Difficult patients. Sigh! (Impact of patient requests on provider-perceived visit difficulty in primary care)

"No ma'am, your thumb isn't broken. I suspect the pain is as a result of pressing your call bell over 43 times in the last hour."

"No ma'am, your thumb isn't broken. I suspect the pain is as a result of pressing your call bell over 43 times in the last hour."

Sometimes physicians talk about the "difficult" patient with exasperation in their voice.  Nurses know these cases even better.

Most patients and families can tell your about a doctor or nurse who was terse, arrogant, disinterested, or even callous.

These encounters can be "soul-sucking," "difficult," and "draining." The individuals are labeled as "entitled," "unrealistic," "demanding," or ... worse.

That's not ideal terminology although the truth is that some patient encounters are harder than others, and we can't always figure out why. If we have a frustrating appointment, we equate the difficulty with the person, not the situation. As physicians, we often blame the patient!

"It's a personality disorder." "She's a rich, demanding snob." "He refuses to accept this."

On the surface are our attitudes, biases, and skill sets. Just like "difficult" doctors, "difficult" patients are, in our eyes, not open-minded, have not mastered skills of effective communication or listening, don't want to be told they are wrong, demand ridiculous things, or dig their heels in despite evidence that contradicts them.

Sometimes stubbornness is advocacy and it is necessary. Sometimes asking lots of questions is essential to developing an understanding from which a partnership can follow.

There is usually more to the story than just a clash of the personality of the clinician and the patient, and the health care provider should be sensitive to this; empathy means acknowledging that other people have "stuff" going on in their life. Fear, anger, embarrassment, uncertainty, and anxiety are among the many emotions that can make a clinical exchange sour.

With time and worldliness, and maybe some training, we grow and learn to help sort through that. Interestingly, the kind of encounters that health care providers find difficult are generally around people asking for tests.

According to Fenton et. al's paper, Impact of Patient Requests on Provider-Perceived Visit Difficulty in Primary Care, in the Journal of General Internal Medicine:

[Primary Care Provider] (PCP)-perceived visit difficulty is associated with patient requests for diagnostic tests, but not requests for pain medications or specialist referrals. In this era of “choosing wisely,” PCPs may be challenged to respond to diagnostic test requests in an evidence-based manner, while maintaining the provider–patient relationship and PCP career satisfaction.

They looked at 824 clinical encounters. Even adjusting for medical and psychiatric conditions, it was asking for tests that made clinicians rate the encounter as more difficult.

Fortunately, there are tools to help with this. A (not well curated) collection of Shared Decision Making tools is available on this site. Another time, I'll write about the evidence of efficacy (or lack thereof?) behind these aids.

The Choosing Wisely campaign is a prominent effort to facilitate these conversations about unnecesary tests. The Canadian and American sites both have many educational resources to help us with discussing diagnostics and therapeutics, and the AAFP has a great article on difficult patient encounters

It's not rocket science. We must remember that patients are human beings. Hopefully they will extend us, as providers, the same consideration.

At least he used the sensitive kind of tooth paste?

At least he used the sensitive kind of tooth paste?

Finally: yes, some people, whether doctors, patients, nurses, or family members, are just plain jerks.

Source: http://www.ncbi.nlm.nih.gov/pubmed/2537383...

Choosing Wisely Canada: 3rd Wave of Reccomendations

Choosing Wisely Canada has released their 3rd wave of recommendations!

Groups like the Canadian Association of Emergency Physicians (CAEP), Canadian Society of Hospital Medicine (CSHM), three psychiatry groups (Canadian Academy of Child and Adolescent Psychiatry, Canadian Academy of Geriatric Psychiatry, Canadian Psychiatric Association) and three surgical groups (Canadian Spine Society, Canadian Society for Vascular Surgery) have all developed lists of the top things that patients and doctors should question. The Canadian Society for Transfusion Medicine also added 5 new recommendations. See the new recommendations here.

