Maria Yang, MD

You’re taking your medications every day, right?” the doctor asked.

“Yeah, yeah,” he said.

“Good. Here are prescriptions with three refills each.”

“What’s the green pill for again?”

“The green pill?”

“Yeah, the green pill, the one kind of shaped like an egg?”

“Uh, I’m not sure. You can ask the pharmacist when you pick up your medications. But if you’re taking all of them, then you’re doing the right thing.”

“Okay, doc. Thanks.”

---

When he got home from the pharmacy, he placed the white paper bag on the table. Dropping himself into a chair, he tore through the stapled top of the bag and pulled out the plastic orange vials. He arranged them in a row on the table.

“One, two, three, four…” he counted as he tapped the white caps. “… ten, and eleven.”

Glancing up, he reached for the shallow candy dish near the middle of the table. A few colored specks were caught within the spaces created by the etchings in the glass.

His eyes passed over the labels on the vials:

• Take one tablet by mouth twice daily.
• Take one tablet by mouth every day.
• Take one tablet by mouth every night.
• Take…

He quickly removed the twist-off caps. His fingers fished out the wads of cotton, which he left on the table. He poured all the pills into the candy dish. His right index finger stirred them into a colorful mixture.

---

Before going to bed that night, he picked up his toothbrush. His eyebrows suddenly lifted.

“Meds,” he mumbled.

He carried a drinking glass from the bathroom out to the kitchen. He scooped up a handful of medications and examined his hand to make sure he got at least one of every color and shape. He tossed them into his mouth and chased them down with water from the glass.

---

“You take your medications every day, right?” the doctor asked him the next month.

“Yeah, of course,” he said.

Father and daughter sat in vinyl-covered chairs that were bolted to the floor. Few other people sat in the waiting room. The heavy door of the psychiatric emergency room was closed and locked.

“She’ll be fine. We’ll be fine,” Father said, his elbows resting on his knees. He examined the intersection of the lines where the floor tiles met. The wedding band on his finger was loose.

“Yeah. At least you’re not actually related to her,” Daughter murmured, picking at a loose thread in a seam of her jacket.

Father turned his head and looked at Daughter. He leaned back and put his arm around her. She turned away for a few moments, though eventually rested her head against his arm.

Which patient would you rather work with?

Patient 1:

This patient is not doing anything to take care of her health. She never listens to my recommendations. If she would take medications as directed, she’d feel better. She doesn’t care about her medical problems. She’s not even trying. If she keeps this up, she’s going to die. Plus, she’s so demanding. She’s a piece of work.

Patient 2:

Things seem to get in the way of this patient’s ability to take care of her health. I wonder if she understands my recommendations. She is trying her best to take her medications as directed. What else can I do to help her learn about her medical issues? There might be a lot of other things going on that worry her more than her medical problems. I wonder if she knows the consequences of her choices. She is skilled at advocating for herself. I feel frustrated when I see her, but let’s see what she will teach me.

---

They are the same patient.

Now: Do you want to be “right”? Or do you want to be effective?

It was close to 6pm and, as usual, the uptown F train was crowded. People on the platform glanced at the subway as it pulled into the station. One of the cars had plenty of standing room. When the doors opened, several people rushed out. Some people walked in, then walked right back out again.

Two ladies rushed through the turnstiles and, upon hearing the announcement, “Stand clear of the closing doors, please,” they dashed into the car. They smiled at each other in congratulations and then looked around.

Seated near the end of the car was a man who appeared to be asleep. His thin frame was lost in two dirty jackets and baggy jeans with tattered hems and a hole in the crotch. Bits of food were caught in his scraggly beard. His legs were splayed out in front of him and his hands, soiled with dirt, were resting on his lap. The odors of sweet alcohol and fetid sweat emanated from him.

New passengers looked at him, their noses crinkled. Saying nothing, they moved as far as they could to the other end of the car. Often this meant taking a mere two steps away.

One of the two ladies was wearing a golden mink coat. An Artsy GM Louis Vuitton bag hung from her wrist and strappy heels that bore the intersecting letters of Chanel were on her feet. She turned to her companion, clad in a white Marc Jacobs Balmacaan raincoat and Jimmy Choo Cosmic platform shoes, and waved her hand in front of her nose.

“It smells terrible in here!” Mink Coat exclaimed, shaking her head. Her dark tresses shifted on her shoulders. “He smells so bad!”

The train rattled as it entered the dark tunnel. A few people turned the pages of their magazines.

Raincoat glanced at the man and stuck out her tongue in disgust. “I know. I don’t think I can stay in this car!”

A man at the other end of the car sneezed. The subway lurched to the left.

“Let’s switch cars at the next stop,” Mink Coat suggested. “It’s hard for me to breathe.”

A woman looked up from her Kindle and glanced at the two ladies. The man next to her suddenly snapped his eyes open when he realized that he was listing to the right.

“That’s a good idea,” Raincoat said, vigorously nodding her head. “He smells worse than trash. I wish the train would hurry up.”

The young man leaning against the door marked with the words “Do not lean on door” plucked his mp3 player out of his pocket and glanced at the screen.

“This is 42nd Street, Bryant Park,” the automated voice announced as the subway burst out of the darkness into the illuminated station. The subway suddenly decelerated. Someone mumbled apologies as he inadvertently bumped into his neighbor.

“Thank God,” Mink Coat said, getting as close to the door as she could. The sleeping man quietly burped.

“Gross,” Raincoat mumbled.

“Do you want to go left or right?” Mink Coat said as the subway came to a halt.

“It doesn’t matter. Just get us away from the stink!”

When the doors slid open, the two Coats stepped out quickly, sighing loudly. The sleeping man shifted in his seat, his chin dropping to chest.

“Stand clear of the closing doors, please.”

Kevin, MD, posted a commentary about encounters with “difficult patients”. He correctly notes that physicians themselves contribute to these interactions. To reduce the likelihood of these encounters, he suggests that physicians would benefit from more training in “psychosocial skills”.

Kudos to Kevin for adjusting his own language by the second sentence of his post: He makes the distinction between difficult patient and difficult encounter.

A vital step in decreasing the likelihood of difficult encounters is recognizing the language we use for these events. The words we use affect our perceptions. Compare:

• “That’s the liver guy. He’s a complete train wreck!” versus
• “That man has liver cancer. He has an infection in his blood, needs a mechanical ventilator to breathe, and now he might be having a heart attack.”

The phrase “difficult patient” automatically suggests that the patient alone is responsible for any conflicts or problems during the appointment. Uncomfortable emotions, like helplessness or anger, that the physician may feel are attributed solely to the patient. If only the patient would change, then everything would be fine!

As a result, the doctor may then feel absolved of any responsibility to alter his own behavior to improve the interaction. The assumption is that the physician is right and the patient is wrong.

If we instead label the interaction—rather than a single person—as difficult, this can help both patient and physician to step back, assess what each is contributing to the situation, and work together to resolve it. The assumptions doctors and patients have about each other are often inaccurate and impede cooperation. Using the time to understand, rather than blame, the other person can decrease the likelihood of these difficult interactions.

Doctors, like most people, often assign adjectives to patients because it can be hard to identify and then acknowledge emotions. It is much easier to say, “She is such a difficult patient! She is never happy with her care!” than to say, “I feel angry and helpless when I see her because it seems like nothing improves her symptoms!” Leaving out the subjective “I” gives the illusion of objectivity and professionalism.

Physicians are only human. Sometimes we have bad days; sometimes our “psychosocial skills” aren’t well developed. However, we must do our best to engage and build rapport with patients to provide optimal care. Watching what we say and choosing our words with care is a valuable first step.