Article review: Teaching learners about 'difficult' patients

Your capable resident comes to you, looking frustrated. He says, 'What a difficult patient. I think you need to get involved.'

This article provides a framework for teachers to allow learners to appreciate these encounters in the Family Medicine. Their points are highly relevant to Emergency Medicine. Strategies include:

1. Label encounters as being difficult rather than patients.

• The difference in language is important. Many factors - perceived physician attitude, life history of the patient - will affect the encounter.

My take:

• In the ED, factors such as wait times, patient discomfort and physician interruption will also color the encounter. Learners need to understand that not all factors can be controlled.

2. Effectively debrief.

• Teachers should challenge the learners to explore their emotional reaction.
• Learners should understand that their own emotions can affect the encounters significantly.

My take:

• While reflection is an excellent learning tool, there may be insufficient time to do it in real time in the ED. (Is there time to do anything in the ED?)
• It would, however, be useful at the end of the shift.

3. Teach learners to say NO more effectively.

• At times, saying no is the correct medical decision.
• However, patients need to feel understood and their concerns taken seriously.
• Deliver the 'no' tactfully. Involve patients in the decision making process.

My take:

• This is probably the *most* useful skill in the ED.
• While to a clinician some demands are 'unreasonable', often a true concern hides underneath. So the 'whole body MRI' might come after a relative gets diagnosed with a rare cancer, or a 'plastic surgeon referral' might be due to worry about a keloid scar.
• Learners need to understand the particular concerns and offer medically appropriate alternatives while involving the patient in the decision.
• This Jedi-skill will take years to hone!

4. Understand the patient.

• Learners need to understand the context of the patient, who they are, and why they might be difficult in their encounters with physicians.

My take:

• This approach is more feasible in primary or longitudinal care than the ED.
• In the ED, the 'why today?' question for chronic problem can often yield the real agenda that clinicians can focus on.

Reference:
Oliver D. Teaching medical learners to appreciate “difficult” patients Canadian Family Physician. 2011, 57(4), 506-508.

Free link to the full article.