This round was particularly interesting for me as I got to witness the process of the development of the CSHM list and participate in some stages, though not extensively. It's a tough task, whittling down all the ideas to find well-evidenced items that represent key areas for improvement, and try to avoid duplication of other specialty society recommendations. The group has to consider that many things which are good ideas and really really important to tackle, may not be suitable as the evidence behind them may be vague.

For example, though we all felt that discussing 'goals of care' or advance directives and resuscitation statuses (eg. DNR) with patients is very important, there's little data about why/how/when this should happen and what impact it actually has on patient well-being. Should it be discussed by the hospitalist? The GP? On all admissions? Only when a patient's status changes?

Ultimately it was impossible to make a firm statement that was robustly rooted in evidence, though our 'gut' feeling was strongly that we need to be having these discussions and that patients and doctors both should be starting conversations on the subject.

Choosing Wisely, as ever, forms a great starting place for discussing overuse of harmful and unnecessary tests and treatments. Yes, some of the recommendations are 'low-hanging fruit' but we have to start somewhere, and Choosing Wisely is great at getting us started talking about the facts that "more is not always better" in medicine.

Source: http://www.choosingwisely.ca

On “Why your doctor always keeps you waiting” & Wellness vs Work [Cross Post from @DrOttematic]

THIS IS A CROSSPOST (from DrOttematic)


A friend shared this article, “Why your doctor always keeps you waiting”. Take a look.

It perfectly sums up the struggle of a day in clinic for a primary care physician (family doctor). I can identify strongly with the author, Dr Sanaz Majd. She’s thorough, she’s dedicated, she cares about her patients, she doesn’t mind that much missing a lunch, and she cannot live with doing anything less than her best.

Trouble is, this kind of care is not sustainable. It is a recipe for burnout.

Is the answer to see fewer patients? Yes, that might help but then many Canadians would be without a doctor, we would not earn the money required to pay overhead, malpractice insurance, to attend conferences, or to live well. We have worked hard and a lot of us (those who aren’t yet burnt out) take a lot of our work (figuratively and literally) home with us.

Are we greedy? Maybe. But if someone got into medicine to make money, they are in the wrong field! Most clinicians are book-smart enough to succeed at business or investing or something else that is less personally demanding, but we enjoy medicine because it is a challenge not just intellectually, but emotionally. It is an opportunity to do something to help others while at the same time feeling stimulated and productive.

I get paid well, and I appreciate that is recognition for the intensity and length of my education, for the responsibility I assume, and for the fact that is is not “just a job” but a life and I cannot turn off ‘being a physician,’ ever.

In addition to lots of journal article reading to keep up to date, I also spend about 20 hrs a week working (without pay) on my project, Less is More in Medicine. This involves reading related articles, spreading the word on twitter, attending conferences, preparing lectures, networking, teleconferences, etc. all on my own time. I do it because I am passionate about it and feel I have a duty to make the health care system better. If I could get paid for it, that would be great! In fact, that’s a dream.

If I was paid to do the advocacy work that I feel is so important, then I could have more time to practice the “wellness” that I preach to patients. Constantly I am bombarded with messages from friends and family to “slow down.” My very patient partner has advised me that I need to view this advocacy work as ‘work,’ and take time for myself, but I haven’t done very well at listening. He suggests I take one week off each month, which technically I do (I keep it free from clinical work) but (he’d tell you) I fill it with meetings and writing and preparing for conferences. Plus I work some of the nights and weekends during the rest of the month, so I wind up doing as much clinical work as anyone else, and I enjoy this also. Whether paid or not, I will continue my advocacy work, because I cannot let go.

There are a lot of mixed messages. On the one hand, I hear I should make sure I am well: As a physician I advise exercise, healthy eating, meditation/self-reflection, and community involvement. I have seen burn-out and suicide and hospitalization of my colleagues thanks to the pressures of this profession. Numerous groups, like The Physician Health Program of BC have talks and booths at conferences, reminding us to take care of ourselves before we take care of others. Parents and partners worry.

