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“Our patients go through some very predictable fears and responses to illness and injury. In turn, medical students and residents also think and respond with some thought distortions and misunderstandings about their patients and themselves. Armed with awareness and familiarity with the typical patterns, we learn more about what to expect. We anticipate when we will get push-back and we are better prepared to act calmly and confidently.
Additionally, we can get curious and ask better questions during those challenging interactions. What else is true about that grumpy old man? Is he someone’s father or grandfather? Could some of the patient’s behavior be a symptom of his disease? If we remember that, don’t those facts make the patient’s actions a lot more understandable? Is there another way to approach a problem to which you see only one solution? Can you reach some collaborative plan that satisfies both the patient and you?”
Joan Naidorf is an emergency physician and author of Changing How We Think about Difficult Patients: A Guide for Physicians and Healthcare Professionals.
She shares her story and discusses her KevinMD article, “Changing how we think about difficult patients.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/follow.
Today we welcome back on the show Joan Naidorf. She is an emergency physician. She’s the author of the book Changing How We Think about Difficult Patients: A Guide for Physicians and Healthcare Professionals. Joan, welcome back to the show.
Joan Naidorf: I’m really happy to be here, Kevin.
Kevin Pho: So for those who didn’t get a chance to listen to our first episode almost a year ago, can you just briefly share your story and journey to where you are today?
Joan Naidorf: Sure, I’d be happy to. I grew up in New Jersey, I went to the University of Virginia for my undergrad studies, and I went to Philadelphia College of Osteopathic Medicine to study medicine. During my third year, I inadvertently was dropped off at the emergency department by a family practitioner I was doing a rotation with, and I discovered emergency medicine and started that love affair. It was so much fun. I got to deal with the challenges of trying to figure out, as the first person who sees a patient, what that patient has. I get a little bit of excitement and everything that happens there, I get to do some procedures, and most importantly for me, I get to say goodbye to people at the end of the visit.
So I did an emergency medicine residency. I would say the field was kind of in its infancy at the time. And I came back to Northern Virginia with my husband, who’s a gastroenterologist, to start practice. I practiced at a community hospital, it’s now called Inova Alexandria Hospital, and I also practiced at an Army medical center, Fort Belvoir Community Hospital. It’s actually multidisciplinary and multi-force now.
As I transitioned out of clinical medicine, I started pivoting to reading and writing, and we had some discussions about various issues. One of my friends suggested, “Why don’t you write a book?” I dusted off a lecture that I gave many years ago, when I was on faculty at George Washington University Medical School, about the problem of dealing with difficult patients. If anything, this problem is more real than ever. And so I decided to take that lecture and expand it into the form of a book. The book was just published in January, and I decided to share an excerpt with your audience, and that’s what we’re here to discuss.
Kevin Pho: Perfect. So let’s get right into that. The title of your book is Changing How We Think about Difficult Patients: A Guide for Physicians and Healthcare Professionals. Now, before I ask you to summarize that book and give the key points, just define: What do you consider to be a proverbial difficult patient?
Joan Naidorf: Well, that’s a great question, and I think all of us have our own ideas about that. We basically have some sort of instruction manual that we feel our patients should follow, an instruction guide, if you will. We want them to keep their appointments, we want them to fill the prescriptions we write for them, we want them to follow our instructions, we want them to get better, and we want them to, of course, thank us at the end of their visit. So when this kind of general script doesn’t occur, we tend to pigeonhole people as difficult.
I’m not saying that it’s fair, but it’s something that is very human. Nurses, doctors, physical therapists, and paramedics all do it. We have patients that we see on our roster, or on a triage board in emergency departments, who we just kind of groan at and say, “Oh, I can’t stand that.” Sometimes it’s the complaint that they have, the chief complaint. For me, I never could stand seeing people with a nosebleed or a fishbone stuck in their throat. For some people, perhaps in an office, it’s a certain patient who has a chronic problem and who really is never satisfied. So that is where I start out with the definition. It’s very much subjective, and it’s something that we all decide for ourselves, and therefore we can rethink it and redecide it.
Kevin Pho: All right, so let’s move on. Now that we have the definition of what, quote unquote, a difficult patient is, what are some of the key points of your book?
Joan Naidorf: Well, the key points in my book are that this kind of definition of what a difficult patient is is totally subjective, and you actually have the power to change your thoughts about that. From so much of what we learn along the way in our training, for whatever reason, and I believe there are three main reasons, we come out with a very negative bias towards some of our patients.
I think that we, quite correctly, have to look for the worst possible diagnosis. We have to worry. We’re not totally sure whether we’re being scammed by some people to get more opioids or to get some sort of treatment that we don’t really support. So we have a negative bias to start with. I think the second thing is that we’re actually taught this in our training. Our senior residents speak this way, some of our professors and trainers speak this way, and everybody in the break room is kind of talking and laughing about our patients. I think the third reason is kind of gallows humor. We think it’s funny. I mean, we have kind of difficult, stressful, demanding jobs, and it all helps to have a good laugh, but sometimes, if you listen to it, our jokes are very mean, and we’re laughing at the expense of our patients.
