Dealing With Asshole Patients: Do You Have Any Advice For a Doctor?

I have written in some detail about how medicine is one of the fields where asshole poisoning appears to run most rampant. I've written about Dr. Gooser and research showing that medical students and especially nurses face many demeaning doctors (See an artist's vision of Dr. Gooser in action to the left).  I have also written about how one surgical resident and his colleagues took action to break the cycle of abuse that is so common in hospitals.  And I recently saw some hints of how doctors -- especially a couple of surgeons -- can have attitudes toward nurses that fuel such nastiness.  I gave a talk to Stanford alums a few weeks back (in fact, Kent Blumberg was in the audience), and two doctors pushed back on my claims that nurses face especially high levels of abuse, both claiming that nurses are often overly sensitive to their comments, and one saying -- at least as I interpreted it  -- that there are times when nurses are messing up and deserve to be slammed,  I am sure that nurses, like everyone, make mistakes, but as Amy Edmondson's research suggests, when nurses are afraid to speak up and are belittled when they make errors, it leads to less learning and more mistakes.

There is,  however, another side of his story that I have not touched on: What about abusive patients?  Certainly, doctors and nurses who face nastiness and insults from patients can suffer the same kinds of negative outcomes -- anxiety, physical illness, reduced motivation, and catching the nastiness -- as happens to anyone else who encounters assholes in the workplace.  I have written about dealing with asshole clients, about how some organizations and people just refuse to serve them, and others levy "asshole taxes" to get some payback for their suffering at the hands of these creeps.  Well, as you will see below, doctors do get rid of difficult patients, but even assholes deserve health care. And charging them more seems suspect to me. 

Along these lines, I got a request from a doctor for ideas about how he should deal with asshole patients. Here is his email (with just a few things removed to protect his identity).  It is a charming little note, with come interesting turns. I invite you to read it carefully, and in particular, to suggest some useful ideas for this and other doctors who face mean-spirited and demeaning patients. This is not an easy task:

When I was doing my internship after medical school, my best friend there and I had our own version of your rule.  This came up while we were playing Monopoly on a day when we were snowed in.  Over the course of a long day of Monopoly, multiple small disputes would come up, and we kept creating rules and sub-rules to address all the different permutations of our disputes.  Eventually, we just created a no a-hole rule, and all the tension subsided.  All parties involved knew what it meant to be a decent person, and wouldn't cross the line.  I've tried to integrate this rule into every aspect of my life, and succeed most of the time (although, as you noted, there are those times where I deviate- and your book brought about some needed self reflection).

On a similar note, there is a version of your rule in Utlimate Frisbee. Even at the highest level, Ultimate is played without a referee.  Instead, the players invoke "The Spirit of the Game"- and all parties agree to not be a-holes and allow disputes to resolve by their good will.  It's a great rule, and it works pretty well.

As a physician, I find the hardest part of adhering to the no A-hole rule is my interactions with patients.  The vast majority of my patients are a delight, and what fuel my desire to be a physician.  However, as you noted, 1 negative interaction can have far more impact than many positive interactions.

In particular, I deal with patients who have some form of pain, and some of these patients can be nasty, impatient, entitled, and just in general be total certified a-holes.  While many of your suggestions work well in other contexts, as a physician I have a professional and ethical obligation to continue to provide as high a quality of care as possible, even if the patient is being an a-hole.

Do you have any recommendations for how physicians should deal with a-hole patients?  The most popular current method is the "dump," where colleagues will refer their problem patients to other physicians (the famous "referral preceded by an apology.").  While this sometimes helps find a patient-physician interaction that works for everyone, more commonly it just spreads misery around, and doesn't help anybody.  Any feedback you have would be appreciated.

Comments

[Shiela]

Where I work (in a downtown walk in medical clinic) there are at LEAST 10 drug heads a day walking in to be treated with "fake" aches and pains hoping to get their pain killers refilled. They are abusive assholes ! It is not only hard for the providers to deal with them, but it's hard for the desk workers and in house pharmacists as well. These dope heads will cuss, argue, throw a fit, cry, lay in the floor, you name it ...trying to get more painkillers. They don't want an xray or an MRI, they know what is wrong with them and they know exactly what they need to make them better. (Lortab, Morphine, Tramadol, you name it). They become self appointed pharmacists and demand certain drugs.

When the doctor pulls up their narcotics history (yes narcotics are tracked by the gov't) and shows it to the patient that they have a record of narcotics abuse 15pgs long ..and says they won't prescribe more narcotics..all hell breaks loose. Everyone gets cussed out and abused. It's awful.

So yeah, MOST PEOPLE have NOOOO idea what doctors and their staff deal with. The first time a patient like that at our practice yells, screams,cusses or gets abusive with the staff the doctors fire them from the practice. Then the next time they try to come in (because God knows in their drug induced stupor they won't remember getting fired) , it's the dear desk worker's job to remind them they have been dismissed from the practice and it gets really ugly again. More screaming ,yelling,cussing ,crying. So, there you have it, there is NO good answer. You can't rationalize with a druggie. Just can't. I've tried !

I am a desk worker (check in/check out/referrals) and due to these type assholes I HATE my job. I have been cussed, flipped off, threatened, had the desk pounded in my face, etc. all by ppl who didn't get the drugs they wanted.

