The Despicable Patient and Name Calling

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~ by Maxwell M. Krem, MD, PhD

How does a physician deal with a despicable patient—not just a difficult patient, but an individual whose maladaptive behavior reaches the extremes of physical and verbal abuse, persistent sexual harassment, and even danger to medical staff or the patient’s family members? The answers lie on two levels, professional and personal.

Professionally, techniques such as boundary- and limit-setting, an empathetic demeanor, obtaining additional staff for security and chaperoning purposes, careful monitoring and documentation of clinical encounters, and reasonable attempts to develop a therapeutic alliance are likely to help the physician navigate encounters with even the most behaviorally challenging patients.

However, on a personal level, the answers are less clear. How does one face regular exposure to some of the ugliest facets of human behavior and maintain sanity? Many, if not most, physicians employ defense mechanisms, and humor is high on the list. In the humor category some unofficial acronyms have emerged, some of which are not intended to be derogatory but are clearly inappropriate for professional settings or patient encounters. Examples include FLK (funny-looking kid) and LOL (little old lady).

A recent Slate article by Columbia University psychiatrist Anne Skomorowsky looks at one of those acronyms, exploring the author’s experiences with it and exposing it to the general public. The abbreviation: SHPOS, standing for “subhuman piece of shit.” The author discusses the acronym as one commonly used by physicians for patients they despise or who behave disgracefully. She describes encounters with patients who displayed severely dysfunctional behavior, such as harassing medical staff or endangering themselves, staff, and family members; she discussed her own intense reactions to those patients, as well as the misogynistic components to the behavior. Dr. Skomorowsky additionally explains that the term has been in use since at least the early 1980s and is “known to physicians everywhere.” She concludes that “[n]o one is proud to call another person subhuman.”

Dr. Skomorowsky is certainly correct that the despicable patient does exist. A recent discussion of her article on Sermo confirms that physicians from nearly all specialties have had similar encounters. Maladaptive, misogynistic, abusive, infuriating, assaultive, and dangerous behavior is not confined to the psychiatry ward, and it cannot be tolerated in a therapeutic setting. SHPOS may reflect “the clash of various narcissistic needs between the resident and his difficult patient,” in the words of Strauss (South Med J 1983; 76: 981-984). SHPOS also goes too far, is not in common usage and carries overtones of arrogance and lack of sympathy by the medical profession.

Why is SHPOS an unjustifiable acronym? Despicable behavior is an element of the human condition. The behavioral range of our species is vast and ranges from the most noble to the most base. The “SHPOS” is as human, and as “subhuman,” as are we in the white coats. Though physicians, professionally and often personally, aim for the noble end of the human behavioral spectrum, members of our profession have committed terrible acts against mankind, their patients, or their families. We are not above reproach and must not rejoice in a false sense of superiority. Superiority is at the heart of the abbreviation SHPOS, which labels the wrongdoer as something less than human; his behavior is explained by his inferiority. When confronted with what seems to be a SHPOS, we are looking at one of our own kind.

The Slate article brought back a memory from the very beginning of my medical education. Stephen Lefrak, MD, Professor of Medicine at Washington University School of Medicine, delivered the address at the White Coat Ceremony on my first day as a medical student. He recounted a story from early in his own training, during which he assisted a Jewish surgeon and Holocaust survivor in a procedure to save the life of a patient. As the procedure was getting underway, Lefrak noticed that the patient was tattooed with swastikas and other neo-Nazi insignias. He asked his colleague whether that patient deserved their efforts. The Holocaust survivor’s response was that to give any less than their best effort would be sinking to the patient’s level.

That ethos is what makes medicine special—a calling—and provides the glue of the doctor-patient relationship. Medical care is nonjudgmental. To be repulsed by despicable behavior is only natural, but to denigrate patients behind their backs erodes the central compassionate culture of the medical profession. The vast majority of doctors do not engage in the denigration of patients. A poll on Sermo (with more than 2500 responses at the time of writing) revealed that 90% of physicians had never heard the acronym SHPOS. We may occasionally have (justified) unspeakable thoughts in response to despicable behavior, but perhaps that is how those thoughts should remain. As one physician on Sermo said, “but when you let it out your lips, others hear you. It makes you look bad.” To call the offender subhuman is a facile defense mechanism, but for our good fortune we do not walk in his shoes. To call him a SHPOS is to be judgmental and be drawn into despicable behavior ourselves.

credit: Seattle Cancer Care Alliance

credit: Seattle Cancer Care Alliance

Bio:

Dr. Maxwell M. Krem, MD, PhD, is a medical oncologist who sees patients with hematologic malignancies at the VA Puget Sound Health Care System. His primary specialty is bone marrow transplantation.

