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The “Difficult Patient”

Ten o’clock…

Eleven o’clock…

One o’clock…

My mind was racing with anticipation the night before I began my internal medicine rotation.

This is what being a doctor is all about, I thought as the hours ticked by. Diagnoses, evidence, groundbreaking trials and managing complex conditions.

I was nervous. Although internal medicine wasn’t my first rotation of third year, I still wanted to impress my attending and residents. I planned to arrive early to pre-round and collect a thorough history and physical so that I would have ample time to come up with differential diagnoses and a plan before rounds began.

Two o’clock … Sleep.

Five o’clock … Alarm bells ring.

Even without a full night’s sleep, I was ready and excited to hit the floors. I looked at the list of newly admitted patients with my residents.

Heart stuff, heart stuff, kidney stuff … Ooohh! Eye pain with possible blindness, I thought to myself. I’ll take the eye pain!

It was different and intriguing. Hopefully, I could follow through with my plan to impress today. The residents looked at each other knowingly, smiled at me and wished me good luck when I called out which patient I wanted to follow. At that moment, I wasn’t sure if they were actually wishing me luck because it was my first day or if there was some other reason that I would soon discover.

Step 1: Dry off sweaty palms.

Step 2: Use hand sanitizer — don’t forget hand hygiene!

Step 3: Knock on the door loudly enough to wake the patient.

Step 4: Enter the room and say, “Good morning Ms…”

“LEAVE ME ALONE! Everyone has been waking me up all night. I’m so tired. My eye hurts so badly. It needs to be closed. Get out of here and don’t come back!”

Step 5: Apologize and quickly back out of the room.

I slinked back to the nurses’ station where the residents were looking at patient charts. They asked me how that encounter had gone, and I could feel my cheeks turn bright red. I was embarrassed that I was not able to connect with my patient. What was worse was that I was kicked out of the room before I even finished saying her name. How was I ever going to give an impressive presentation on rounds?

I looked through the chart and did the best presentation I could, but it was far from remarkable. I felt like a failure, but more than that, I felt disappointed: disappointed that I couldn’t care for my patient, disappointed that I couldn’t give a good presentation and disappointed in myself.

After lunch, I squashed my disappointment and tried again.

Step 1: Dry off sweaty palms.

Step 2: Use hand sanitizer — don’t forget hand hygiene!

Step 3: Knock on the door loudly enough to wake the patient.

Step 4: Enter the room and say, “Good afternoon Ms…”

“Oh, it’s you again,” she chimed.

“Yes, it’s me again,” I replied. I tried to sound confident but felt my nerves creep up into my throat. “I can see that you’re in a lot of pain, and I was wondering if we could talk more about it so that we might be able to do something to help.”

She paused for what felt like an hour. “Alright, if we can talk quietly.”

That was it; I had my in. We sat and talked for a little while before I went back and reported to the residents. All of them seemed genuinely shocked that I was able to have a conversation with this patient. They repeated how they weren’t able to “get much out of her” and how she was a “difficult patient.”

What does the term “difficult patient” mean? Is it a patient who doesn’t do exactly what doctors want? Is it a patient who takes too long to answer questions or whose answers are too wordy? Is it a patient whose family member asks too many questions?

Why are we throwing around this label — which has no specific definition — to describe patients who take up too much time or are not always pleasant? It doesn’t seem fair that it only takes one provider using this label to bias the rest of the healthcare team.

Over the next several days, my patient began feeling a little better. As her pain decreased each morning, our conversations became more comfortable, livelier and deeper. The vision in her affected eye was still not good, but it improved slightly with each passing day. It became a running joke that she could distinguish a little bit better what colors I was wearing and if I had a necklace around my neck.

On my last morning with her before she went to the operating room, she asked me if she would get an eye patch if she went blind. I told her that I was not sure and then inquired why she asked. She wanted to know if her eye patch could have glitter and bedazzling on it so that she wouldn’t have to look like a regular pirate; she stressed that she wanted to be a pretty, sexy pirate.

We laughed for a good while about this. The moment was brief, but it lifted a weight out of the room. As the laughter subsided, both of us let out a sigh of relief. For several days, her room was filled with pain that was more than just physical. She had fears and frustrations due to uncertainty about her future, but with time, she found acceptance. One moment of acknowledgement that everything would be okay, even if she went blind, allowed her to attain comfort, hope and even laughter.

As I left her room, I couldn’t help but think that this “difficult patient” was actually very funny. She managed to find positivity in a negative situation: the potential loss of vision in one of her eyes. For many people, this situation would be one filled with grief and self-pity. For her, it was different, as she viewed it with humor and a silver living. I admired her greatly for this. I think about this patient often, especially when I hear of other “difficult patients.”

Lesson learned: Always be considerate.

Are your patients scared? Are they in pain? Are they frustrated? It is common knowledge that feeling unwell can completely change a person’s demeanor. In the hospital setting, there are many sick patients and many more patients who are waiting at the door, desperate for help. It can be frustrating when patients who come seeking help seem to be the ones adding barriers to their care by not readily providing a history, being willing to participate in the physical exam or other tests or complying with the treatment methods suggested. It is important to remember that the main goals of care are to help patients feel better and improve quality of life. Ultimately, taking a little extra time to assess for other factors that are making the patient seem “difficult” may help achieve these goals, strengthen the physician-patient relationship and may even save time overall.

After taking the time to empathize with patients, we should always follow up with one of the most important questions in health care: “How can I help?”

Amanda Walker (1 Posts)

Contributing Writer

Albany Medical College

Amanda is a third year medical student at Albany Medical College in Albany, New York. In 2014, she graduated from Fordham University in Bronx, New York with a Bachelor of Science in biology and a Bachelor of Science in theology. She enjoys running, hiking, playing with any animals, and trying new foods in her free time. After graduating from medical school, Amanda would like to pursue a career in pediatric hematology and oncology.