Treating the difficult patient may require stepping out of your comfort zone

It is impossible to avoid difficult patients while in surgical training. Surgeons offer a unique set of services that can heal or harm, and this inherent dichotomy lends itself to difficult situations. Every surgeon has experienced the hardship of dealing with patients who carry heavy emotional baggage, families that impede rather than assist in the care plan, or patients or family members who have earned online medical degrees; each of these presents unique challenges for the surgeon. Although these situations are inconvenient, I believe that the most difficult patients to treat are the ones who take you out of your comfort zone and run counter to your core beliefs.

Recently, I was called to see a 24-year-old female for appendicitis—a routine general surgery consult. Just before I arrived at her bedside, the emergency room physicians told her she was pregnant. She was currently in the process of a divorce, and this news was a real shock to the patient and her family.

When I arrived, everyone was on the verge of hysteria, and there was not a dry eye in the room. A long conversation ensued, but the major finding from the encounter was that her abdominal exam was very worrisome. Even the slightest touch seemed to cause her agonizing pain. Unfortunately, all objective testing, including magnetic resonance imaging, was equivocal in identifying acute appendicitis. Fixated on the patient’s excruciating pain, the family members were forcefully advocating immediate surgical intervention.

Serve as a trusted partner

After some effort, I was able to get the family out of the room and speak with my patient alone. I explained to her the risks of surgery in early pregnancy and the very real possibility of a spontaneous abortion. It was at this point in the conversation that her demeanor changed completely and in a calm, clear voice she said, “I do not plan on having this baby anyway. I think you should take me to surgery and take care of my appendix.”

As surgeons, we know that once the patient is asleep and the drapes go up, we have full control, but until that moment, we are partners in a complex decision-making process. As trusted collaborators, it is imperative that we attempt to understand or, at the very least, acknowledge the context in which our patients are making these decisions. As our busy, overbooked schedules force us to spend less time with patients, it is important to understand that communication is key in resolving a difficult situation. As you start to understand the patient’s perspective, it becomes easier to connect and resolve conflict. Many times the right answer has nothing to do with a knife.

I started talking to my young patient about her new pregnancy, her divorce, her young daughter, and her overbearing mother. I attempted to see the world from her perspective. As she engrossed herself in the conversation, she did not seem to be bothered by the palpation of the right lower quadrant.


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