Work life in health care is filled with stress. There’s time stress, lack-of-sleep stress, role stress, and computer stress. One of the most challenging stresses for caregiver professions, though, is people stress.
Every student at her medical school interview will say she wants to be a doctor to help people. That remains true at some level for all doctors, but sometimes we have to help people who are trying to control or manipulate us, who are making demands on our limited time, who are being defensive or hostile, who don’t follow our good advice, or who don’t seem to care about us and our feelings. There’s no way to avoid these people, and it’s unprofessional to be rude or hostile or aggressive in return.
Ask the Right Question
So, what’s a healthier way to deal with unpleasant encounters? Several years ago at a Humanities in Medicine retreat, I wrote about this encounter. I was called to do a consult for a patient who was in isolation for MRSA. When I got to the floor and asked the nurse about the patient, she just rolled her eyes.
I pulled on my yellow isolation gown and then my blue gloves, left first, then right, always in the same order. The patient sat with arms crossed answering my questions with mono-syllables. I sat on the fake leather sofa across from him. Experience and intuition prompted me to ask him, “Do you know why you’re in isolation?” “No,” he said. “They told me I have MRSA, but I don’t know what that is.”
A Short Explanation
I launched into my well-practiced explanation. “Everyone has bacteria called Staph on their skin. Yours has just gotten resistant to certain antibiotics. It’s not causing you any harm right now, but we have to wear these gowns and gloves to make sure we don’t carry those bacteria to another patient who might be sicker than you. It’s important for you to know, though, in case you get a skin infection, the doctors will know which antibiotic to put you on.”
It took me less than 30 seconds to say all that, but when I left, his arms were unfolded. He was smiling as he said, “Thank you, doctor, for your time.”
Take Time to Save Time
In the years since I started medical school, I have learned not to run away from these encounters. I have learned the value of remaining in the room and remaining present even if my patient is crying or visibly angry. A calm demeanor and true deep listening are comforting. They will often defuse anger, especially if the anger is over an unmet need which you can provide in just a few seconds. There are some corollaries to this which can make life much easier.
- Taking time to develop trust and rapport leads to much less time needed at future encounters.
- Changing how you react and respond internally changes the external reality for the better. I know it sounds somewhat metaphysical, but I’ve observed it again and again. Maybe it’s really just human nature. Think of the pesky little brother. Once he stops getting the response he wants from his sisters, he stops pestering them. Once you stop having buttons to push, people stop pushing them.
- Learning to listen before you speak can save time as well. I admit that it’s my nature to be patient and tolerant, but even impatient people can take the few seconds that will save them long minutes in the future. Patients will be able to tell that you are making an effort to slow down and explain things. They will appreciate it.
Developing Equanimity
I prefer not to label patients “difficult” if I can help it, since it’s often a condition which is temporary, not permanent. Mindfulness is just one of the tools I use to help deal with these potentially unpleasant encounters, but it’s probably my most powerful one. That’s why this post is subtitled “Simple But Not Easy.” Developing the formal and informal habits of mindfulness takes some training and practice, but the time spent is well worth it, and the pay off is not just in patient encounters. Having more equanimity helps a lot when dealing with coworkers, too. That’s a topic for a future blog post.
What skills and tools have you developed for dealing with people stress? Please share them below in the comments section. I’d love to hear from you.
Wonderful blog Debbie! Good information!
Thanks for reading, Lynn!
So simple yes and not so easy. Ultimately it’s about being able to step outside of your self and be fully present for the patient! Have you ever heard of any “tricks” to resuming full presence when one is in the heat of a clinical encounter? ?
Yes, you told me about the trick of keeping a worry stone in a pocket as a reminder to breathe and listen instead of talking.
Very nicely stated Deb, and I love your blog.
I am dedicated to nurture a relatedness that embraces compassion, harmony, and contribution. This relatedness is not only outward toward others, but just as significantly to ourselves. Keeping it simple, though as you say not easy, I am fond of the simplicity of Miguel Ruiz and his four agreements, the first of which is to be impeccable with your word. As you have pointed out above, the importance of the PAUSE, to listen, learn, gain rapport, and discover what you need to share is so pivotal. Before reacting, whether it is to a patient or to our own thoughts, I like to consider whether that reaction is informed by what is true, useful, and kind. Particularly when dealing with others, can we pause long enough to discover something important to share and be impeccable with our word. Learning to pause, to just be present with the moment, and mindfully consider how best to share what we have to say, enriches our communication and nurtures the three other agreements of Ruiz as well, to not take anything personally, not make assumptions, and always do our best.
I hope that keeps things simple enough for know, and that you keep up the good work, Ken
Wow, Ken, thanks for the reminder about The Four Agreements by don Miguel Ruiz. I had read this some years ago. I’ll have to talk to you about doing a guest post! Here’s the link for the book if anyone else is interested: http://www.amazon.com/The-Four-Agreements-Practical-Personal-ebook/dp/B005BRS8Z6
Great blog, it is information I can certainly use and share with my co-workers.
