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Changing how we think about difficult patients


Recognizing that our own thoughts cause negative emotions can positively change everything

Every physician, nurse, EMT, respiratory therapist, and clinician of every specialty has mused about how much better their work­place would be if they did not have to deal with difficult patients or demanding families. What a delightful fantasy!

Distressed doctor: ©joyfotoliakid -

Distressed doctor: ©joyfotoliakid -

It is helpful to remember the four core ethical principles form the base of the health care provider– patient relationship:

1. Autonomy. Autonomy is the ethical principle widely considered most central to health care decision-making. In medical practice, autonomy is usually expressed as the right of competent adults to make informed decisions about their own medical care. Adult and emancipated patients with decision-making capacity have the right to accept or decline offered health care, and physicians have a duty to respect the decisions of those patients, even if they disagree.

2. Beneficence. Beneficence means promoting the patient’s best interest by treating or preventing disease or injury and by informing patients about their conditions. We also must protect our patients’ right to confidentiality.

3. Nonmaleficence. Do no harm. We are expected to avoid actions or treatments likely to cause the patient harm. Our patients trust us; they have faith in us that we will not harm them.

4. Justice. We are expected to allocate the benefits and burdens related to health care delivery fairly. We must act impartially regarding patients’ gender, race, age, or ability to pay.

In medical training, the hidden curriculum refers to the les­sons that medical trainees receive behind the scenes and in “the real world.” Some of these lessons stand in stark contrast to the high ideals of humanism and professionalism proclaimed in medicine’s codes of ethics and echoed during the first day of medical or nursing school orientation.

And yet patients become problematic only when they evoke negative thoughts in the mind of the treating clinician — thoughts that create feel­ings of frustration, confusion, anxiety, sadness, and disgust.

Those negative feelings can lead to undesirable actions such as arguing, snubbing, or prematurely discharging the patient. Those who entered the medical profession with the highest and noblest intentions do not want our actions to stem from feelings of anger, fear, and hatred. We are far better than that.

In my book, “Changing How We Think About Think About Difficult Patients, A Guide for Physicians and Healthcare Professionals,” I detail the lessons I’ve learned about how changing the thought process can positively impact how the clinician feels and performs.

Human behavior has been described in the literature of psy­chology in terms of the motivational triad and the think-feel-act cycle. Human beings at their most basic level are motivated to seek pleasure, avoid pain, and minimize effort. Our thoughts cause us to feel a certain way and act — or not act — accord­ingly.

We can apply this think-feel-act triad to our clinician-patient relationships. Once we accept that our own thoughts and beliefs create our emotions and are what cause us to act — not the words, emo­tions, and actions of others — we can obtain better results for our patients and for us. If a “problem” exists only in our minds, we can solve the problem by changing how we think.

The arrival of a patient in an office, on the hospital floor, at the urgent care center, or in the emergency department presents a situation or event over which we have no control. The situation is neutral until a physician or nurse has a thought about the patient. Often, the generous thoughts of the health care professionals cause emotions like compassion or concern that drive the actions and determine the results. However, if the arrival of the patient results in negative thoughts reflecting resentment or disgust, a far different set of emotions, actions, and results occur.

Recognizing that our own thoughts cause negative emotions can positively change everything. It is possible to change what you think by replacing that thought with a new thought.

When a PA thinks, “I’m not very good at draining paronychial infections,” he thinks he is stating the truth. Yet, that thought is just that — a thought. Because of that thought, he may avoid seeing patients who present with that common problem. The PA can instead choose a thought that better serves him and his next patient: “Every time I treat a person with paronychia, I get better at doing it.” With this thought, he can build self-confidence and feel proud of master­ing this skill.

Choosing better thoughts is not just wishful thinking or slap­ping an optimistic idea onto an unfortunate situation. The first step is finding an intermediate, slightly more positive thought that feels believable. We can’t just conjure up rainbows and dai­sies where the reality appears murky and dark.

If we could retrain our brains to think about people, not as challenging patients, but as people who challenge us, what a difference that very subtle change in thinking would make! If the clinician places the blame for difficult interactions on the patients or families, then the cli­nician has taken on the role of powerless victim. As the victim, with the patient or the family as the villain, clinicians have no power to improve the situation.

Patients will never change, and demanding family members will never change.

The solution to the problem is to manage the way we think about them. I did not perfect this practice and see unicorns prancing through the emergency department. I still felt frustrated, lost my temper, and said things I wished I hadn’t.

However, I did learn to ask better questions and to manage my thoughts a little better each day.

Joan Naidorf, DO, is an emergency physician and author of “Changing how we think about difficult patients: A guide for physicians and healthcare professionals.”

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© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health