Some comic relief in a day of stupid paperwork: Medical Reconciliation forms must be filled out when patients are admitted in order to make none of their usual medications are missed. This is important.
The pharmacist was upset that I left this page, a prescription for a generic erectile dysfunction drug (like Viagra), blank.
"Just doing my job," I know, I know. But what a system we would have if people kept only "just doing my job."

On the other hand, I should work harder and do more with less: patients are upset they can’t find a GP taking patients, they complain about waiting in the office or in the ER, colleagues ask for their shifts to be covered, emails come in constantly seeking locums, while in the middle of telling someone their loved one is dying a nurse calls and ask “when are you going to come and see this patient?!”, hospitals grow more crowded and we are seeing people in hallways, the public tells doctors we are paid to much and work too little and I’m to blame for everything that is wrong with their health, despite electronic records the pile of paperwork only seems to grow, the government of Quebec tries to pass legislation to (#PL20) forcing doctors to work more hours and take on more patients.

These messages are hard to reconcile, which is why we need to challenge the status quo. (I learned this formally, once). We need to change the way health care is delivered. We need a revolution in primary care, and we can only do this by using our time outside of clinical hours.

We must be brave and tackle conflict and embrace controversy. This makes life more difficult, but how can we – the thorough, the dedicated, the caring, the hungry, the unwilling to give less than 100 % – live any other way?

Must Watch VIDEO: (TEDMED) Are zombie doctors taking over America?

I don't know how I hadn't already seen this. It is perfect.

I've been feeling lately that it is impossible in this system to deliver good quality care and to be 'happy and well and fulfilled' myself, I can related to almost everything Dr Zubin Damania (aka ZDoggMD) says in his TedMed talk.

For years I've enjoyed ZDoggs hilarious videos but for some reason I did not see his TED talk until today.

Physician Zubin Damania, Director of Healthcare Development for Downtown Project Las Vegas, has a plan to fight back against a system that can dehumanize doctors and patients alike.

So much of what he says about his journey into medicine resonates with me, but this one section captures it all perfectly:

"A typical day in my life went something like this:

It begins with a mad scramble from room to room seeing complicated, sick and scared patients and their families, followed by three hours of paperwork using an electronic medical record that's two keystrokes away from becoming sentient and destroying humanity, all the while answering phone-calls from insurance companies, colleagues, and administrators each asking that I do more and more with less and less while improving quality and patient satisfaction. And speaking of which, that patient for whom I refused Vicadin because I was convinced it was destroying his life just ripped me a new one on Yelp! And I get through my 31st voice mail and I'm trying to delete it and it won't delete and I'm thinking I have to call I.T. now and I realized the reason it won't delete is that it's a live person I'm talking to. And it's my wife. And she's asking me to come home.

When I finally do get home, I can't be present with my two little girls because all I can think about is 'could I have missed something in this insane shuffle that could hurt or kill somebody?' Later, rinse, repeat for an entire career."


"Enough was enough. I realized I had a choice to make. I could either submit to this insane system and retire and then do my thing, but have my soul crushed and join the ranks of the swelling physician-zombie apocalypse. Or, I could surrender.

Just give up the external validation, drop the mask, and really surrender to who I actually was and have some hope of reconnecting to my purpose."


I need to do that. Dr Damania and Iora Health understand the fundamentals of providing the right kind of care. If we weren't wasting so much time and energy on all kinds of things that don't really matter, we could start to care for people again.

How can we do it?

- remember "medicine is about human relationships"
- "fix the reimbursement system . . make it an affordable, flat fee that incentivizes everyone to keep everybody well."
- "revolutionize the care model and the culture of the team; health coaches, nurse practitioners, doctors, and patients working together collaboratively non-hierarchically to change the health of the whole community"
- "glue it together with technology that helps rather than obstructs
- "do things FOR people instead of TO people"

I want to be a part of a clinic like that!

Source: http://www.tedmed.com/talks/show?id=34752