Dealing With The Challenging Patient

We all have “that one patient” we remember. The thorn in our side while we were on service. The one patient who resulted in that extra grunt prior to knocking and entering the room. I vividly remember my first patient who embodies these aforementioned statements. I met this particular patient on my second day of my nursery week while on my Pediatrics rotation, which was my second rotation of my third year. After an incredible first day where I witnessed the miracle of childbirth and each parent’s incredible joy in bringing their baby into this world, I left the hospital that day excited to return the next day. As the wide-eyed and eager third year that I was, I came in early and reviewed our census and was pleased to see that there were many potential deliveries to occur that morning.

By the afternoon, I was excited to have helped participate in the evaluation of many newborns. I was pleased to see each mother beyond ecstatic to be caring for their newborn and all the joys that accompany this exciting time. However, one mother was less than pleased at this new responsibility, which frankly caught me by surprise. When being introduced to this patient and mother by my resident, I was pointed to a note in the progress flowsheet that read “mother wants no male providers or interns for religious reasons.”
We went to examine the newborn on pre-rounds prior to attending rounds and met a pleasant mother who was understandably exhausted after having endured a C-section. We completed our newborn exam and noted all the common newborn findings to the mother (i.e., milia, angel kisses, etc.). However, the mother became inquisitive and concerned when I noted the prominent xiphoid process present in her newborn to which I answered every question accurately, with confidence, and with endorsement of the resident. She remained concerned although we did our best attempts at reassuring her.

Over the course of the week until eventual discharge on my last day of the rotation, this mother caused angst in the healthcare team as essentially, they were told to take care of the newborn (i.e., feeding, changing diapers, even babysitting the child in the newborn observation unit). On the third day of my rotation, the mother told me she had held her newborn twice and did not change his diapers. At this point, I had discussions with my resident of my displeasure at seeing this newborn being cared for in this manner in the observation unit. However, I later reflected on this situation and was appreciative for this patient as she taught me valuable lessons that I continue to incorporate in my training to this day:

1. Spend time at the bedside: As trainees, we generally have the most amount of time to be at the bedside and listen to our patients’ concerns. In between the complaints that my patient voiced, there were complicated social circumstances that made this a very stressful time for the patient. Our entire team could have been more mindful of this in our care by spending more time at the bedside.
2. Avoid countertransference: It is easy to get caught up in the emotions of patient care, especially in the demanding role we serve as trainees. However, it is important that you do not compromise the special trainee-patient bond and let various aspects of your interactions with other patients interfere with what you can offer patients.
3. Be mindful: One thing that I constantly remind myself when I encounter tough patients is that each individual is a mother, brother, father, sister, aunt, uncle, etc. to a loved one, and they are trusting me to care for this patient. I therefore consider it an incredible honor to be caring for my patients and look forward to meeting my patient’s family members during their hospital stay. One of the most rewarding aspects of a career in hospital medicine is admitting a patient from the emergency department and then caring for them and discharging them from the hospital. The smile on their face when I tell them they have since been discharged and the gratitude I receive in return is something I will always cherish throughout my career.

In sum, taking care of patients is an honor. I hope these tips are helpful for the next time you encounter a difficult patient.

Aram A. Namavar, MS