Amanda: Hi guys. Welcome back to the podcast. I'm Amanda.
Laura: I'm Laura.
Kendra: and I'm Kendra.
Amanda: Before we get started today, we have another review of our podcast and this one's very timely and I'll tell you why. It says, “PMG. This is your podcast. It's from Moxi and Ollie. And it says, thank you for all your insight, honesty and humor. Listening to this podcast is a great way to start my day. It helps to get me in the right mindset, to enjoy my day and provide the kind of care I want to give, do yourself a favor and check out this podcast.” Thank you so much, Moxi and Ollie! And why that is so pertinent is because our next guest is Dr. Joan Naidorf. We just met her at a PMG conference. PMG for people that don't know is physician mom group. So Dr. Joan Naidorf joins us today to talk about difficult patients. We met her at the physician mom group conference in South Carolina, where she was lecturing on this topic. In fact, she's written a book, “Changing How We Think About Difficult Patients, a guide for physicians and healthcare professionals”. So we are so excited that she's joining us today.
Laura: Oh, I am so excited because especially for those of us who work in the emergency department, this sounds like excellent information that we can use. So would you mind just telling our audience a little bit about yourself, about your training and just tell us about yourself.
Dr Naidorf: Hi, I'm really glad to be here. And it was a pleasure meeting two of you at the PMG conference. And I really like talking about this topic. I went to The University of Virginia and then I went to the Philadelphia College of Osteopathic Medicine. Just by happenstance during one of my family medicine rotations. The doctor decided that she wasn't working two afternoons a week and wanted me to get some other experiences and drop me off at the emergency department of one of the local hospitals. And I discovered emergency medicine. And there was no going back because, you know, it was just so exciting, so different. I got to do things, got to think about things, got to solve all those difficult problems from the very get go. We were the first ones to see them and it was a different place every day. And so I really loved it. And then when it came around time to apply for emergency medicine residency programs, I tried, I failed. I finally connected with the program at Philadelphia College of Osteopathic Medicine, the osteopathic medical center. It has moved to Albert Einstein in Philadelphia. So it's now called the Albert Einstein Medical Center training program. At that time, I would say there are only about 300 residents coming out in emergency medicine every year. And the training was a two year program. It had gone to a three year program. I had already done an extra year of internal medicine at Albert Einstein. So I had four years of postgraduate training. And then when I came out, I moved to Northern Virginia. This is where my husband had come from and he was also a physician. He went to Eastern Virginia medical school and was becoming a gastroenterologist. He was gonna open a solo practice. I joined a practice in a suburban emergency department in Alexandria, Virginia. And from there I went to having a clinical associate clinical faculty position with George Washington University Medical School. And during that time I discovered that I was having a problem with some of my interactions with some of the patients. I loved emergency medicine. And like, why did I feel so terrible at the end of the day? And one of the reasons, it's not the only reason, but a big reason was some of the interactions with patients went terribly. And I did some research about it. There wasn't much written about it. What was written was mostly in the psychiatric literature. And there was a physician at Massachusetts General Hospital who wrote an article called, “Taking Care of the Hateful Patient”. And some of that translates to our patients in the emergency department for sure. He was talking more about long term patients. We obviously have short term patients, but we see those types all the time. So I gave a lecture about it. I put it away for about 30 years. Had three kids, worked, had my whole career and I decided to start speaking about it again a year or two ago when I started during COVID times and I wanted to do some lecturing. I lectured to continuing medical education groups and to resident groups about changing how we think about difficult patients. I can tell the story a little bit later. I decided I was gonna write a book and I submitted it to the publisher, who gave me a contract. So here we are.
Laura: That's amazing. So was it during COVID time that you decided that you were gonna write down all this information that you gleaned from your research for? and was, is the audience, so the audience obviously is healthcare professionals?