Kevin Pho: So knowing that some of us have these preconceived biases that can strengthen that perception of whether a patient is difficult or not, what are some ways that we can move forward, or prevent us from having these preconceived notions?
Joan Naidorf: Well, I think one thing that we can do, which I discuss in the book, is to try to understand what our patients are going through when they come to the office or emergency department. They may have some new symptoms. For parents, there may be a fever or some very worrisome symptom in their child that they don’t understand, and they have a lot of fears. There are certain types of behaviors that we see again and again in both good and bad patients, difficult patients, and the more that we understand those, the more that we can empathize with our patients, and the more we can understand or address some of their objections and some of the problems that they have in adhering to our plan.
Kevin Pho: So can you give us a case study that really illustrates what you’re talking about, perhaps in the emergency department setting? Can you give us a story or a case study of a patient or family that could be perceived as difficult, and what that clinician can do to help mitigate that perception?
Joan Naidorf: Well, I think there’s one kind of case study that we see again and again. A parent will bring in a child with a fever and some cold symptoms. We go through a whole exam. Perhaps we do a strep screen. We run through all the appropriate tests and the physical exam, and we present our best guess, our judgment based on our years of experience, that the child has a viral syndrome. And the family, not the patient so much as the family, may hear that we don’t think the child is really sick and that they’re not going to get the antibiotic that they think they came for.
Now, this is a scenario we see again and again. We have to be prepared for it. Instead of being upset and saying that they shouldn’t be that way, we need to say, “Nothing’s gone wrong here. I know this is going to happen a lot, and I need to be prepared for it. I need to find out from the parent what the issues are, what they think might happen or should happen.” We need to be able to explain to them that perhaps, in this situation, giving an antibiotic or taking an antibiotic for the child would actually be the wrong thing and perhaps make them sicker, and try to address the questions, try to find common ground that we both want the child to get better, and go from there.
Kevin Pho: What are some misconceptions about patients who are perceived as difficult? Are there any reasons that are not immediately obvious to the clinical team about why patients act a specific way, or why families could be perceived as difficult? What are some common misconceptions that are not immediately apparent?
Joan Naidorf: Well, I think there are huge cultural differences that we’re not always aware of. For example, some cultures don’t really even believe in Western medicine as much as we do. Obviously, we’re trained in it. They come to have us help them and feel better, but they don’t always want to follow our prescriptions.
I would say another issue is kind of a whole field, which I don’t address per se in the book, the social determinants of health. You would like a patient to follow up with a certain type of physician or some sort of specialist, and they perhaps don’t have the transportation or don’t have the insurance to be able to get there, and this is a huge issue. Some of our patients get labeled as, quote unquote, non-compliant, and it may or may not really be their fault. They just have no access to specialists or to certain medications that are actually quite expensive.
Kevin Pho: We’re talking to Joan Naidorf. She’s an emergency physician. She’s the author of the book Changing How We Think about Difficult Patients: A Guide for Physicians and Healthcare Professionals. Joan, you touched upon a few scenarios and tips that can help health care professionals in a room with patients who could be perceived as difficult. So I want to summarize some of your top tips. I’m a primary care physician, as you know, and we do have a lot of primary care clinicians listening to this show. So if we walk into a room, what are some things that we can do to better help overcome some of these preconceived notions that we have of some of our patients?
Joan Naidorf: Yeah, I think one of the most important things is to not make it about you, the clinician. So many times the reasons, or what I call the agenda of the patient, have nothing to do with the clinician. One of our kind of thought distortions that I talk about in the book is that we tend to personalize everything. If a patient, for example, does not want to follow our advice on a matter, we think, kind of reflexively, “Don’t they respect my opinion? Don’t they know I’m the doctor? Don’t they know I have all this experience?” And it usually has nothing to do with that. It has to do with their preconceived notions, their access, the beliefs that they have.
So if you can find some answer. And usually, another trap we get into is kind of all-or-nothing thinking. We think, “You either do this, or I’m going to write an against-medical-advice slip for you.” We’d like to find some common ground, some middle ground, that gets them towards our goal of getting them to feel better.
Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?
Joan Naidorf: I think the most important thing that I want my colleagues, physicians, nurses, all the PAs, and nurse practitioners, to realize is that how they feel and what they think really matters, because they can power through and see some of these people and feel terrible about it, and they’ll get bad results. With some of the tools that are discussed in the book, we can actually guide our thoughts and think with more intention, and not only will we get better results with our patients, but we’re going to feel a heck of a lot better about it. It takes practice, and we have to keep reminding ourselves to look for some of the good things about our patients and about our workplaces, which, for some of us now, is getting really hard.
Kevin Pho: The book is Changing How We Think about Difficult Patients: A Guide for Physicians and Healthcare Professionals. Joan, thank you so much for coming back on the show and sharing your time and insight.
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