Reprise on the Difficult Patient

  February 28, 2009

            The tacit Coda to our discussion of Difficult Patients[1] (and students) who like injured animals can bite, is that successful mentoring is so rewarding. This mentoring, or eldering, sometimes falls somewhere between housebreaking and soul catching, when by not responding in kind to anger or fear expressed as anxiety, we can open a still point, or door for them to grow by example.

            There is nothing that would suggest to me that the persons selected for medical school are any more ethical or empathic than their peers. Any intelligent sociopath can write a convincing admission letter; the job of the medical school is not so much to “choose” more empathic, ethical persons for their programs as it is to facilitate the development of ethical empathic behavior in the medical students who have arrived at their doorstep. We should strive for 100% retention of Osteopathic students. We should not expect less of them because they are disabled, troubled, women, short, personality disordered or religiously challenged, as they attempt to evolve, ultimately applying Osteopathic principles to the particulars of their professional lives.

            Difficult patients (and students) can be voracious in their consumption of time and energy. In the absence of a medical emergency, sometimes the best course of action is for the physician/teacher to take a “time out”, rather than responding to anger or anxiety with aggravation.[2] Full unraveling of a Gordian Knot rarely occurs as the result of one interaction; it is the perception of an external core stability [3] that allows them to express themselves in what is perceived as a relatively safe microenvironment.

            What medical schools are good at is accepting students who are both intelligent and have a high degree of personal discipline. Academics and administrators who aspire to a testing format that after years of refinement would exactly distribute a class of 1000 Osteopathic students into a perfect bell shaped curve distribution miss the point that a group of college graduates that cluster in the top 10-15% academically can only fall into a standard bell curve distribution with average teaching.

[1] Barsky, AJ, Saintfort, Ralph,, Nonspecific Medication side effects and the Nocebo phenomenon, JAMA, Feb 6, 2002,V287#5,p 622-27. Ambady N,, Surgeon’s tone of voice: a clue to malpractice history, Surgery, 2002 Jul;132:5-9.
[2] Larson EB, Yao, Xin, Clinical empathy as emotional labor on the patient-physician relationship, JAMA, March 2,2005,V293#9,p 1100-05.
[3] Brown, Walter, Harnessing the Placebo Effect, Hospital Practice, July 15,1998, p 107-16.