Friday, February 10, 2006

Friday Intern Topic of the Day IV: Say you Hate your patient?

As a follow up to the previous post I would like to throw out this as a topic of conversation.

My wife, who is an attorney, recently had to excuse herself from a case after finding out that one of the clients involved is a relative of ours. The law, fearing this could lead to bias, demands that lawyers disclose such information to their clients and, when possible, excuse themselves from the case when such a situation develops.

I often wondered what goes through the mind of Israeli doctors when they are forced to attempt to save the life of a suicide bomber after he has just murdered so many other innocent lives. It happened to this doctor in Iraq and he describes the anger that was slowly building within him:
“The more of the story I heard, the more angry I got,” he said. “But I was still able to do my job and realized I am a professional and I’m going to take care of this guy.
It always ends that way doesn't it? "I'm a professional. I did my job". Well, but all professionals are also human beings who have feelings and exhibit anger and resentment. Can one really, honestly, say that those feelings will have no consequence on the type of care your patient recieves?

In other words, should physicians be forced to dislose when they feel anger towards their patients. And...should they then be forced to sign off the case? After all, we don't even trust lawyers when it comes to simple money matters. Should we trust physicians when it comes to human life?


Blogger The Squire said...

Far be it for me, as a lowly premed, to say anything authoritative on the subject, but my understanding is that recusing one's self from treating a patient would be permissible if and only if a physician of equal or greater skill were present/readily available to step in. Medicine isn't like law - disease and trauma don't wait for another trained professional to wander by. If a patient were bleeding to death on a table, and the nearest doctor was hours away, then the "I'm a professional and I do my job" aspect has to come back into play.

10:46 PM  
Blogger Echo Mouse said...

I don't think so. You're human beings who happen to be doctors. You're allowed to be angry. The problem would be in denying the anger. Instead of doing that, work it out by working furiously to save the patient. Use your skill. That lets them live to suffer the consequences of their actions anyway ;)

It's the same everywhere. The business world for example. Some people who are mistreated at work might deliberately sabotage the company etc. But most remain professional and push on. Which is what I did. But that made me sick so I'm not sure that's the best thing. When it comes to business, if I had to do it again, I would quit flat out if things were bad. But as a doctor, the person is just a patient. Just look at them as a car engine or something and pretend you're a mechanic. Remove the emotion if you have to just to get through it. But I don't think you have to report your state of emotion. Imagine if all professionals had to do that? That's just shooting yourself in the foot I think.

4:05 AM  
Blogger Ali said...

Well said, Squire.

2:16 PM  
Anonymous Seasoned Crusty said...

I have been an RN for 13 years. I travel a lot, and have been exposed to many different types of patients.
There are times when I can barely stand to be around some patients. This is due to knowing what these people are like out in the 'real world'. There are plenty of people in this country that act like jerks outside the hospital, and when they are admitted, they expect lots of sympathy from the nurses. The way I have learned to cope with these situations is exactly what echo mouse said to do. I look at them as an object that requires an expertise I have, including the sympathy, which is part of my job description.
I can behave as though I am sympathetic, while I do my treatments, etc., but I really don't give a hoot. I'm detached from the entire situation. Granted, it's not satisfying, to have to care for those patients, but there are always some of those around.
And I still provide top notch care, just for my own conscience.
I have been known to crack jokes later with my colleagues, about these troublesome patients. That helps to take the tension off.

10:33 PM  
Blogger keagirl said...

It's hard to recuse yourself in an emergency situation. One of my anesthesiologist colleague who is jewish was telling me about the time he had to intubate a gun-shot wound patient covered with swastika tattoos...As a physician, you have a moral obligation to take care of that patient, no matter how distasteful that may seem.

9:09 PM  
Anonymous Anonymous said...

Yes, it really is as simple as "I'm a professional" and that's that. We're allowed to get angry, sad, upset or feel anything else. We're not allowed to allow our feelings to change how we treat a patient (even if the patient is not a nice person).

