Are We Biased Against “Difficult” Patients?
Author: Joan Naidorf, DO
I speak to physicians and med students about interactions with patients and their families they label as “difficult.” I speed through one very important aspect of the issue that I would like to pause and spotlight.
Physicians create an impossibly high standard for what they consider “good” patients and label those who fall short as “difficult.” We appreciate mature and logical people who will obediently comply. Good patients follow instructions, take their medications, and take responsibility for themselves. Physicians want patients who think, look, and act the way that the physician does.
This part is where things get sticky. In the history of organized medicine, distinguished white men presided over the education of medical students (also male) and set the high expectations of how their patients should behave.
The paternalistic model for the doctor-patient relationship ruled the day. An unrealistic expectation was placed on shared language and cultural values for setting and implementing the plan for treatment. In other words, physicians traditionally treated their patients and made recommendations based on the physician’s value and culture, not the patient’s.
In the way that the father of decades past purported to know what is best for his children, this old-fashioned model for the doctor-patient relationship placed the physician in the role of making key decisions and knowing all. In today’s world, when the economic and cultural divide between physicians and their patients is so wide, how can those decisions be correct or include what the patient and the family actually want? Traditions and cultures are bound to set up antagonism and conflict.
One obvious example is the way the historically male-dominated physician fields have diagnosed and treated their female patients. The dramatic responses of women were often labelled as hysteria. The symptoms and illnesses of women were attributed to the presence of the womb and dismissed as over-reactions. (The start of medical gaslighting.)
We can see the effect of stigmatizing language in the medical record and societal narrative. Physicians who did not understand or disapproved of the way their female patients reacted when they were ill, likely thought they were “difficult.”
The sense of misunderstanding and disdain surely extends to black people, queer people, and those who came from cultural traditions that differ from the physician. People who look a different way, dress a different way, practice alternative customs, are routinely perceived as non-compliant and oppositional.
Physicians cloak their feelings of frustration, intolerance, and misunderstanding of certain patients behind a polite label of “difficult.” This word feels acceptable for professionals who do not view themselves as explicitly sexist, racist. or biased toward their patients. I think that medical professionals are fooling themselves. As humans raised and trained in a culture of both explicit and implicit bias, physicians, and I am one of them, cannot help but to have picked up quite a few of these thoughts.
Enter real life patients in the 21 st century. They speak hundreds of different languages and come in every color of the rainbow. They practice many different religions with non-traditional, non-Western healing practices and beliefs. They have unique tattoos, piercings, hair styles, and gender expression. They do not have homes or transportation or resources.
The need to act quickly in an emergency medical situation necessitates making some arbitrary inferences that are made based on limited information. We read old charts and take report from the prior shift of doctors and nurses. Assumptions are made and not infrequently, they are wrong.
Language used in the chart to convey information to the next shift such as “hysterical,” “non-compliant” or “drug-seeking” can prejudice all the care that follows. Because of confirmation and anchoring bias, we tend to look for evidence of what we already believe to be true. What if the initial assessment was wrong? Do those assumptions contain racist, sexist, and cultural bias?
For those of us working in the emergency department, we might get only one chance to address the issues, educate, reassure, and encourage. Many patients will still make choices that we disagree with. They are unable or unwilling to follow the plan. Radical acceptance of all our patients is a goal I write about and discuss as a speaker.
The differences we have with our patients need not be interpreted as difficulties. Our challenge is to listen to our patients and believe their interpretations. We can present an assessment and plan to them without judgement and condescension. There will be some common ground to explore if we only reach out to find it.
About the author: Joan Naidorf, DO, is an emergency physician, author, and speaker based in Alexandria, VA. She is the author of the book “Changing How We Think about Difficult Patients: A Guide for Physicians and Healthcare Professionals”. She also enjoys reading, reviewing, traveling, tennis, parenting, and being ruled by Dolly the poodle. (Website: https://www.drjoannaidorf.com/ , Twitter: @JoanNaidorf)
