Fools, Fights and Foibles

Why have patients become angrier despite the rise in patient centricity?



April’s Fools Day. Before noon, a prank is played and when revealed the recipient is shouted at for falling for it – ‘April fool!’. After noon, however, the prankster becomes the token idiot. Different cultures have variations on this theme, but it more or less runs with the same underlying principle. It’s fine to highlight how gullible, vulnerable, perhaps easily duped someone can be. But time out. After that, making mischief for mischief’s sake, to keep being provocative, intolerant and shouting is, well, foolish.

Furious patients; frightened physicians

I’m concerned that the strive for patient empowerment is at the 12:01 timepoint. Increasingly, there are examples of people using ‘patient centricity’ as an opportunity to lambaste the medical support they receive or attack the HCPs trying to help them. The British Medical Association has a training course entitled; “How to manage angry patients”. Obviously, when a person is in pain they are scared, fragile, anxious; they are entrusting their wellbeing to another. But why the upswing in rage and fury? Even worse; why are we cross before walking into the doctor’s surgery, the emergency department or to a follow-up appointment. The time spent sharing stories so rapidly using social media has a dark side to it. On the one hand, we share experiences and generate insights rapidly to facilitate diagnostic decision-making and have a broader appreciation of treatment options. At the same time, we need to remember that being self-obsessed is natural but HCPs will have a greater collective practical experience of the practice of medicine that isn’t fingers typing a post on a thread or searching in Google, but actual hands-on dealing with the problem directly in front of them. Logically, therefore, this is not the moment to use anger as a method for collaboration. There are many examples of doctors missing things; 20 percent of all medical cases are described as ‘grey area’ where even the most proficient practitioner will struggle to draw the right medical conclusions and course of action. Sadly, there are also many examples of patient-rage – even pre-patient rage or post-patient disappointment manifesting as rage. Here are some examples garnered from medical colleagues and described by patients:

  • The patient mid-labor who turns the air blue with profanities, lashes out at the anaesthetist there to provide pain relief and the second the baby is delivered returns to a beatified, benevolent state.
     
  • The intoxicated patient; mind and reasoning distorted, convinced that they are not being properly cared for.
     
  • The patient who receives bad news from their physician and responds with blame, accusations or even tries to attack the HCP: I once asked a cancer nurse why it was that a certain doctor always brought two nurses into a consultation (the patient had posted on social media that they recognized a pattern of ‘no-nurse - good results’, ‘nurse present - bad results’) and the nurse told me that it was likely less to do with worrying that the patient needed more time after the consultation to discuss things with the nurse and most probably to intercept if the reaction was a little rough.
     
  • The patient who refuses to believe the medical advice received and will keep seeking different opinions or disregard the test results in front of them. The flamboyance of ‘I discharged myself; I felt fine, the HCPs were all patronizing me’ is an increasingly common adversarial avenue taken by the self-informed patient.
     
  • The patient who has gone past ‘well-informed’ to ‘well-armed’ – ready to unleash a war on the doctor who is just trying to do their job. This is another rising problem where, socially goading is like the playground antics of the bystanders to an altercation who yell ‘fight, fight…’ to be excited or have their cynicism rewarded from a safe distance. I recently challenged a friend of mine whose daughter had been involved in an accident and had swollen fingers, to accurately determine a fracture at the time in the Emergency Department. She had been treated with pain medication and as the injury wasn’t life-threatening, within 3 weeks had received a follow-up letter from the consultant wanting to check for fractures now that the swelling had subsided. My reaction to this was; how fortunate and how wise that a system triages medical catastrophe whilst dealing with minor injuries but then competently follows up – for free. My friend’s response however was, “if there was a break and they missed it then I’m going to go crazy with them…?”

Why would we? When has anger ever achieved a better service in any sector? Of course, medicine is different, and thank goodness the HCPs are able to appreciate fear that manifests as anger. But that doesn’t mean we should encourage anger as a productive solution.

Bad news: bad patients?

In November, I was privileged to be part of a faculty at a meeting designed to address the needs of people with cancer. I was running a series of workshops about the online lives of patients – how they retrieve, review and use the information they find on the internet and in patient communities to fuel their interactions with their HCPs and with each other. We are awash with health anecdotes in this era of socialized health – every 9 seconds in a community, for example, there is a discussion about cancer and there are more than 20 million websites about cancer. But anecdotes aren’t scientific data. Nor is data an attack. In parallel, other workshops focused on how doctors communicate bad news. The correlation – patients bolstered by anecdotes react to data presented by doctors and then may misinterpret the exchange as a call to arms. This was reinforced by a Shapira et al’s 2016 study describing that although doctors try to behave empathically in difficult situations and often do so, they often felt overwhelmed, frustrated and resort ‘to more reductive behaviors that [did] not match the needs of the patient.’ A similar study by Igior et al in 2015 also describes the impact of this miscommunication as segmenting patients into the following angry ‘types’ according to how much ‘truth’ was perceived to be needed or transacted:

  • 28% of participants preferred the full truth to be told;
     
  • 36% preferred the truth to be told but understood that the physician would inform the family first;
     
  • 13% did not think that telling the full truth is best for patients;
     
  • 23% understood that the full truth would be told in some cases and not in others, depending on the physician's perception of the situation.

What is clear is that patient-centricity is a multi-faceted endeavor that requires the hot-headed urgency of the patient’s needs to be met by the cool-headed logic of the medical practitioner. Igier et al describe this as 'mapping patient’s positions regarding breaking bad news’ that must take into account five factors:

  • The emergency of the situation/severity of the disease (severe but not lethal, extremely severe and possibly lethal, or incurable)
     
  • The patient's wishes (insists on knowing the full truth vs. does not insist)
     
  • The level of social support during hospitalization
     
  • The patient's psychological robustness
     
  • The physician's decision about communicating bad news (tell the patient that the illness is not severe and minimize the severity of the illness when talking to the patient's relatives, tell the full truth to his/her relatives, or tell the full truth to both the elderly patient and his/her relatives).

Is it before noon or is it after noon? Whatever the hands on the clock say, anger can only ever be an April fool. 


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