In our March 2018 issue, ASH Clinical News Associate Editor Alice Ma, MD, recounted an unnerving experience with a threatening patient in “Not What I Signed up For.” Unfortunately, as Dr. Ma noted in her editorial, the occurrence of violence against health-care workers is rising, and it can be challenging to keep patients and providers safe while addressing the concerns of those with specialized health-care needs. Below, two readers react to the editorial and share their own experiences treating potentially violent patients.
I read Dr. Ma’s editorial and, having worked in North Carolina for 15 years, my first thought was, “Is Dr. Ma now treating sickle cell disease and some of my past patients?”
I have had similar experiences with a couple of congenitally and chronically ill patients who – after years of being in my care and even more years of dealing with psychosocial issues – decided to find a scapegoat in their longitudinal medical team. I want to highlight the psychosocial components of these patients’ lives, because I believe that these factors greatly impact their clinical care. Each patient is dealing with poverty, depression, poor coping mechanisms, lack of social support, perpetual stigmatization, and undiagnosed or mismanaged neurocognitive deficits.
I agree that ethics, safety, and patient representatives all need to be involved and taken into consideration to ensure the safety of other patients and staff during these situations. At the same time, what really keeps me up at night is the reality that, while we are providing the best and most comprehensive medical care for these unfortunate patients, some people feel that their needs are unmet, even when multidisciplinary teams are available at most outpatient clinics. We the providers (including the care managers, social workers, pain specialists, and psychiatrists on these teams) can sometimes feel impotent to help them.
—Laura M. De Castro, MD, MHSc
University of Pittsburgh Medical Center
In our particular practices, where we encounter difficult medical situations – sometimes resulting in the death of a patient despite what we believe to be our best efforts – it is imperative to act with honesty and to serve as fervent advocates for our most fragile patients and their families.
While I, too, have experienced a small share of threatening situations from patient families, I have found that, in most instances, the best defense is not a strong offense. Rather, true engagement with the individual and a show of sincerity have gone further than defensive tactics.
Of course, doing so might require us to cross an emotional boundary that we raise to keep ourselves both objective and removed from the trying situation (perhaps that’s another defense mechanism?).
I learned this while working with two families during my fellowship, one with a child who had Langerhans cell histiocytosis and one with a child with systemic lupus erythematosus. The former succumbed to her condition, while the latter is a high school student interested in robotics and dance. I have kept close ties with both families and speak to them every few months. While working with these families, there were many moments of angry outbursts, disillusionment, and blame that I chose to try to resolve or redirect.
I’m not saying this formula will work in every instance. However, I do know that we practice in an electronic health record–based world, where reimbursements are contingent on work Relative Value Units. The art of medicine and the healing touch of a physician’s mere presence are diluted by our scarce time and the cursory nature of our interactions.
I wonder if the problem arises from a perception of a lack of investment? Thus, does the solution lie in trying to maximize the value of our short interactions?
The editorial was a good read that didn’t simply raise questions about the safety of health-care providers in the current political climate, but also triggered introspection into what a valuable interaction should feel like both to the patient and the physician.
—Sidharth Mahapatra, MD, PhD
University of Nebraska Medical Center