We do have our nice/normal patients who are compliant and respectful but the assholes ruin it for everybody.

I know every office probablly isn't like the one where I work because I have a friend who works a very cushy job at an eye doctor office and says she maybe has 1 hateful person every FEW months. Must be nice !

[sf]

Some posters here seem to be aholes.

[chuck RN]

in response to KENT. you sound like a nursing instructor. my advice to you is do some bedside nursing guy. you sound lika "babe in the woods."

[chuck RN]

in response to bob. i find it funny that people who surf the "web" think they have a firm grasp of medical diagnosis. its been my experience that a patient who asks an "informed"question doesn't really know a damn thing. people like you are like a MONKEY WITH A MACHINE_GUN.to you own admission, your wifes disease was poorly known. perhaps only to you. i have people caome in claiming "their going to die." only to refuse treatment cause it doesn't involve morphine. when your car/house/whatever breaks, to you tell your serviceman how to fix it? NO YOU DON'T. stay outa the way, keep your mouth shut and your ears open. my condolences on your loss. chuck RN

[sugarplum]

I am a nursing student, and I have had patients who have called me stupid or cursed at me, and even screamed at me refusing to take their meds. You can't help but feel like you'd rather be helping patients who want to be treated. When some one yells at me to get out of the room and they don't want their meds, rather than putting myself behind and spending an hour trying to coax them into taking their medications, I feel like saying, hey, what are you here for? there's the door.

A lot of patients treat hospitals like a hotel and the nurses worse than bellboys or housekeeping.

I never realized nurses took so much abuse from patients. You can see why they burn out so fast as floor nurses.

[HR Wench]

Patients may be in pain, anxious, afraid of outcomes, afraid of medical personnel in general and associate even the cushiest medical office with very bad memories. I don't know if many medical personnel think about this on a daily basis as they are probably used to their work environment. So the first suggestion I have is, if you don't already, remember where you are and what you represent to a heck of a lot of people.

My second suggestion is to acknowledge the emotion the patient is presenting. I know my job is very different from a doctor's but I find that if I say (in a sincere manner) to an employee "I can see you are upset right now" or "It sounds like you are very upset" it helps to pacify them.

My third suggestion is the louder someone gets the quieter you should get. This makes them concentrate harder on what you are saying and notice the contrast between their volume and yours.

If someone is REALLY ticked off and being a major asshole I have even put up my hands and literally taken a step backwards. This immediately puts the person on notice that their behavior is attack-like. Sometimes it even shames the person into immediately apologizing for their behavior.

[Kent Blumberg]

I'd be tempted to be frank and honest about how folks in my workplace (hospital or otherwise) were expected to behave:

"Mr X, I know you are in pain and frustrated and perhaps a bit scared. However, we have a rule here that we don't abuse fellow workers or patients. And we work best when our patients live by the same rule."

"What I want is for you to follow that rule also, and treat all of us with the same care we are extending to you. We're going to do our absolute level best to help you get better, and the less abuse you throw our way, the easier it will be for us to give you that excellent care. Are you willing to do that?"

If that fails, perhaps one of the caregivers (physician, nurse, orderly, admin asst - somebody) can provide a willing ear - act as an ombudsperson for that patient. If commenter Bob is right, that ear - and some corrective actions - might calm the wild beast.

[Great talk, by the way Bob S! It was super to meet you finally.]

Kent

[Bob]

My wife, who died recently after a long, painful, and little-understood illness, encountered so many doctors who could not walk into the room without tripping over their own ego, that I am loathe to address the question of how to deal with asshole patients without feeling obligated to ask what the doctor's criteria is for "asshole patient".

In our experience, many, many doctors, sadly, consider you an asshole for simply asking informed questions about treatment options, asking them to explain the rationale behind a decision, or asking if they would consider trying another treatment option that we knew about and they didn't. They have such fragile egos that they take offense at anything other than unquestioning docile "compliance" with their wishes. This is VERY common.

Assuming that the patient truly IS an asshole, though, I think it's significant that this doctor mentions it in context of people who are in a lot of pain. Pain and suffering cause people to "regress" and become more childlike and immature. I don't think you can expect nearly as much from the sick. You can also expect that patients who can barely drag themselves into the office will experience an amplification of the usual annoyances in a doctor's office (running late on appointments without explanation or apology, or dealing with less than competent administrative staff, for example; in our experience few doctors know how to run a business well and in many ways don't even treat their patients like customers). So the first rule is, don't tempt people to be assholes.

Lest you think I'm down on doctors and think patients can do no wrong, though, I did once witness a doctor handle an asshole patient with finesse. He simply, matter-of-factly, stated that he wasn't able to provide the service the patient wanted and recommended that he seek those services elsewhere. That's really what it comes down to: boundaries. In this case the patient left in a huff, and that's fine. The other possible outcome is they would back down and decide they want the services on the doctor's terms more than they want to change doctors. Either way, everyone wins.

But please, please, please deal with your patients as human beings, respect the value of their time as much as you value your own, and LISTEN, LISTEN, LISTEN. You'd be surprised how many asshole patients that will eliminate. I'm willing to bet that most patients "loose it" because they aren't feeling "heard". Modern medicine is very impersonal, and any doctor who overcomes that somehow, will never lack for grateful patients. Empathy is a rare and wonderful thing in medicine.