An article from the Wall Street Journal caught my attention, and for all the wrong reasons. It was a review of two recent studies showing that medical trainees have difficulty diagnosing patients with complicated histories or confounding psychosocial features. At least, that’s the way I would describe those studies.
The WSJ, however, used much more pejorative language, referring to them as “difficult patients,” “a nuisance,” and “an annoyance.” The author wrongly presumed this perception was shared, not only by young doctors-in-training, but also by mature professionals. And her title — “When Patients Are a Pain for Their Doctors” — grossly misrepresented the way that health professionals feel about their sick and suffering patients.
The journal that published the two studies, BMJ Quality & Safety, didn’t do a whole lot better, sometimes referring to the patients as “difficult” as well. Perhaps the Dutch authors didn’t understand the nuances of the English language, but the British Medical Journal editors surely should have.
This type of language — and worse — was common among the house staff subculture when I began my career in the 1980s. Samuel Shem’s book, House of God, exposed the cynicism of trainees, who were themselves victims of an abusive training system.
Today such pejorative labels are viewed by most health professionals as on par with ethnic, racial, and gender slurs. In fact, research has shown that many of the patients so-labeled in the past were indeed from another race, another ethnicity, or another economic or social class. Others were mentally ill, didn’t speak English, or had the audacity to be gay or lesbian, old or female. In the youthful, male-dominated house staff culture of that era, it was considered a character flaw just to be over fifty or have two X chromosomes.
The research has shown that these were not “difficult patients” by any objective measure. What made them “difficult,” frankly, was that their caregivers were themselves sleep-deprived and victims of an abusive training system. The proverbial shit flowed downhill: from senior faculty to trainees to patients.
The other reason patients got sacked with such pejorative labels was that they had complicated histories or incurable chronic conditions. They weren’t difficult people per se, but had conditions that were difficult to diagnose or treat. Some physicians at the time — again, typically, the younger trainees — felt overwhelmed and developed a language of blame as a way of masking their ineffectiveness, incompetence, and insecurity. The litany included code words such as “difficult patients,” “hateful patients,” “malingerers,” “dirtballs,” “gomers” (Get Out of My ER) and “shpos” (Sub-Human Piece of Shit). Remember, the house staff was a male, twenty-something subculture, so if the language sounds “locker room talk,” that’s basically what it was.
Look back in the medical charts of yesteryear, and you’ll find students and residents writing things like, “The patient was a poor historian,” “The patient failed therapy,” or “The patient was noncompliant.” Nowadays every good doctor knows not to say or even think such things. After all, it’s the doctor who serves as the “historian,” so if the medical history isn’t up to snuff, we should blame the doctor, not the patient. And if the patient doesn’t get well, it’s the therapy that failed the patient. To label a patient as “noncompliant” implies that the physician’s job is to “bend” the patient to his will, and the patient’s job is to submit. (The root is plié, as in a pair of pliers.) Ouch! The doctor-patient relationship should be one of collaboration and mutual respect. Not the doctor barking our orders and the patient blindly submitting.
When patients have complicated health histories or confounding psychosocial situations, the last thing they need is to be labeled as “difficult” or “disruptive,” a “nuisance” or an “annoyance.” Perhaps the diagnosis is what’s difficult. Perhaps treating more than one condition is what’s disruptive. Perhaps what makes them a “nuisance” and an “annoyance” is that the bean counters are measuring success in terms of quantity rather than quality of care.
Oftentimes illnesses are complex. It takes time to build trust, gather information, determine the diagnosis, and develop a treatment plan. All the while educating, comforting, and healing. You can’t do this in drive-by fashion, while the patient rolls down a 12-minute assembly line.
It’s important to note that neither of the two studies that the WSJ comments on were studies of real doctors — or real patients, for that matter. The researchers presented complicated, hypothetical situations to medical trainees. Predictably, these young docs stumbled. But the WSJ article misleads readers by concluding from these studies that real patients are a “nuisance” and a “pain” to their real and fully formed physicians.
I have observed, studied, and trained physicians in medical communication for the past three decades, and in my experience, no good physician ever speaks or even thinks this way about her patients. Instead, she would describe the challenge as being that of a complicated diagnosis or a complex or incurable chronic condition. She might say that this is a “difficult case” or a “difficult relationship,” but she would rarely refer to her patient as a difficult person. Doctors understand that patients come to them in pain, vulnerable, and afraid. They last thing they need is to be blamed for their problem and shamed by their caregiver.
Doctors view their work as a sacred calling, not a fee-for-service transaction. They don’t expect patients to present with neat and tidy problems at convenient times and places. Doctors do have high expectations of themselves: to be caring, competent, effective, and respectful — in short, professional.
Medical trainees, like the ones in the study, are in the process of learning their medical skills. It’s human nature to be defensive, to project, and to transfer blame when under stress. As time goes on, they’ll learn how to manage projection, transference-countertransference, and other psychodynamics of intimate, professional relationships. Another problem for many trainees is that they haven’t yet figured out that a big part of health care isn’t “curing” or “fixing” problems, but managing them. So they get frustrated when patients with chronic conditions don’t meet their unrealistic expectations.
The bottom line here is that the term “difficult patient” should be removed from the lexicon. It should never appear in newspapers or medical journals. The language is blaming and makes it sound as though doctors and patients are at war with each other, when actually they have an incredibly collaborative relationship. They don’t stand face-to-face in some power struggle, but side-by-side to manage health problems as a team. A cure may not always be possible. But as long as there’s collaboration, cooperation, and a positive vibe, healing always is.
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