RAMOSA’S MAR [15-05]:Reaching the Boiling Point

Indexing Title: RAMOSA’S MAR [15-05]
MAR Title: Reaching the Boiling Point
Date of Medical Observation: May 2015
Tag:   Dealing with difficult patients effectively
Category:  Professional/Ethical, Stimulus


I was on duty at the emergency room when a 16-year-old male arrived for medico-legal consult. He was accompanied by his father and another man. A neighbor allegedly punched the patient, hitting the side of his head and neck. Routinely, I stood up and examined the patient. The patient only complained of minimal pain on the affected area and had no headache or vomiting. Simply put, the patient had no external signs of physical injury. As I explained these to the patient and his father, the other man who accompanied them interrupted me and asked in a condescending tone “Hindi ba dapat magpa-CT Scan diyan?!” (Shouldn’t a CT Scan be done?!) I was already annoyed by his belligerent demeanor but I again explained the physical findings and said that there was no need for it. “Hindi eh! Paano ka nakakasiguro?! Dapat masulat diyan na hindi ninyo kaya tingnan pasyente.” (No! It should be written that you can’t handle the patient.) Once again, I re-explained the physical findings to him. However, he kept on insisting that we write in the medical certificate what he wanted. Again, I had to re-explain everything to him. This happened repeatedly and for each exchange, his voice would get higher. I was already irritated and was already losing my temper. The medical interns who were on duty with me were also trying to talk some sense into him. He then said “Yan na nga ba sinasabi ko eh! Pagka mahirap kasi pasyente, wala kayong pakialam. Wala naman kayong ginawa!” (That’s what I’m saying! If the patient is poor, you don’t care. You didn’t even do anything!) At that point, I was already mad. He kept on ranting but I remained silent from then on. Thankfully, my immediate senior took over and clarified everything to him. However, he still wouldn’t give up. Eventually, he had no choice but to accept the medical certificate we made. After receiving it, they immediately left.

INSIGHT: (Physical, Psychosocial, Professional/Ethical), (Discovery, Stimulus, Reinforcement)

At one point or another, we would encounter difficult patients who would challenge us and try to stretch our patience to its limit. My previous encounter was a prime example of such. I was already annoyed at him at the very start but I tried my best and still talked to him. In the end, I lost my temper and just couldn’t handle it anymore. I then opted to remain silent. I knew that if I talked back, he wouldn’t like what I would have to say and matters would get worse.

Being emotional, I admit that I still have difficulty controlling my temper and masking it. Having my senior take over, made me rethink. Years from now, I would be a senior. What if I encounter another difficult patient in the future? How would I handle the situation? I don’t think that remaining silent would be enough. I would have to learn how to handle such difficult patients.

I came across an article and found some useful tips in managing difficult patients:

1. Gain personal emotional control. Don’t react, be proactive, and know your triggers. Slow down your breathing, speak slowly and quietly, lower your tone, and think about your body language. When feeling frustrated or angry, try reciting to yourself a few times: “I’m alert, I’m alive and I feel good”. Although this may sound someone ridiculous it can be an effective technique in shifting your ‘flight or flight’ amygdala-mediated physiological response to a positive, calm and constructive state of mind.

2. Start with a good first impression. Smile, use an open posture, introduce yourself, extend your hand for a handshake, look patients in the eye for 3-5 seconds.

3. Help your patient get emotional control. Don’t argue (arguing will lead to a vicious cycle of attacks and counterattacks as described above). Patients want to feel heard, understood and validated. Say “I’m here to help you and hear you out”.

4. Effective empathetic listening.  Search for the patient’s agenda. Echo or paraphrase what the patient says, and acknowledge their feelings. Say “I can see you are frustrated”

ROJoson’s Notes (17feb19):

Physicians encounter such a situation every now and then – “difficult patients.”  They should learn how to handle the situation – control your emotion, act professional, ask for assistance if need be.

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