Dr Naidorf: I wrote initially presented it as a grand rounds presentation. My director liked it so much. He asked me to give it the next year. I put it aside. I went to revisit it and what I discovered was it had a lot of overlap with the type of thinking that life coaches do, which is learning how to change the way we think. And what I discovered is that we were actually taught by our senior residents, by our professors, to have a very negative opinion of our patients. We adopt a very negative view and part of it we're taught and part of it we just have a negative bias, naturally human beings do. We have a tendency to, you know, scan the horizon for danger and we're looking for the worst possible diagnosis in our patients. So all that's like part normal. But we can fall into a big trap in our departments. And I first wrote the book for the emergency department, emergency physicians. The publisher, who is the American Association for Physician Leadership, wanted me to revise it and try to include all healthcare professionals. We know from working with our nurse colleagues that they kind of fall into some of the worst judgemental habits. Walk into their break room and you will hear them talking about the patients in a very derogatory way. And I'm not throwing them under the bus. Some of us are right in there agreeing with them.
Amanda: One hundred percent. I've been, I've had shifts like that.
Dr Naidorf: So what I found was that we could look at those ways of changing our thoughts. Again, some of it from cognitive behavioral therapy and the life coaches use and apply some of those ideas to this topic. That's when I expanded the original lecture and started writing. I decided to write a chapter a week. And so there are about 17 chapters, it's not very long. It's simple. It's a simple idea. And it's very focused and for those of us who need to hear this message, it's super important.
Laura: Yeah. So who would you say, how could someone identify themselves as someone who needs to hear this?
Dr Naidorf: Well, I think we all find ourselves passing judgment on our patients. And what I mean by that is there are certain expectations we have for them. We want them to do what we say. We want them to take the medicines we prescribe for them. We want them to do the follow up. We want them to agree to the testing that we set up for them in the emergency department and people who don't wanna follow the plan. They want something different. They're asking they're not behaving the way we say, we label them as difficult patients. And I think that nurses do it, physical therapists do it, respiratory therapists do it. Anyone who comes in contact with patients can easily fall into this category of labeling people in this very negative way. And I think the first step to changing it. And we'll talk about that a little bit more later, is to become aware that you're doing it and don't beat yourself up, cuz it's kind of a normal human doctor and nurse thing, but just be aware of it.
Laura: Yeah. So those of us who work in the emergency department really feel like difficult patients are a huge issue, especially for us. How often does the data suggest that this is an issue?
Dr Naidorf: The data that I cite and the only thing I saw that really addressed this issue was in an internal medicine practice. And there was an estimate that between 15 and 20% of the patients were considered difficult by the practitioners. Now for us in a busy emergency department, that could be 4, 5, 6 patients per shift. And that's a lot. And we have to kind of keep things in perspective, which means, you know, 15 to 20 patient interactions are going just fine, just the way we want them. But it's sometimes the four to six of them really on any given day. All it takes is just one horrible one that just sends you home to, you know, a half a bottle of wine, or into the break room for a few extra donuts and just leaves you feeling terrible.
Laura: I think we all know that feeling.
Amanda: Absolutely. I feel like it's probably the average too. So like some days it might seem like they all came at the same time. It seems like it.
Kendra: Yeah. I'm also thankful that we didn't always have donuts and at least we could pick cheese sticks or chocolate milk.
Amanda: The classic graham cracker and peanut butter steal from the classic ER meals.
Dr Naidorf: One of the articles I wrote recently came about the same topic in the Washington Post and was picked up in Doximity, and one of the comments that was received by one of the physicians was, “Well, I just fired the patients.” But, you know, we don't have that luxury in the emergency department. We've got to take care of them. We have to do a medical stabilization exam. We have to do the right thing even though sometimes, quite frankly, they're acting like jerks or even worse or violent. So, you know, we have to learn how to deal with it. We have to kind of accept that it's part of what we have to deal with. Even when some of these things that I'm gonna talk about don't really work and you can't get yourself into a better frame of mind about it. We just have to accept, this is part of being a human in the emergency department. You're gonna have some terrible interactions with people and it's part of the 50-50. You have to work a little harder to remember the great ones, the great interactions.
Amanda: I think it's so important too, like, this is just what, how it's gonna be and you don't have to take it personally. That helps me whenever I realize they're behaving in this way cuz it's the best they've got at the time and it really has nothing to do with me.
Dr Naidorf: Absolutely.
Kendra: Yeah. I think that's, yeah, a real good point there. If you have an internal focus of control, you are always trying to take responsibility, like you have anything to do with the way they're feeling right now, what they're thinking or the thought process of them even getting to the emergency department at that time. It's like you have some control over that. And so, speaking of that, what are some of the thought errors that happen with physicians when we label patients as “difficult”?
