Treating the difficult patient can be a long journey

Ten miles. That’s how far Mr. P had walked from a nursing facility to our emergency department (ED) one day after discharge from the hospital. A month earlier, he had been in that same ED, septic. Short and rotund, his scrotum was so swollen and erythematous it looked like someone colored a grapefruit with a red Sharpie. He was suffering from Fournier’s gangrene and needed emergent surgical debridement. But, as would become his daily routine over the next month, Mr. P politely declined.

He would dramatically clasp his hands in prayer and beg, “Please doctor, please, no surgery.” I patiently explained the nature of the infection and the need for surgical debridement. But he insisted that although antibiotics may not work for Mr. Fournier, they would certainly work in his case. The crepitus—that’s always been there, he explained. Sure, it’s a bit swollen, but perhaps he slept on it wrong. It’ll improve by morning.

Not a blood draw went by without discussion nor a dressing changed without debate. I explained and rationalized the need for surgery, used pediatric tubes for blood draws, and found him a room with a north-facing window to make him more comfortable. I involved social work, psychology, psychiatry, and acupuncture in his care plan, as well as the counsel of three chaplains, as he was non-denominational.

Equip yourself with understanding

Increasingly, medical schools are emphasizing bedside manner. Courses on breaking the news of a fatal illness, discussing end-of-life care, and patient interaction are now routine parts of surgical education. Mock encounters with actor-patients are evaluated in national licensing exams. The art of patient care is being transformed into a science. But just as in surgery, knowledge does not always translate to skill. Effective management of patients, especially the difficult ones, requires repetition, dedication, and an understanding of human nature. Some patients may be difficult because they are scared, others may feel helpless, and some simply do not comprehend their illness. I tried to allay Mr. P’s fears by empowering him with options and explaining his condition in as many ways as possible.

Surgeons spend more than a decade in postgraduate education and training; the hours are grueling and the stakes are high. Treating a difficult patient can seem like a daunting task. And yet, if we allow ourselves, there is a joy in doing it well—not unlike the joy of tackling an abdomen wrought with adhesions or dissecting out a difficult tumor.

Taking care of a Mr. P at times called for elegant and careful maneuvering—at others, brute force. After two trips to the operating room for debridement and a prolonged hospital stay, Mr. P finally got better.

In successfully caring for a difficult patient, the surgeon should take the time to pause and appreciate the accomplishment. I know the thought of Mr. P strolling into the ED with a roll of gauze spilling out of his scrotal wound and asking to see Dr. Kaplan certainly put a grin on my face.


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