Another training: “Difficult” patients

More than half of my work as a gastroenterologist at Children’s involves critical skills I never learned in medical school, residency or even fellowship. I enjoy using these skills and have been lucky to have some gifted mentors. But having these skills shouldn’t be dependent upon luck.

I am talking about bedside manner generally, but more particularly, about communication in the context of strong emotions. It is true that knowing the causes of painless rectal bleeding in a toddler, or how to optimally perform a rectal suction biopsy in an infant, are both essential components of my doctoring as a gastroenterologist. I learned both from my colleagues as a GI fellow.

But other bedside capacities are equally weighty: knowing what to do when a parent is sobbing or yelling; how to reassure without discounting the seriousness of a situation; how to respectfully disagree with a patient or parent; or how to move forward when patients and parents are tuning out your words.

When clinicians don’t employ, or lack proficiency in, “relational” skills, the highly emotional patient or parent becomes Difficult. I suspect The Difficult stay in hospital longer, receive excessive treatments and undergo unnecessary testing; I know they dampen medical team spirit or, worse, create damaging conflicts between and among physicians and staff. In either case, patient outcomes suffer.

Major efforts are underway to improve proficiency in relational medicine. Yet for many of us, medical school and post-graduate training have already reinforced a discomfort with and lack of awareness of negative emotions – of patients, parents and even our own. Gaining adequate proficiency in relational skills may be surprisingly effortful, uncomfortable and even unmanageable.

Medical schools and residency programs have recently boosted their focus on “Professionalism”; role models abound for young physicians and physicians-in-training to witness relational medicine in action. But these efforts can’t just be episodic: without rigorous, regular use of these skills, the default setting gets the upper hand: assumptions of failure or mistake when negative emotions exist in our interactions with patients or colleagues.

We can’t all be social workers or psychologists, but we need to be able to think and act like them sometimes. Finding a creative path forward might not just ease “compassion fatigue.” It might also propel forward the hospital’s goals of improving efficiency, decreasing errors and optimizing patient satisfaction.

So, how can we teach relational skills without being uncomfortably saccharine or irrelevant? A practical innovation would include piloting a rigorous educational program to train experts in leading team meetings.

Team meetings for hospitalized patients offer a discrete, recurring venue for practicing relational skills where they really matter. They are typically multidisciplinary gatherings involving physicians, nursing, social work, discharge planners and patients/families, whose purpose is to review medical progress in detail, sort through treatment options more thoughtfully, clarify confusing aspects of care and address relational difficulties.

Outside of the ICU, there are few resources to help physicians learn how to conduct these meetings. Addressing relational tensions must be a critical focus in the meetings, and in training the leaders — as important as any other organ system in distress.

Relational medicine ought to be as important as pharmacology, and taught with the same rigor. Enhancing the inpatient team meeting, though just a small innovation, will move us closer to experiencing The Difficult as presenting little difficulty at all, but instead, an opportunity to practice good medicine.