Dr Naidorf: Well, that is the crux of the matter. The problem is we expect that they're going to do what we say. And we kind of forget that our patients have autonomy. Competent patients have the right to refuse medical care or refuse your prescription or whatever you're offering. And that's exactly the way we want it to be. We just want them to do what we say. So I think that what you touched on was one thing, one sort of thinking that we get is “all or nothing thinking”. And that is thinking that it has to be my way or there's no way or else, you just have to sign out AMA, against medical advice. Thinking that my way is the only way it's the best way. And, and that just isn't realistic. If you think someone needs to be admitted and they have a disabled child or a pet at home and they wanna get home and take care of that person or that pet. You're gonna have to find another way. It doesn't help just to have them sign out AMA you're not giving your patient the best care there. There isn't just one or another answer. Isn't just all or nothing. It isn't just black or white. There are a lot of choices and you have to put on your problem solving hat to find them.
Kendra: Yeah, that's a really good point. And I think a lot of it too, is the frustrations with some of the processes in the emergency department also don't help. So if that patient has been “difficult” to begin with and then the lab takes too long, or the x-ray read doesn't come back or the consultant that you're trying to call to get them admitted is giving you a hard time. And then you just have this compounding effect and the frustration is exponential. So, what are some of the common fears and behaviors that occur in our patients?
Dr Naidorf: Well, our patients have a lot of symptoms. They go right to the internet where they get their webMD degrees and interpret it in the worst possible way. Cuz of course some pain or ache gets interpreted, well, this could be cancer, it could be a tumor. And they can't put it in context, of course. So they imagine the worst and they come in very anxious. Our patients have to deal with their prior experiences in the emergency department, prior experiences of their family, if something bad happened, you'll always hear about them as soon as they come in. And I think that trying to understand where they're coming from will go a long way to being more compassionate, to understand why they may be a little bit oppositional or frustrated or angry. And, if they are angry about waiting and I agree, Amanda, there's all those are, there are all those things we have to wait for to get those labs, get the person to x-ray, etc. It's wise to just apologize to them. And say, “It really is so frustrating when you have to wait for this and I'm frustrated too”. So, I think that kind of holding space with them goes a long way to making, to diffusing the situation may not always work, but apologizing is easy.
Kendra: Yeah, that's a good, that's a good point too. Just like almost creating a community. Like I hear you, I'm empathizing with your situation, how frustrated you are. I feel the same way, kind of creates a little autonomy with your patient. So how do we start to change these thoughts or thought errors about these difficult patients?
Dr Naidorf: Well, as I said a moment ago, the very first thing is to be aware that we're having negative thoughts. Some of the words that we use, some of the ways that we refer to patients are very negative, very derogatory. Everyone in your department may be talking that way and thinking that way. So you have to actually hear it. That's the first thing. The second way is to ask better questions. Like, could I be wrong about this? Is my way the only way of treating this problem, is my way the only approach? And the answer is invariably, no. You could agree to some common ground about how something could be treated with an oppositional patient. I think the other thing that is very helpful to do, I mentioned this to the mom group, those of us who are mothers, is to imagine that the patient is someone's child, even an adult. Someone's child or someone's mother or father or brother, it's some relation. And if we think about people in that way, we have a lot more compassion about them. I know that sometimes some of my relatives act like jerks. They don't do what they want. They overreact to pain and I would like the emergency department staff to treat them with compassion and give them the benefit of the doubt.
Laura: I love that. I use that trick all the time, thinking of the patient as a small child. Cuz they were a small child at one point and it really does help you have more compassion for them.
Dr Naidorf: Well, and I think that for those of us treating children in the emergency department and other settings. We view them as innocent. Sometimes their parents or caregivers can be difficult, no question. But I think what we realize, if we put ourselves in their shoes, they have very strong feelings, very strong emotions about what they think is right. Now, maybe we haven't presented the information to them in a way that they understand so that they will wanna do things we do. And you know, they have some autonomy in those situations to make decisions we don't agree with.
