Week 6: Patience With Patients

The doctor entered the emergency room ward with a smile on his face.  “Good news,” he told the patient,  “your heart is fine”.  Rather than being relieved the patient was confused.

“What are you talking about? I had like eight heart attacks in the last week.”  The doctor smiled knowingly and nodded.

“Based on everything, I’d say they were anxiety attacks.”

“Anxiety attacks?  Do I look like the kind of guy that panics?”  The patient advanced on the physician, who suddenly looked as if he wanted to be somewhere, anywhere else.  The doctor backed away, trying unsuccessfully to conceal the tremor in voice.

“It’s a common thing.  Nothing to be ashamed of.”

“Listen to me you idiot, I had a heart attack, o.k.?” 

“Not according to your EKG…” the doctor trailed off as the patient reached up pulling around the curtain to conceal himself, the physician and the hospital bed from view.  A crash was heard from beyond the drape, the unmistakable sound of the doctor being thrown bodily against the wall…

If the drama above seems like a scene from a movie, it’s because it is.  Specifically, “Analyze This” with Robert De Niro and Billy Crystal.  However, while the details of this scene may be overly dramatic for the sake of thrilling moviegoers, the occurrence represents a very real issue that I observed this week at New York Presbyterian Hospital: the frustration of treating non-cooperative, argumentative, and stubborn patients.

Throughout the week on rounds, I returned day after day with some of the IR physicians to check on one patient that had gotten a reputation for being particularly grumpy.  Without fail, the patient complained each day about not getting enough rest.  The patient felt disturbed by the physician’s presence and not without reason.  Multiple times, as the IR physician’s left, another entered the room, extending the time when the patient had to be awake.  Mostly it was the patient’s attitude toward new procedures that made the treatment difficult.  With fluid accumulating in the patient’s abdomen, two options were available: a paracentesis, in which fluid is drained by IR physicians through a needle inserted with the aid of ultrasound or a drain, a semi-permanent catheter that could be hooked up to a bag to drain fluid even in the patient’s own home.  Refusing to listen to the various merits of each the patient concluded that both options were bad.  The patient had a strong desire, understandably, to leave the hospital and go home.  Although the drain might allow this to happen, the suggestion that additional tube would be hanging out of the patient’s skin seemed as horrifying to the patient as an amputation. 

It is hard to criticize a patient for feeling frustrated with repeated procedures, extended hospital stays and the likely possibility that life would never get back to “normal”.  I can only imagine what it must be like to feel trapped in a hospital, choking on pills, enduring examination after examination, being dragged off to the OR every other day for another procedure, without even the hope of one-day being cured.  Nevertheless, for clinicians, dealing with such a patient is not easy.  I watched the physicians, residents, and fellows patiently explain each new procedure over and over never becoming angry or irritated at the patient’s questions or complaints.   The patient’s comfort was always foremost in their mind.  The physicians worked the treatment plan around the patient’s wishes rather than forcing them aside. 

It seemed to me that the ability to interact well with patients, what we call “bedside manner”, is perhaps one of the hardest parts of the clinical profession.  A cranky patient struggling with terminal illness is only one of the many challenges associated with such interaction.  Before every procedure, informed consent must be obtained, either from the patient directly, or in the event that the patient is not able to provide such consent, a legal guardian, family member or other individual able to make healthcare decisions on the patient’s behalf.  The informed consent process ensures that the patient understands the various treatment options and is able to make an intelligent decision as an autonomous individual.  However, the informed consent process also gives the patient the opportunity to refuse treatment even when such treatment may be in the patient’s best interest.  I witnessed one case, in which anesthesia-requiring procedures could not be performed because the patient had refused the placement of a tracheal tube.  Such refusals can cripple a treatment plan, making what a doctor knows to be the most optimal therapy for a specific condition impossible to perform.

Another type of challenge that can strain the patient-doctor relationship is when a patient or patient’s relative becomes unreasonably argumentative.  This past week, I overheard one of the nurse practitioners describe a phone conversation she had had with a patient’s daughter.  A gastric-tube, used to provide direct access to the patient’s stomach for feeding, had become clogged.  The daughter was wildly angry, accusing the IR physicians who had placed the tube of implanting a faulty device.  The nurse practitioner quietly explained to me that in all likelihood it was attempts to force pills that had not been properly crushed and dissolved through the narrow tube that had caused the blockage, but the daughter didn’t want to listen to reason.  I am sure that the nurse practitioner wished she could simply avoid talking to the daughter, but it wasn’t an option. 

The array of skills needed to join the medical profession is vast: knowledge of disease, diagnosis, and the physical techniques required to apply a given therapy.  My experiences during this week have shown me that another skill is necessary: an ability to work well with people.  It is not that I have never recognized the need for this skill in the past, but rather my observations have underscored the awesome patience that is often required to translate the science of medicine into healing.