April 27th, 2016

The Dark Side of Medicine

Ahmad Yousaf, MD

Ahmad Yousaf, MD, is the 2015-16 Ambulatory Chief Resident in Internal Medicine at Rutgers New Jersey Medical School.

The following is paraphrased documentation, authored by a physician I know, regarding an intoxicated patient in the ER:

1AM: Patient is telling nurse, “Before I leave, I need everyone’s name for my lawsuit. Tell the phlebotomist that if he’s good, he’ll  get a cut.”

1:40AM: Patient is making inappropriate sexual comments and is verbally aggressive with medical staff. He is advised to stay in bed.

2:02AM: Patient (who had been sleeping comfortably) wakes up and begins screaming obscenities at everyone. When a nurse asks why he was angry, he says, “What do you think , mother f*****? I will wipe your a**.” Multiple attempts to calm patient fail.

depressed girlI will stop here, because the insulting language, obscene physical gestures, and eventual threats of physical abuse only become more vulgar and inappropriate. The attending recorded in the chart, word for word, the things that spewed from the patient’s mouth and, eventually, when he became physically aggressive, called the Crisis Team who came and restrained the patient.  The story was shared with me by one of the residents who had witnessed the entire discourse, and we laughed about the absurdity of some of the drunken babble. We also smiled in speaking about the state of mind of the doc who documented the conversation so meticulously in the chart. She must have just had it with the abuse and decided she was going to permanently record all the nonsense in the EMR.

As I sat by myself, thinking about the somewhat comical story, I realized that it really was not funny at all. This is the status quo. Healthcare professionals deal with patients like the one above every day. The verbal abuse and physical threats are so common that we have settled in to just trying to find some humor in them. This type of abuse is not unique to the healthcare field, but the difference is that you cannot just stop treating your abuser. You have to make sure he or she gets better… You cannot fire a patient in an ER who would die in the street if you kicked him out. Every doc or nurse has an anecdote in which they have been spit on, urinated on, cursed at, assaulted, or threatened.

In the medical world, we do not talk a lot about this aspect of our training and experience. Incoming residents have no idea that, along with their medical education, they will be getting a pedagogy in dealing with some seriously aggressive personalities. Whether it is a drunk patient in the ED, an angry family member, or the overtly psychotic patient on the psych ward, being on guard becomes second nature.

I remember one resident laughing hysterically as he described an enraged patient using the TV remote as weapon against his caretakers, swinging it in circles like a lasso. Or the time a family member broke into the medical lounge and attempted to physically intimidate a resident into changing a medical plan for a dying patient in the ICU. I have seen female trainees and attendings cat-called, harassed (both physically and verbally), and made to feel unsafe by the people they care for. It is tough to diagnose and treat someone when you cannot put your hands on them without fear of a violation of personal space.

This is medicine. There is so much beauty in the patient-doctor relationship and so much that I could say about the wonderful people whom I have learned from and loved while they were under my care. But, like anything else in life, medicine has a dark side that we rarely discuss with people outside of the field. With an increasing percentage of doctors feeling unappreciated, abused, and depressed, maybe it is time to share the whole story (N Engl J Med 2016 Apr 28; 374:1661).

Please share your experiences.

P.S. God bless nurses, who deal with this stuff even more often than docs do.

36 Responses to “The Dark Side of Medicine”

  1. Axel says:

    That’s a big problem, but I think that patients who are in a phsychotic attack, they are dangerous but they are really sick and thats not their fault, the big problem are the angry family members who assault the medical staff should be prosecuted.

  2. tom benzoni says:

    Dr. Yousaf:
    You bring up a timely issue; actually, several.
    1. No one has a right to assault my staff. Period. Drugs, psych, whatever, nothing gives someone that right.
    It would behoove anyone working in an Emergency Department to be familiar with their own state laws; in Iowa, we have Iowa Code 708.3A. contact the police and request charges be filed.
    2. Administration must create an expectation that these charges are filed and back it up with action. There are several compelling reasons, not the least of which is the legal threat of creation of an unsafe/hostile working environment. (It would be pretty easy to demonstrate an unsafe working environment when one can show that management expected staff to take abuse and not do anything; that’s the definition.)
    3. Management must lose the (occasionally unspoken but, in best passive-aggressive fashion, always present) mantra of “customer service above all else. There are really good business reasons for this; Google “5 reasons why the customer is always right is wrong”, Huffington Post.
    4. There is a medical side as well. Once we have decided the patient is not experiencing an Emergency (EMTALA is ok, but we can do better.), we are free to discharge them, whether to jail or with family. Importantly, being drunk but able to carry on ADL’s is not an EMC; the patient has capacity. If the patient goes out and gets more drunk, that is not your issue; you do not own them and are not responsible for the decisions of another competent adult.
    Stay safe, work safe, and enjoy.
    “Illigitimi non carborundum”

    • Mrs.walkley says:

      The paternalistic society we are now in is forcing us to live with behavior that is frustrating and inexcusable. We’ve become those bad parents who just won’t stand up to their misbehaving adolescent.

  3. Nena says:

    I just register patients in the ER and have seen this behavior. At least one a week a nurse gets injured from crazy patients. There’s no excuse for this behavior. What can we all do about this?

  4. Luckily, in Colorado, spitting is now considered assault and patients are being charged. Glad you added your PS because nurses are receiving the bulk of this abuse.

    I’m also surprised you only spoke of the alcohol inebriated patients. There are just as many patients who are intoxicated, demanding and abusive because of other drugs including running out of the physician prescribed opiod that is now the patient’s addiction!

    And unlike some bigotted bakers who refuse to serve people whose religious or political beliefs do not meet the standard of business owners, we are obligated to treat all, including those who mistreat and assault us.

    I don’t disagree that some/many of these people are “sick” whether self-induced or not. However what of the safety, protection and health of the health care professional?

    This is more than the “darker” side of medicine.

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