace the negative with positive. Awareness of your thoughts is the first step toward understanding why you feel a certain way; this one step will give you much relief. Maybe the disagreeable, non-compliant old coot Mr. Cunningham is bitter because he can no longer drive himself to get his medications, and he doesn’t like losing his independence. The derogatory terms you used so casually about Mr. Cunningham now seem cruel and callous.
Most of us want to think of ourselves as thoughtful and compassionate. Becoming aware of our thoughts places us in more of an observer position and allows us a moment to reflect on our thoughts.
Excerpted from Changing How We Think About Difficult Patients, by Joan Naidorf, DO.