Kendra: Yeah. That's a good point. To just having part of the empathy is also being able to have a little bit of perspective. So how do you, or how would you say that changing how we think or changing our thoughts on these difficult patients actually benefit us in the long run?
Dr Naidorf: Well, this is, I think, kind of the secret sauce. I mean, when we kind of come to our patients, approach them with better thoughts. At least not thoughts that are quite so negative. We have more curiosity about what's going on with them. We have more compassion. We spend more time with them. We ask better questions. We listen to them. So we'll kind of make our way to the right diagnosis. I mean, if we can't stand even being in the same room with someone, we're definitely not gonna listen to them and we're definitely not gonna examine them. So, the likelihood of us finding the right answers or some sort of hidden trauma are not going to be available to us. So we get better results. We feel better about it. I think that's the most important thing. See, if we keep thinking that our patient's behavior needs to change for us to feel better, we're just putting ourselves in the victim mentality. I think you talk on one of your podcasts about emotional adulthood and taking charge of your own emotions. Those patients aren't gonna change. There are always gonna be some difficult interactions with people. We have to change the way that we think about them. And if we do, then we can find that we have more power and we're more empowered in our interactions with them. And in order to do that, we actually have to be confident. We have to know that we're well trained. We have to know that our staff is backing us up. Our administrators are backing us up and we have to feel better about making our own decisions. So I think it means everything. And, again, it's not the only thing that we have to deal with in emergency medicine, but it's a big deal.
Amanda: This was just mind blowing for me when I first learned the concept of emotional adulthood and the fact that at work, I am going to be professional. I'm not going to be calling people out or yelling or anything else like that. So if I'm carrying around these thoughts that this patient is difficult and really working myself up about it on the inside, literally I'm the only one, I'm making myself suffer. So I totally love this concept and thank you for writing this book because it just is a fact that we are going to have some situations that in the past we might have labeled difficult and it only benefits us to learn these tools that you're teaching. So now I get to transition though, to something kind of fun. So you did write a book, so are, do you have any, and our listeners, you know, doctors can do all kinds of things and a lot of times we aren't, you know, doing all of the things that we have interest in, and it's always good to do something that lights you up. So do you have any advice for our listeners who want to start writing and getting published?
Dr Naidorf: I absolutely do. I think it's such a great idea. I think that the very first step is that people should start journaling. I never did and I'm sorry I didn't. Because there are a lot of things that I forgot. There would be a situation, not even just so much something happening with one patient, but there'd be a row of people I'd be looking at and the weirdness happening from patient A, to B, to C, to D and all the yelling and the screaming and everything happening. I'm going, like no one would ever believe this if I told you that. And of course, I forgot the major things about it. So of course there are a lot of things I remember, and I write some stories. I started writing for my own blog about some of my experiences, some of my experience with mentors. And it's not the only thing I write about. I write about travel and I also write book reviews. So I love to read and I feel that reading helps augment our experience. We can't always walk in. It'd be great if we can walk in the shoes of our patients, but I have never had some of these diseases or never been in some of these situations. There are amazing, amazing patient memoirs out there and amazing books that are great. I share some of the reviews with the DO magazine and on my blog. I think there are more avenues than ever to get published. And I mean published online. I mean, there are also print publications, but I think that's probably gonna go away in 10, 15, 20 years. So, you know, you can submit and to Doximity, KevinMD.com. Kevin Poe was the person who I first had something published. Oh, I first started in Doximity and then I submitted something to Kevin. I asked him and he basically introduced me to the publisher who gave me the contract to print the book. So there are two other venues that are interesting. One is called CLOSLER, it's through Johns Hopkins. It's kind of about narrative medicine. So I think that writing a narrative piece about something that happened to you with a patient is one way to help process some of the emotions about this. You know, some of these interactions, the reason that they feel so terrible is that they get us feeling sad and depressed. I mean, and it's totally normal to feel grief, and sadness cuz we're in some very sad situations. And I think writing about it helps us process it and it's fun. So I recommend it to everybody. The other one that I think just started and I published something very short is called medmic.com. So, you know, I think you have to check what the word length is and meet certain criteria, but they're looking for submissions. So if you're interested in doing something like that, you can have a lot of fun with it.