As a Jewish hospitalist, I have treated patients with swastica tattos while they were awake. Patients and their families have called me names I'd rather not repeatbeen called names that are not appropriate to repeat.

You still act like a doctor. Personally, I think God judges,w hile we diagnose and treat and this helps me get through the day (well, that and the many pleasant patients that I have the honor/pleasure to help treat).

Giving anything less that the best care possible is simply wrong; it's a violation of everything medicine stands for.

10:46 AM  
Blogger Internal Medicine Doctor said...

dear jewish hospitalist:

Althought I agree with much of what you said and...I'm jewish and...considering becoming a hospitalist ;-} I find that it is rather strange that we are expected to overlook everything and provide the best possible care. What my main concern is as such:

My wife had to resign the case simply because she was related to the client and she had no intentions of providing less than the best care. BUT, the law ASSUMES that this is unlikely to result since bias inevitably occurs, on a concious or subconcious manner, and demands you excuse yourself.

Why do we assume anything less of physicians?

6:51 AM  
Blogger red fish said...

I think it all comes down to the legal system. If someone loses a case, they can appeal on the grounds that their attorney had bias due to being related to someone involved. They may or may not win, but it could be a basis for an appeal.

I don't think a Nazi would have a good malpractice case just based on the feelings of the physician. It is not like there are many physicians that are Nazi sympathizers who would have been a better alternative.

I have seen several instances where physicians, nurses, phlebotomists, respiratory therapists, radiology techs, etc. have been ANGRY with patients but I have never seen less than the best care given. It is how we are trained, and how we perform our jobs.

The conversation in the break room may reflect our disgust with the Nazis, homicidal drunk drivers, or just plain homicidal whackos, but it is not reflected in our care.

Most hospitals I've worked in had a policy for professionals to recuse themselves. For instance, a nurse who is a Jehovah's Witness can elect to not transfuse blood. However, the policy always says that in emergencies patient care must always be a priority over our convictions. And again, I can't imagine a nurse recusing herself because a drunk driver angers her. Who doesn't he/she anger?

On the other hand, had the physician in Iraq had an Arab collegue handy to take over, no one would have blamed him for asking his collegue to take over.

9:20 AM  
Anonymous Kel said...

I think I echo others sentiments where I flip on the "professional" switch. That doesn't mean I can't complain about it later.

2:15 PM  
Blogger Kim said...

There have been times when I have asked a nurse colleague to step in when I have reached a point that I no longer feel my presence is "theraputic".

It may be due to anger (I very rarely get angry at my patients), the feeling that I am being manipulated by a patient or just that the feeling that a patient needs a different type of personality than mine.

I have been asked on occasion by my colleagues to do the same for them.

But in my case, it is easier, because a nurse is available.

The one time I had to put it all aside and do my job, complete with compassion, was when I had to do a blood alcohol on the man who had just beaten his girlfriend to death and I had been there for the pronouncement.

I treated him just as I would have treated any other patient. It wasn't hard....I was numb.

7:47 PM  
Blogger shadowfax said...

It depends on the setting and the illness of the patient. In an emergency, the patient is at their most vulnerable and your duty to the patient is at its highest. I have had many times to 'suck it up' and take care of someone I really personally disliked because I was the only doc on duty in the ED. Occasionally, when things spiral out of control with a given patient (not to be judgemental, but this is more common with Axis II disorders), I will ask one of my partners to take over the case, if we are in double coverage. But we don't take care of saints, we take care of human beings, and there are a lot of them that we don't like or may disapprove of.

OTOH, I think that in a clinic setting, there is less of a problem with selecting a patient population that is 'in tune' with your preferences. I have heard of private practice docs declining to be the primary care providers for patients who wouldn't vaccinate their kids, stop smoking, or sign a malpractice reform petition. Presuming that these individuals have access to care elsewhere, I am more sympathetic to these docs, though there is a tough ethical slippery slope to be aware of.

11:45 AM  
Anonymous My Blog said...

The law, fearing this could lead to bias, demands that lawyers
disclose such information to their clients and, when possible,
excuse themselves from the case when such a situation develops.

7:04 AM  

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