Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

“Difficult” patients: Is it them or is it us?

Laila Knio
Education
April 16, 2021
456 Shares
Share
Tweet
Share

It was past midnight in the ED, and she was writhing on the bed, palms clutched over her abdomen. I pulled up a stool, notebook, and pen in hand. I was ready to listen to Mrs. Walker’s story. But I also felt a sense of dread rising: From a quick chart review, I knew that Mrs. Walker had 23 negative CT scans for abdominal pain within the last 18 months. Her labs and vital signs were consistently normal.

“Mrs. Walker, when did you first notice this pain?” She wasn’t sure.

“Where does it hurt the most?” Mrs. Walker moved her palms over the right side of her abdomen, then the left side. She noted that the pain was sometimes sharp and sometimes dull.

The encounter continued like this for several minutes. The ambiguity of her answers disheartened me. This is not going to be a great presentation, I thought. I quelled my irritation, uncrossing my legs and channeling empathy into the murky space between us.

Now, at the cusp of completing Columbia University’s Masters in Narrative Medicine, I know that it’s not enough to respond with patience and empathy to a patient’s disjointed story. We must fundamentally change the way we receive stories of illness.

What I would ask Mrs. Walker now, if I could:

What are you most worried about?

What has this pain stopped you from doing?

In what ways has it shrunken your world?

In what ways has it upended your sense of time?

Phenomenology, a branch of philosophy centered on the lived experience, would be invaluable to medical school curricula. Merleau-Ponty, Husserl, and others emphasized that the body is more than a familiar object; our body is the framework that structures our existence in the world. It is the point from which we perceive, think, and act. For this reason, bodily breakdown in illness can drastically alter the way we exist. For instance, illness can shrink our world (the physical inability to climb stairs), which can lead to social isolation (the inability to meet up with friends); it can make it hard to predict the future (how much longer will my oxygen tank last?) which limits the possibilities available to us. Only the patient can speak to their particular experience and the treatments that will best address how their world has broken. Phenomenologist Kay Toombs writes that an important part of healing is having the patient’s own role as knower valued: “If therapeutic intervention is concentrated solely on the dysfunction of the biological body, with little attention paid to the disturbance of lived body, [the patient] feels himself reduced to a physical object, and consequently dehumanized.” Modern medicine’s ability to gather quantitative measures of illness has unquestionably brought us far. But our fetishization of objective data over subjective ways of knowing has come at a cost.

Patients’ feelings of dismissal by providers is a rapidly growing problem. A 2019 study found that patients were interrupted after a median of 11 seconds, about as long as it takes to sing Happy Birthday, once. The same study found that patients were asked why they presented for care only 36 percent of the time (this percentage grew to 49 percent in primary care clinics and dwindled to 20 percent in specialty care settings). Which begs the question, who exactly is the clinical encounter aimed to serve? Moreover, a 2014 study found that at least 1 in 20 US adults treated in an outpatient setting are misdiagnosed. In primary care clinics, as many as 1 in 5 patients unexpectedly return for care. We aren’t very good at asking for the story. We aren’t very good at listening. Even when we ask for the story and listen, we aren’t always right. “Facts” in medicine continually change. Objective data is not static.

As we restore value to the patient’s subjective ways of knowing, we must not forget that the structure of a patient’s narrative – what they choose to share first, what they avoid saying, what they emphasize multiple times – is itself data. Yet medical education numbs us to these nuances. From the onset of medical training, we are asked to “present” the patient interview in a standardized way: Patient’s name, age, relevant past medical history, chief complaint, events leading up to presentation in chronological order, including symptom onset, location, duration, quality, alleviating/exacerbating factors, etc. As a fourth-year medical student, I have never encountered a patient whose story unfolded in this order (including physician-patients). But this is what we probe and listen for, at near exclusion. What violence does this do to the way we listen to our patients? What do we miss when we enter a clinical encounter with a template to fill?

Of today’s patient charts, Dr. Rita Charon, founder of the discipline of narrative medicine, writes: “As the free space for narrative prose diminishes in our checklisted and templated electronic medical records, our waning ability to register the aspects of care that exceed the technical may preclude our very experiencing of them, perhaps impoverishing the care overall.” Our prioritizing of the technical, or objective, leaves less time, energy, and space to address the patient’s lived experience of illness. But we need to listen for words like think and fear, and hope in the clinical encounter. And we need to record words like think and fear, and hope in our documentation. Because if we are driven to document our patients’ complexity, then we will likely listen for it too.

It’s true that restoring value to the patient’s subjective experience and documenting this knowledge won’t be enough to repair the chasm that has opened between patients and providers. This work must occur concomitantly with systemic change: For instance, with the expansion of appointment time slots in outpatient care and a dramatic decrease in the amount of superfluous documentation required of providers. Importantly, educators should give prominence to medical humanities topics, including phenomenology, in medical school. Our health depends on it.

Laila Knio is a medical student.