Another trick if you would, comes to me from tonglen practice, to breathe into the patient’s suffering and breathe out a wish to contribute to its relief in some way.
Anyone use any brief prayers or rituals for centering or promoting presence prior to seeing patients?
Great post. I heard last year about a study in which medical students and residents were trained to be cued to presence by a momentary pause when their hand touched the doorknob of each patient’s room. Better for the patients but also better for the physicians… More empathy and less burnout after a few months. I think even when a patient is persistently difficult, mindful awareness of one’s own unpleasant feelings in the moment can help a lot as you point out – and on a really good (successful at the not easy) day so can practice of metta, or wishing loving-kindness towards the difficult person.
I agree. Ron Epstein at U. of Rochester has done some helpful research on using mindfulness, appreciative inquiry and reflective writing as tools to improve communication and reduce burnout.
Often a patient believes that his concerns are not validated, therefore he becomes “difficult.” Once we validate and accept his perceptions, the “difficult” goes away.
Nicely said, thank you.
I agree that having a calm demeanor and allowing the frustration/anger/fear to flow works best. Also connecting to the lessons from “The Four Agreements”, I always try to remember not to take it personally and that each person is doing the best that they can at the time. This helps me to be present in a nonjudgmental way.
I agree – simple but not easy.
I find success when I try to see the situation more holistically – what defines “difficult”? What is being gained – by the person defining difficult and by the patient who is defined? What negative emotion is being felt? How can I ease the pain – of the patient, the staff members – and yet remain whole and able to give fully? Trying to determine what potential barriers each member of the situation may have allows me to be able to see more objectively and minimize any barriers that I bring to the encounter.
I recently met Mary Catherine Beach, M.D., M.P.H., of Johns Hopkins University. She speaks powerfully of Relationship Centered Care. This idea takes patient-centered care a step further. When you see the “patient” as a person, someone worthy of, and in need of, a partner/guide in their wellness, your perspective changes. Instead of believing that you know what is best, and possibly being disturbed when the patient does not follow your directives, you learn about this person and how you can help them define and achieve their wellness goals. The relationship that is built – like you did by sitting and describing to this man – resulted in his anxiety being lessened and him welcoming you with trust.
Deborah,
Bravo! for writing this blog post on how to handle “difficult” people. From a patient’s perspective, (& a wife of a doctor, who uses medical lingo that I never understand & say, “Okay, please translate!) I think if doctors remember that they have this wealth of information & vocabulary that they use and the lay person doesn’t have any knowledge, or perhaps even worse, a little bit of knowledge. When someone is in a strange land, with others speaking an incomprehensible language, the fall back response is defensiveness. A smile and an explanation will always go a long way.
Hi Dr. Bayer, I believe in listening to those in crisis. Every morning, as a team leader, I would listen to the day shift and the night shift voice their complaints. They always seemed satisfied that I had solved their problem even though I had offered little more than my ear and my time. Patients and their families are the same. The few minutes we have to “bond” is critical to the relationship. Listen and listen well and hear what is bothering them. With family meetings, I have learned to let the families tell us what they know and this reveals much information and the people often answer their own questions. Listening is good for patients, family members and co-workers as well. Nice article, Bren
This is very much in keeping with our Serving Leader body of work…treating a person as a legitimate other with feelings, concerns and desires just as important as yours, and not an object or a nuisance, problem or distraction. I actually carry a “PAUSE” button around with me.
Thanks for sharing!
I hope you do not mind, but I shared this blog with our staff. We all have those clients who can be “difficult” and its a good reminder that a little time may help them not to be. Thank you!
Thanks, Georgette. Carol told me you were doing this. I’m honored.
Debbie, very nicely said! One maneuver that you practiced in your example is quite meaningful. By having sat down when talking to the patient has not only been shown to make the patient feel that you have been with them longer than if you stood but it also allows you to feel more comfortable and thereby have the opportunity to be more present for the patient.
Very timely, thoughtout, and thoughtful writings. Helpful to anyone who reads.
Thank you, Mat.
Thank you Dr Bayer for this invitation!
I work to empathize. I remind myself that there is a loss of control, perhaps fear or anxiety, there can be pain and discomfort … in healthcare we have our own spoken and written language. We must translate what we are saying and thinking to that patient. I try to place myself in the patient’s position and respond as I would like to be handled if I were that patient.
I received a refresher course on this almost 2 years ago now when my father was diagnosed with pancreatic cancer and my (at the time) 101 year old grandmother was GI bleeding. I was on the OTHER side of the chart … I waited for providers to come, while I understood the language and translated to my family … I learned a great deal in that role. While I think I am busy all day and I spend enough time with my patients … when you are the patient/family and you wait 6 hours for a 5 minute visit … it’s NOT enough!
Yes, sometimes increased empathy comes from having been in the patient or family role. I like your concept of being a translator. Being mindful of vocabulary is key to good communication.
“Once you stop having buttons to push, people stop pushing them.”
Thanks. I’m a poet who is newly involved in caring for someone with homecare needs. Metaphysically developed skills of relating do come into play.
So glad you found my blog. As a hospice physician, I care about burnout in all caregivers.