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Doctors Reject Ron Klain as Ebola Czar

Ron Klain poll, doctors and Ebola Czar

click to enlarge, credit: Whitehouse.gov

Ron Klain, the newly appointed Ebola Czar, has come under harsh criticism from physicians for having no prior healthcare experience. Klain, formerly was Chief of Staff to Joe Biden and Al Gore and is known as a Washington insider. He is a lawyer with no formal medical training.

We asked our doctors, “Do you approve of the newly appointed Ebola Czar, Ron Klain?” The response was overwhelming:

  • 79 % No
  • 21% Yes

What Doctors Think of the Ebola Czar

A few physicians were willing to take a wait and see approach. One Physiatrist wrote, “There are few physicians qualified or competent to run a major government task force. He is running an organization, not making medical decisions. The team will likely contain qualified scientists and physicians as well as on-the-ground experienced people. I would reserve judgment until we see the team assembled, and the responses developed and implemented. Right now, it’s all just knee jerk reactions.”

For more about Ebola protocols, click here.

One ophthalmologist reflected the majority opinion. He wrote, “Something is terribly wrong when the Czar is obviously chosen on the basis of who is most likely to contain the political fallout, rather than who has the most expertise in containment of bio-hazard. The Czar should specialize in bio-terrorism and bio-warfare. This should be obvious to anyone who understands the medical, environmental, and healthcare systems hazards.”

Do We Need an Ebola Czar

Many physicians questioned why we needed another administrative position to execute on Ebola matters. One Family Practitioner asked about Nicole Lurie, MD, MPH, who is the Assistant Secretary for Preparedness and Response (ASPR) for the Department of Health and Human Services.

From the HHS website, “The ASPR serves as the Secretary’s principal advisor on matters related to bioterrorism and other public health emergencies. The ASPR also coordinates interagency activities between HHS, other Federal departments, agencies, and offices, and State and local officials responsible for emergency preparedness and the protection of the civilian population from acts of bioterrorism and other public health emergencies. The mission of the office is to lead the nation in preventing, responding to and recovering from the adverse health effects of public health emergencies and disasters.”

As a physician, what do you think about the new Ebola Czar? What attributes should a candidate have? We discuss Ebola thoroughly on our new Infectious Disease Hub, if you’re an M.D. or D.O., please join us.

Sermo Poll Results: Prescribing Antibiotics in the U.S.

antiobiotic poll

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There is no doubt that antibiotics save lives and stop infections. So why has the use of these drugs been a trending topic for debate?

According to the CDC, “…poor prescribing practices put hospital patients at risk for preventable allergic reactions, super-resistant infections, and deadly diarrhea caused by Clostridium difficile.  These practices also drive antibiotic resistance, further endangering the future of these miracle drugs and the patients who need them.”

We polled Sermo physicians about the practice of prescribing antibiotics in the U.S.  Of the 2,459 physicians that answered, an overwhelming 92 percent believed antibiotics were over-prescribed. This left only seven percent saying they were prescribed appropriately, and one percent saying they were under-prescribed.

The staggering reaction to our poll resulted in some followup questions:

1)  Why are antibiotics over-prescribed?  Is it because of patient demand? Do physicians need more education?  Is the problem with other prescribing HCPs who need education?

2)  How do we “right-size” antibiotic prescriptions? What criteria should be followed to give just enough?

After a robust conversation, the most common theme addressing the over-prescription trend was due to patient demand. One doctor wrote, “It’s the path of least resistance and sadly in the era of health care now being a customer service industry, patient satisfaction trumps evidence based medicine. A patient going into the office with the sniffles wants something tangible in hand to “fix their problem” not an explanation why nothing is needed and leave the visit, in their mind, empty handed.”

Another doctor compared prescribing to the McDonald’s view stating, “Most patients have a McDonald’s approach to antibiotics and other medical treatments. They want it their way and fast. In the past, they went to their health care provider for the providers knowledge and expertise. They did not come for simple self-resolving problems and they respected the doctor’s opinion. Now the McDonald’s mentality is to demand expensive tests or unnecessary meds.”

As a society of quick fixes and fast solutions, this conclusion does not come as a surprise.  Support for this view comes from an article presented by Medscape discussing a study which found that “…out of 3402 adults presenting to primary care with cough, roughly 45% “expected” antibiotics, 41% “hoped for” antibiotics, and 10% “asked for” antibiotics.”

So how can this issue be solved?

A family practice MD expressed her opinion of further education. “All of us need to do a better job and only prescribe antibiotics when it is clear that we believe there is a bacterial infection that we are trying to cure. Otherwise, antibiotics will no longer work.  I think doctors don’t need more education. The public does. We need to learn how to say no. The public needs to learn the difference between infections that are viral and bacterial and that antibiotics don’t cure all infections.”

