Just had lunch today with a friend whose daughter has had a long history of mental illness, heroin addiction, and a slew of chronic medical conditions. He was telling me of her frequent interactions with medical and mental health personnel. She sounded like a lot to handle, with intense emotions, high levels of distress, and demanding behavior that would test the patience of a saint. He was telling me how angry she often got with health care professionals who she felt treated her with disrespect. It got me thinking of her experience and of my own when I’ve interacted with patients like her.

I would summarize the best approach as including these two parts (with the constraints of one’s less-than-saintly patience, of course):

  • Always treat the patient with respect
  • Always expect that respect to be reciprocated

From my end, showing respect means:

  • Apologizing to them if I’m running late (even if they come regularly come later or miss appointments)
  • Listening carefully to them
  • Acknowledging their concerns, fears, and perspective on anything without necessarily agreeing with it
  • Providing them with realistic hope
  • Explaining my decisions and recommendations
  • Keeping an open mind and non-judgmental facial expression and attitude, even when I’m saying I disagree with them or rejecting their requests
  • Doing my best

It doesn’t mean I’m a sucker.

  • If a patient misses an appointment, I ask them what got in the way of keeping it and what would help them be on-time for upcoming appointments. (An option to consider: Keep a half-day a week open for drop-ins for patients who regularly miss or are late for appointments. This may or may not work in your specialty, of course.)
  • If a patient curses or calls me, or other people, names, I tell them to stop and not to do it again.
  • If a patient acts or speaks in an intimidating way, I tell them that behavior is unacceptable, that no one can expect to work effectively when they are unsafe, and not to do it again. (This presupposes that I judge the patient not to be a clear danger at that time that would require more drastic interventions, including calling security and triggering safety protocols.)
  • If a patient requests a medication I judge to be unwarranted or that requires further evaluation, I decline to provide it and explain why. (Sample script below.)

“I understand you’d like me to prescribe you [X]. You’ll probably be disappointed to hear that I will not write you a prescription for [X]. My job as a doctor is to do what I believe is safe and effective for you and all my patients. Sometimes that means disagreeing with what a patient asks for, such as this case with you now. In my professional judgment prescribing this medication can lead to more harm than good. Here are some other approaches that we can consider …”

The patient will often respond with one of the following approaches:

  • Continue to try to change my mind by providing more information
  • Bully me into complying
  • Put me down, call me names, and engage in vulgarities

I will respond with something like:

“I can see you’re upset. I understand your point of view. I must repeat though, that I do not think it would be in your best interest for me to give you a prescription for what you’re asking. That is my professional judgment, and I won’t do otherwise. Another clinician may disagree with me. You are free to seek another opinion or care from someone else. Would like me to proceed to explain what options are available that are more likely to help than hurt you? Is there anything else you’d like to discuss with me?”

Remember that the ‘standard of care’ is your friend. Only offer options that you believe meet the standard of care. I find it helpful to use the phrase ‘in my professional judgment.’ It’s both an accurate reflection of my approach and harder to argue against. It is the rock on which I build my decisions.

Remember also that in non-emergency situations, the AMA tells us we are free to choose who to treat. We don’t need to keep putting up with abuse. We can terminate a patient from our practice. Of course, there are correct and incorrect ways of terminating a patient. We need to avoid ‘patient abandonment’ – a topic for another day.

Thanks,

Dr. Jack

Language Brief

“Be sure to put your feet in the right place; then stand firm.” – Abraham Lincoln

“Strong roots can make you stand or stumble depending on your relation to them.” ― Curtis Tyrone Jones

“Action springs not from thought, but from a readiness for responsibility.” ― Dietrich Bonhoeffer

“Character — the willingness to accept responsibility for one’s own life — is the source from which self-respect springs.” ― Joan Didion

“It is poor faith that needs fair weather for standing firm. That alone is true faith that stands the foulest weather.” – Mahatma Gandhi