Viewpoints: Annoyances are Unavoidable; Frustration Isn't

When my daughter recently received her PhD in psychology from Rice University, I was particularly happy as an alumnus. Sitting through the beautiful Saturday morning commencement, I reflected about what undergraduate courses were pertinent to clinical neurology. Most were not specifically useful although the love of learning and critical analysis are invaluable. Curiously, the one subject I took at the last minute for two semesters—Spanish (I speak it poorly)—is the one that I often use. The typing skill I learned from a junior high school class is something I use all day long.

The commencement speaker, New York Times columnist David Brooks, spoke about happiness. I was thinking about our professional happiness. Although most of us are very happy as neurologists, we have become increasingly unhappy with the practice of medicine due to issues large and small ranging from decreasing reimbursement to loss of autonomy to bothersome patient behaviors.

We performed a survey of Texas neurologists on bothersome patient behaviors (Evans RW, Evans RE, Evans RI. A survey of neurologists on bothersome patient behaviors. Medscape General Medicine 8(4):35-43, 2006; available at http://www.medscape.com/viewarticle/546878_4) and found that the top five bothersome behaviors were: no show for appointment; verbally abusive with your staff; poor compliance with medications or treatment; late for appointment; and do not know the medications they are taking.

We're not the only ones, of course, subject to bothersome behaviors of others. A new book by Palca and Lichtman, Annoying: the Science of What Bugs Us, discusses bothersome or annoying behaviors of strangers, friends, and spouses, such as uncouth habits, inconsiderate acts, intrusive behaviors, and norm violations. Consider the following public behaviors: cell phone conversations, crying babies, or someone picking their nose or clipping their fingernails. How irritating is someone kicking your chair in a movie or car alarms that don't stop or a buzzing fly?

More research should be devoted to what bugs physicians and detracts from the care of our patients. This would almost certainly include precertification forms for medications (consider one insurer only allows FDA on-label use, while another wants you to use a generic for off-label use), imaging pre-certs, meaningful use requirements for EHRs (which are certain to grow and have questionable meaningful use), and increasingly complicated coding. Many things are more complicated without clear benefit. Does the maze of recertification improve patient care?

There are trends in healthcare that physicians cannot easily counter but which require more work by physicians or addition of staff. Payors want to save money and seem to set up human speed bumps. Federal agencies want to analyze our behavior with EHRs. Shouldn't we be compensated for our time for all of these increasing mandates? More importantly, will there be any time left for the physician and patient?

Neurologists may not have much power to change the mandates of Payors or the Federal government, but there are steps we can take to address other annoyances of daily practice. First and foremost, neurologists should recognize and attend to their own needs for personal time to deal or reduce stress and support their own good health and well-being.

Randolph W. Evans, MD is Clinical Professor of Neurology Baylor College of Medicine in Houston.

Adapted from an article first published in Broca's Area, the newsletter of the Texas Neurological Society, Summer 2011.

Minimize Frustration

Ahead are a few additional suggestions for taking control of frequently-encountered challenges in the clinical setting. If you have strategies to share with your colleagues, let us know.

Focus on quality and stress reduction. Although the culture of the practice setting overall was not found to significantly impact physician stress or burnout, an organizational emphasis on quality led to fewer medical errors, a recent study found.¹ The same study showed that stressed and burned out physicians were more likely to make errors. Taking some time to de-stress in whatever manner is effective for the individual may be good for clinicians—and their patients.

Confront burnout; Be proactive. It's better for surgeons to avoid burnout before it sets in, researchers discovered, rather than try to reverse it.² The same seems to hold true for all healthcare providers. Confronting stress is essential. As the authors state, “Silence on career distress, as a strategy, simply does not work among professionals whose careers, well-being, and level of patient care may be in jeopardy.”

Consider that frustration with patients may say something about you. While some patients are clearly difficult to deal with (see below), frequent frustration may indicate high stress on the part of the physician.³ Analysis of data from a survey of various physicians found that, in addition to a greater number of patients with psychosocial problems or substance abuse, “factors independently associated with high frustration included age < 40 years, work hours > 55 per week, higher stress, practice in a medicine subspecialty.”

Adopt strategies for “difficult patient” behaviors. Empathy can be a useful tool in dealing with difficult patients. Patients who seem angry, irritated, emotional, or otherwise challenging often move past their challenging reactions when the physician responds with validation, agreement, or even just a few minutes of time for the patient.⁴ Abbott provides an overview of physician responses in a recent edition of Topics in Stroke Rehabilitation⁴ or you may wish to read Hull, et al's piece in Family Practice Management.⁵

Know your rights regarding difficult patients. Faced with a difficult patient, a physician has the right to terminate the physician/patient relationship. Importantly, the physician must do so in an appropriate manner to avoid charges of patient abandonment.6 This is not as cumbersome as it may seem. Guidelines are available from the AMA (http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physicianrelationship- topics.page), and it is wise to verify state law as well.

1. Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev. 2007 Jul-Sep;32(3):203-12.
2. Balch CM, Shanafelt T. Combating stress and burnout in surgical practice: a review. Adv Surg. 2010;44:29-47.
3. Krebs EE, Garrett JM, Konrad TR. The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data. BMC Health Serv Res. 2006 Oct 6;6:128.
4. Abbott Moore L. Being empathetic: benefits and challenges for the clinician and client. Top Stroke Rehabil. 2010 Jan-Feb;17(1):20-9.
5. Hull SK, Broquet K. How to manage difficult patient encounters. Fam Pract Manag. 2007 Jun;14(6):30-4.
6. Randolph DS, Burkett TM. When physicians fire patients: avoiding patient "abandonment" lawsuits. J Okla State Med Assoc. 2009 Nov;102(11):356-8.