Amanda: I will second that we, when we first started, we have this passion for physician wellness and all of that sort of stuff. So we just started asking some of the ER magazines. Do you want us to write a column? And then shockingly, Emergency Medicine News was like, well, actually first they said no, cuz they thought that we were soliciting, like trying to do advertisements or something like that. But then I was like, no, no, no. We're actually are ER docs. And we're trying to talk to our, our you know, colleagues who I know are hurting and then they were like, oh, okay, sure. So all of a sudden we have a column in Emergency Medicine News and I would've never in a million years ever thought that, but I love that. I mean, who has better stories than us and all the time people are like, what's the craziest, whatever. I can't remember, cuz I haven't written it down and I just like the second that I walk out the building, it just goes blank after that. It's gotta be really incredible for me to remember it at this point.
Dr Naidorf: I know, if we could potentially get to that some sort of habit, even, maybe just once a week or even just do a voice memo on your phone. And we see people submitting things on some of the Facebook groups, little stories, and they're pretty wild.
Amanda: So we will obviously put a link to your book in our show notes. And then, now I'm excited because you told us about the Washington Post article. We'll put a link to that too, but how else could people contact you or find out more about your work?
Dr Naidorf: I have a website called, DrJoanNaidorf.com. And put the link in the show notes and I am gonna be giving the speech that it's gonna be two parts, about 30 minutes each at OMED in Boston. There is maybe eight hours of emergency medicine content in that conference. So I love that. That's what I got into now. There's one more thing I wanted to say. I think that one of the thought distortions or thought errors that is so common for us is we see a triage line. We see a note, the first thought in our head is that person shouldn't be here. They should have seen their primary care provider. They should have gone to that other hospital. Don't they know that we don't see those kinds of patients here. And I think this is one of the worst things we could do. It is just trying to argue with reality. They're here. We really need to change our feelings about that. Change our thoughts, which will change our feelings. The patients are exactly where they're supposed to be. We have the best doctors, the best nurses, the best testing. We get it back right away. All our patients belong in the emergency department. They are exactly in the right place.
Amanda: I love that. Well with that, are there any closing thoughts?
Dr Naidorf: Well, I just wanted to let everybody know that you can change your thoughts about interactions with difficult patients. We try not to say that. The conclusion is there are no difficult patients, but there are some really challenging interactions with people and you can approach the situation with more intention and change the way you think about them and it takes practice. It doesn't just happen in one day or one week. That is kind of helpful about having the book cuz you can go back to it and give yourself a little pep talk. So, the most important thing here is to hear that message that it can be done and I just want to make sure everyone hears it. I want everybody to stay in clinical practice. I don't want this part to drive them out. I need you all your beautiful people to take care of me when I become an old lady right around the corner. And I just hope everybody gets back to finding the joy that brought you in the first place.
Laura: That's the take home is that you're doing this for you. You wanna change your thoughts about these patients? Not for them, but for yourself.
Dr Naidorf: Absolutely.
Kendra: Thank you so much, Dr. Naidorf. That was an amazing time to just kind of identify some of these thought errors and really seemingly, you know, small things that we can do just a little bit to switch on our brain and make it work for us now. And I just wanted to let you know that I read your blog on your website after South Carolina and you did an amazing job just capturing that whole conference. Just really describing all of us there and the atmosphere and all of the lectures. It was truly fantastic. When I read through that, I was like, I was there. Yes, that's exactly the way it was. So thank you very much. It was a fantastic piece of work.
Dr Naidorf: That was fun. First of all, I love that conference. It’s so different than like emergency medicine conferences, which is what I usually attend. And I would say that in terms of capturing it well, I've been putting a blog out there like every week for the last year. And I'm getting better at it and all of you can too. It just takes practice.
Kendra: Well, thank you. Yes, very well done piece. And I encourage you all to check out her website. She has a ton of blogs. I checked out a few others too, but I just wanted to comment on that one cuz I actually was at the conference and it was a fantastic article. So thank you. And to our audience, we are so grateful you found us today. You found our podcast and we want you to stay well connected to us. So please go to our website, www.thewholephysician.com to sign up for our weekly well check. It's delivered right to your inbox. So, until next time, you are whole, you are a gift to medicine, and the work you do matters.