Image credit: Shutterstock.com

Prev

Why we deny our imperfections in medicine

April 16, 2021 Kevin 0
…
Next

Post-pandemic life: Back to the future

April 16, 2021 Kevin 0
…

Tagged as: Medical school, Primary Care

Post navigation

< Previous Post
Why we deny our imperfections in medicine
Next Post >
Post-pandemic life: Back to the future

Related Posts

  • She sees difficult patients, but is a difficult patient herself

    Kristin Puhl, MD
  • Patients are an integral part of medical student education

    Orly Farber
  • Are patients using social media to attack physicians?

    David R. Stukus, MD
  • Patients with severe autism: medical and dental care in the community

    Irene Tanzman
  • I vow not to call my patients “difficult.” Here’s why.

    Weisheng Mao
  • As a medical student, you find potential patients everywhere

    Daniel Azzam and Ajay N. Sharma

More in Education

  • Breaking the silence: the truth about mental health challenges among medical students and why medical schools must take action

    Erin Waldrop
  • Breaking the stigma: Encouraging mental health help-seeking in medical trainees

    Anonymous
  • I’m not so different from Lionel Messi – and neither are you

    Lauren Tien
  • 6 ways ChatGPT can help you succeed in medical school

    Drew Bergman
  • Is it time to say goodbye to medical school rankings?

    James Goldchild
  • The unintended consequences of ERAS: Are we losing unique applicants?

    Ank Agarwal, Aditya Narayan, Joshua Leaston, and Akshay Bhamidipati
  • Most Popular

  • Past Week

    • A patient’s perspective on the diminishing relationship between doctors and patients

      Michele Luckenbaugh | Conditions
    • Unmasking wage disparity in health care: the truth behind the Elmhurst Hospital physician strike

      Kevin Pho, MD | KevinMD
    • Why affirmative action is crucial for health equity and social justice in medicine

      Katrina Gipson, MD, MPH | Policy
    • How electronic health records preserve patients’ legacies in the words of oncologists

      Marc Braunstein, MD, PhD | Physician
    • Unmasking the brutal reality of gun violence in America: a call to action for unity and meaningful change

      Osmund Agbo, MD | Policy
    • Emulating Michael Jordan’s winning mindset: a path to success for health care professionals and entrepreneurs

      Harvey Castro, MD, MBA | Physician
  • Past 6 Months

    • The growing threat to transgender health care: implications for patients, providers, and trainees

      Carson Hartlage | Policy
    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
  • Recent Posts

    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • The surprising medical mystery of a “good” Hitler: How a rescued kitten revealed a rare movement disorder

      Teresella Gondolo, MD | Conditions
    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • Why doctors aren’t to blame for the U.S. opioid crisis [PODCAST]

      The Podcast by KevinMD | Podcast
    • Raw humanity on night float: inspiring patient encounters and overcoming challenges

      Johnathan Yao, MD, MPH | Physician
    • Is AI the solution for the shortage of nephrologists? ChatGPT weighs in.

      Amol Shrikhande, MD | Tech

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 10 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • 'Medically Relevant to Saving the Life of Your Patient': What We Heard This Week
  • Want to Solve the Nurse Shortage?
  • Why Are Female Doctors Sued Nearly Half as Often as Male Doctors?
  • What Drug Did FDA Just Approve for COVID?
  • PET Scan for Alzheimer's Dx; Predicting Colon Cancer Survival

Meeting Coverage

  • No Access to Routine Healthcare Biggest Barrier to HPV Vaccination
  • Trial Results Spark Talk of Curing More Metastatic Cervical Cancers
  • Cross-Border Collaboration Improves Survival in Pediatric Leukemia Patients
  • Monoclonal Antibody Reduced Need For Transfusions in Low-Risk MDS
  • Less-Invasive Surgery for Pancreatic Cancer Proves Safe, Effective
  • Most Popular

  • Past Week

    • A patient’s perspective on the diminishing relationship between doctors and patients

      Michele Luckenbaugh | Conditions
    • Unmasking wage disparity in health care: the truth behind the Elmhurst Hospital physician strike

      Kevin Pho, MD | KevinMD
    • Why affirmative action is crucial for health equity and social justice in medicine

      Katrina Gipson, MD, MPH | Policy
    • How electronic health records preserve patients’ legacies in the words of oncologists

      Marc Braunstein, MD, PhD | Physician
    • Unmasking the brutal reality of gun violence in America: a call to action for unity and meaningful change

      Osmund Agbo, MD | Policy
    • Emulating Michael Jordan’s winning mindset: a path to success for health care professionals and entrepreneurs

      Harvey Castro, MD, MBA | Physician
  • Past 6 Months

    • The growing threat to transgender health care: implications for patients, providers, and trainees

      Carson Hartlage | Policy
    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
  • Recent Posts

    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • The surprising medical mystery of a “good” Hitler: How a rescued kitten revealed a rare movement disorder

      Teresella Gondolo, MD | Conditions
    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • Why doctors aren’t to blame for the U.S. opioid crisis [PODCAST]

      The Podcast by KevinMD | Podcast
    • Raw humanity on night float: inspiring patient encounters and overcoming challenges

      Johnathan Yao, MD, MPH | Physician
    • Is AI the solution for the shortage of nephrologists? ChatGPT weighs in.

      Amol Shrikhande, MD | Tech

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

“Difficult” patients: Is it them or is it us?
10 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...