What do you believe is the reason for over-prescribing? Do you have an idea of what can aid in decreasing this practice? If you are an MD or D.O. we will be continuing this conversation within Sermo.

 

Sources

Danger to Teens: What physicians look for in their patients

danger to teens We have an important poll today and wanted to send it out as a message to parents, guardians and other care givers who work with teenagers. We asked our physicians, what is the biggest danger to teens today?  Their answers largely focused on mind-altering substances;  82 percent of physicians chose among using illegal drugs, abusing prescription drugs, or drinking alcohol.   Smoking (9%), teenage pregnancy (6%) and contracting sexually transmitted diseases (3%) ranked far behind. The concern is warranted.  A recent survey showed that about 50 percent of teens have tried an illicit drug at least once before high school graduation and 80 percent had tried alcohol.   Risky behavior leads to true tragedy.  One study estimates that from 35,000 deaths between the ages of 15 and 24 about 20,000 could be prevented if teens and young adults made better choices. Another report from the U.S. Substance Abuse and Mental Health Services Administration shows the statistics of abuse and treatment.

  • 600,000 teens smoke pot
  • 400,000 teens drink alcohol
  • 71,000 in any given day will be in inpatient treatment programs
  • 10,000 a day in other substance abuse programs

Physicians and Teen Drug Abuse Physicians should regularly screen patients and their families about the potential of drug or alcohol abuse.  Changes in behavior, sleeping patterns, grades falling suddenly can all be clues substance abuse is present. This brief video discusses why physicians can sometimes get patients to open up when others can’t. Another big issue is the occasional drug or alcohol abuser who doesn’t display any outward symptoms but will occasionally participate in dangerous activities.  Physicians should work with families and the teen on prevention and on seeking help if needed. As a physician, how do you talk to teens about drug or alcohol abuse?  What have you found to be the most effective way to communicate with teenagers?  Do you find working with families as a whole more or less helpful than dealing with the teen one-on-one? We will discuss all this and more inside our Sermo community.  If you’re an M.D. or D.O. please join us. 

Sermo Poll: Have you ever done medical mission work?

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Volunteerism runs deep in medical circles.  The daily business of saving lives certainly creates empathy for those in need.  While our physicians improve the lives of others daily, medical mission work is a more formal step sometimes requiring months of training and weeks away from home.

We recently asked our doctors, “Have you ever done medical mission work?”

  • 37% responded no, but would like to volunteer
  • 37% responded no, and were not interested
  • 18% said they have through a local/domestic organization
  • 8% said they have through an organization aboard

Our doctors shared wonderful experiences about their mission work.  One doctor wrote,

“I have been involved for years with a local group of doctors who provide surgical care to those in low resource countries. The work is challenging but rewarding – no administrative, insurance, legal hassles. I feel like a real doctor, using skills learned in medical school long since abandoned due to technology, regulations and so on. The patients are just so appreciative and wait patiently for hours to be seen. If possible, I would do nothing else.”

International vs U.S. based work

Beginning in the late 1800’s, medical mission work developed as a way to share advancements of western medicine to the rest of the world. Today, you can find hundreds of different organizations supporting both international and domestic relief. Both types of organizations commonly focus on impoverished communities so why would someone choose one over the other?

Mission trips vary in length, depending on the location and organization. Of our physicians who said they completed mission work, the majority of them have only worked with U.S. based organizations.  American organizations are more accessible for physicians who already work long hours. They could volunteer over a day or a weekend.  In contrast, the usual length of international missions varies from a few weeks to months. Travel and living costs are not covered by organizations and international travel can be quite costly.

If expenses and time are not factors, consider these points when volunteering:

  • Your faith. Mission trips are commonly faith based, but there are trips sponsored by nonreligious organizations as well.
  • Your sense of adventure. Volunteering overseas will bring in a lot of new experiences and possibly uncomfortable situations; language and culture barriers.
  • Simple life necessities. Can you adjust to not being able to shower, running water, or electricity? If you’re considering international, you will need to think about how you deal with these types of situations.
  • Where you want to give back. What is most important to you? If giving back to your community is close to your heart, a local organization is your obvious choice.

Lastly, research other people’s experience. We sent our Community Director Christian Rubio on a short stint with Floating Doctors to Panama last year and put together a short documentary about the experience.

 Why would someone not want to volunteer?

According to one doctor, “I feel like I do mission work every day seeing Medicare/Medicaid and ACA patients. No need or desire to do this offshore.”

Do you have experience with domestic or international medical mission work? Do you want to share why you do or do not volunteer? We would love to hear your stories. If you are an M.D. or D.O., will we be continuing this discussion in Sermo.