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Challenging times

Being a junior doctor can intensify the level of stress in what is already an extremely stressful job. We sometimes deal with the most challenging of patients, often at the most challenging of times, says Dr Lynelle Govender

Patients, as we are so often taught at medical school, are more than simply a vessel for pathology. They are living human beings, and human beings do not always display the most harmonious behaviour.

Challenging patients come in a variety of shapes and sizes: aggressive, flirtatious, demanding, drug dependent. You will see it all: patients who will stretch you to the limits of your kindness and compassion. As with all pathology, however, having an approach to dealing with the different types of challenging patient, prior to seeing one, often makes the difference between a successful consultation and a near-disaster.

Factors contributing to a challenging interaction are two-fold: patient factors and doctor factors. Whereas patient factors are easy to understand, it is often a bitter pill to swallow when realising that some of the blame has to be pointed to ourselves.

Patient factors include:

  • High expectations
  • Personality traits
  • Feeling misunderstood, or otherwise dissatisfied with treatment
  • Cultural differences
  • Substance abuse.

Doctor factors:

Junior doctors are in fact more likely to have challenging encounters with patients, due to a combination of factors:

  • Personal stress
  • High patient volumes
  • Long working hours
  • Burnout
  • Focusing on the disease instead of the person
  • Inexperience.

No matter how challenging a patient, it is important to avoid labelling them as such, whether mentally, or physically in a patient’s records. It is common practice to check a patient’s file before seeing the patient.

A quick glance at the triage notes unconsciously sets up the doctor’s mind with preconceived ideas of what lies ahead.

For example:

“hurt hand during domestic dispute” = aggressive patient

“complaining of headache, requesting pain relief” = patient possibly addicted to pain medication.

This survival strategy is simply learned behaviour from seeing similar cases previously. However, it runs the risk of labelling patients inappropriately. This can set up a negative attitude in your approach to a patient, which the patient meets with a response of dissatisfaction and neglect; and so begins a vicious circle. It can also place you at risk of missing serious pathology; for example, a patient who you believe is combative may indeed have a head injury, and someone with a chronic headache may have underlying organic pathology and not simply an opioid addiction.

Strategies for dealing with challenging interaction

Demanding and needy patients will often ask more and more of you, and seem perpetually dissatisfied. The key here is setting boundaries and realistic goals. It is perfectly acceptable to ask a patient at the outset what their expectations are from the consultation and thereafter keep the consultation short and focused on trying to meet those expectations.

It is perfectly acceptable to ask a patient at the outset what their expectations are from the consultation
Simply put: drug-seeking patients can be manipulative. They have done this before and know all the tricks to getting a prescription of their favourite fix. Red flags include “doctor shopping”, requesting specific addictive medication on the premise of being allergic to others, and classically aggressive behaviour from the patient when you fail to provide the requested script. As a junior doctor, the key is to recognise the signs of drug-seeking behaviour, do a proper history taking and examination, make good notes, and if you are suspicious, alert your senior.

Most patients become angry and aggressive for a reason (with personality disorders and intoxication being the obvious exceptions). In dealing with this type of behaviour, your greatest ally is to find the cause. Address the reason for a patient’s irritation and you are more likely to resolve the situation. It is important to remember, however, that doctors are not invincible. Aggression can progress to violence and it is important to keep yourself safe. Always sit closest to the door and call for help and exit immediately if you feel threatened in any way.

Crossing boundaries happens; no-one ever really expects it from a patient, but it happens nonetheless. Patients may be inappropriately seductive with you and may make you feel uncomfortable in your own work space. In these situations, emphasise that this is a professional relationship, request a chaperone to watch over your consultations and, if necessary, alert your senior that you may need an alternative doctor to see the patient. Remember that it is unethical to become romantically involved with your patients and such relationships may have a profound negative impact on both your personal and professional life.

Crossing boundaries happens; no-one ever really expects it from a patient, but it happens nonetheless

Non-compliance with treatment can be intensely frustrating to deal with. Patients will seek help, with apparent desperation, but not comply when such help is provided. You will do no-one any good by getting angry. Try, if possible, to educate the patient about their condition and the dangers of non-compliance and then make clear notes. Beyond that, the situation is out of your control and it is easier to accept that reality than try to force treatment on a patient.

Ultimately, realise that the key to dealing with a challenging patient interaction is good communication. Cultivate good rapport with patients and success is likely to follow. Furthermore, as with all consultations, detailed note-keeping is your ally. Whatever the situation may be, be sure to document it extensively. If nothing else, a challenging interaction is a learning experience which will only serve to improve your skills in future.