April 14, 2016
Memo to Wall Street Journal: Patients Are Not a “Nuisance” to Their Physicians
By Warren Holleman
The other day an article in the Wall Street Journal caught my attention, and for all the wrong reasons. The article reviewed two recent Dutch 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, repeatedly 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.
This type of language—and worse—was common among the house staff (medical students, interns, and residents) 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. Since that time we’ve made progress, both in the way we treat trainees and in the way they talk about patients.
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 from another race, another ethnicity, or another economic or social class. They were homeless or poor or mentally ill. Or, they didn’t speak English. Or, were gay or lesbian or transgender. Or elderly. Or female, for that matter. In the youthful, male-dominated house staff culture of that era, just being over 50 or having 2 X chromosomes was enough to make them a target.
The research has shown that these were not “difficult patients” by any objective measure. What made them “difficult,” frankly, was that their caregivers were immature at best, and bigots at worst. It didn’t help 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 incompetence and insecurity. The litany included code words such as “difficult patients,” “hateful patients,” “malingerers,” “entitled demanders,” dirtballs, “gomers” (Get Out of My ER) and “shpos” (Sub-Human Piece of Shit). Remember, the house staff was a male, 20-something subculture, so if the language sounds like that of a football locker room, that’s basically what it was.
Look back in the medical charts of yesteryear and you’ll find students and residents saying 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.” If the medical history isn’t up to snuff, we should blame the doctor, not the patient.
Nowadays we also know that patients don’t “fail” therapy. If the patient dies, or doesn’t get well, isn’t it more accurate to say, “The therapy failed the patient”? No good doctor today would add insult to the patient’s injury by accusing her of “failing therapy.”
In a similar vein, to label a patient as “noncompliant” is unprofessional because it implies that the physician’s job is to “bend” (the root is plié, “to bend,” as in a pair of pliers) the patient to his will, and the patient’s job is to submit. Today we realize that the best doctor-patient relationship is one of collaboration and mutual respect. Not the doctor barking our orders and the patient blindly submitting.
So when I read the recent WSJ article about patients being a “pain” for their doctors, I couldn’t believe what I was reading. I was shocked that the British Medical Journal (BMJ), who published the two papers, used the term “difficult patients” as well. The papers were written by Dutch scientists. Perhaps something was lost in translation. But still there is no excuse for the BMJ to use such language—not in the 21st century. When writing about such negative perceptions, journals generally use a modifier such as “the ‘so-called’ difficult patient,” or “patients whom doctors perceive as difficult,” or “difficult doctor-patient encounters.”
It’s important to underscore that neither of these BMJ papers studied real doctors—or real patients, for that matter. They 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 3 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 never 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. They do expect themselves to be caring, competent, effective, and respectful–in short, professional.
If the blame is to go anywhere, let it go to health executives and clinic administrators who now place time limits on patient visits, thus pressuring physicians to diagnose and treat complex illnesses, while comforting and educating shocked and saddened patients, in 8 minutes or 12 minutes or some such ridiculous time span. This is health care, not automobile manufacturing!
One reason medical students, interns, and residents develop negative feelings toward their patients is that they haven’t yet learned how to manage projection, transference-countertransference, and other psychodynamics of intimate, professional relationships. Plus they are novices and understandably feel insecure about their skills. So, when things go wrong, it’s human nature to get defensive and throw someone else under the bus. Another problem 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.
One other thing to keep in mind: a significant portion of the presenting concerns patients bring to primary care physicians are psychosocial in origin and impact. That’s how suffering and healing are experienced in real life, and it takes a while for young doctors to figure that out. Doctors who carry such anger, or who have trouble managing chronic illness and psychosocial symptoms, shouldn’t be in primary care—they should find other specialties or administrative positions where they don’t have to deal with inconvenient, real-world patients and their suffering.
The bottom line here is that the term “difficult patient” should be removed from the lexicon, unless of course we wish to create a parallel category called “difficult physicians.” Which we don’t! This language is blaming and makes it sound like doctors and patients are at war with each other, when actually they have an amazingly collaborative relationship. They don’t stand face-to-face in some power struggle, but side-by-side to manage a problem together.
Next time the WSJ publishes an article on this subject, I recommend they use terms like “difficult situation” or “challenging relationship.” That focuses the attention where it should be—on the challenge of creating an effective, therapeutic collaboration, where a cure may not be possible, but healing always is.
The photograph above epitomizes for me the way most primary care physicians feel about their patients. I snapped it 25 years ago in a overcrowded, urban clinic, and I still remember the occasion. The doctor, Susan Cauley, MD had a long line of patients waiting to see her, and as a family practice resident she was sleep-deprived, having worked every day and every 4th night. Yet she was respectful and kind toward her patients and did her best to help them all. In this case the mother was clinically depressed (you can see her shoulder in the lower left corner of the photo) and her child was hungry. Dr. Cauley found a loaf of bread for the child and held her on her lap, giving the troubled mother a break, while she addressed the mother’s medical problems. The agency that housed the clinic was documenting their work that day, and the mother gave permission to photograph her family.
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