Responding to Patients and Society in Distress.

Not long ago my mother was hospitalized. She shared a room with another patient who, within minutes of her arrival, verbally threatened her. The roommate complained bitterly, used abusive language, and often raised her voice toward both my mother and also the hospital staff and resident physicians when they entered the room. This patient was unpleasant and relentless in her demands of the nurses. As we waited for an operating room to open up over many hours, the patient continued with her intimidating remarks to my mom. My mom was frightened—frightened by her acute health condition that required surgical intervention and frightened by her roommate. When my mom was transported for her procedure, the roommate demanded to be moved to my mother’s spot in the room because it was next to the window. She yelled at passers-by in the hallway that she was being mistreated, and told the staff that she had lodged a complaint with the CEO because of their incompetence. She turned her attention to me at one point, screaming that she hoped my mother “would never come back” from the OR. Without a word, I left the room and looked for a quiet place to sit and wait. After a bit, a nurse came up to where I was sitting. She reached into her pocket and offered me a mini-chocolate bar. She said, “I am so, so sorry.” While I felt a bit rattled by the roommate’s behavior, mostly I felt a bit detached, preoccupied with concern for my mom. I explained to the nurse that I was a physician—a consultation–liaison psychiatrist with many years’ experience in general medical settings—and that I had seen behavior like that of the roommate before, but it was still surprising. The behavior was not what I expected from seriously ill patients on the internal medicine floor. The nurse shook her head and said, “That’s how it is now. It’s really something.” I thanked her for her kindness and excellent care for my mom, and I complimented her on the excellent care for the roommate, too, who had not made it easy. After a while, I got news that my mom had done well and was being moved to a different room for post-op care. After a very long couple of days in the hospital, we got her home, safe and sound. Once it was over, I started to think about the roommate’s words and behavior and the different repercussions for my mom, me, and the caregiving team. I mentioned this experience to a couple of my colleagues with significant duties in inpatient and emergency medicine settings. Just like the thoughtful nurse, they shook their heads and said, “Yes—things have changed. It’s really different.” The current milieu of medicine is different. My sense is that things have changed because our patients, and our society, are in great distress and that this distress is finding expression in health care settings. In a report1 appearing in this issue of our journal, Hu et al explore the experience of mistreatment of medical students by patients in the learning environment in a qualitative study involving 14 student volunteers enrolled at a large Canadian medical school. The students describe numerous negative encounters with patients—none of which were formally reported to the administration—in which they were mistreated. The authors discuss influences that may promote or perpetuate mistreatment, creating a nonequitable learning environment, and also describe the sense of futility, discouragement, and resignation felt by students. In this study, trainees who had been mistreated by patients predictably “described struggling to maintain empathy for, openness to, and overall ethical engagement with discriminatory patients.” Because the mistreatment by patients recounted in Hu et al often focused on the gender, ethnicity, or racial identity of students, it could be reasoned that mistreatment by patients, sadly, will be an increasing concern as the health professions become more inclusive. In the past I have written quite a bit about how as physicians we should always remain mindful of our professional values and our clinical responsibilities when encountering a disruptive or challenging patient.2–6 In our roles as health professionals, we should view problematic, and even dangerous, behavior as a clinical sign—an indicator of anguish, underlying symptoms, or physical or psychological pain. Patient behavior, I have suggested, gives us the key to helping our patients. Our task is to use that key to respond therapeutically, rather than react negatively. Furthermore, we should conduct ourselves in a manner that seeks to ensure safety in the health care environment and to protect the dignity of our patients who express their distress. Both professionally and personally, I continue to believe and espouse this view. Moreover, I have come to realize that difficult behavior, which is increasingly common in health care settings, is more than simply a clinical sign. It is a societal sign—a reflection of divisiveness, isolation, and mistrust in our world. I worry, moreover, that such difficult behavior may be an indication of the erosion of respect for health professionals and medical institutions. Our task is the same—to interpret behavior and respond therapeutically and, at the same time, to ensure safety and protect patients’ dignity—but it is clear that we must do more to understand and address the larger forces at play in the health care environment. Such efforts are crucial since interpersonal tension, harassment, threatening behavior, and even violence are commonly reported in health care settings.7,8 The Bureau of Labor Statistics9 documents an increase in nonfatal intentional injuries inflicted by another person upon private health care workers between 2011 and 2018. Similarly, a recent single-site study10 indicated that 87% of registered nurses experienced incidents of workplace violence, of which more than 96% were patient related. Another study,11 in 2018 and 2019, found that more than 60% of responding hospital employees had been victims of physical violence by patients, and 12% had experienced actual physical harm. The factors that are leading to increased aggression in health care settings require careful study. Reasons posited include patients’ anger related to their worsening health, problems of access to services, and grief associated with losses of loved ones, often in hospital settings.12 Patients and families may also be expressing their frustration with staffing shortages and the lack of services in many communities.13 And worsening health and socioeconomic disparities and the current adversarial political environment, I posit, contribute as well. Fortunately, there are many constructive strategies that may help to reverse the trend of increasing aggression in health care settings. Intensified and specialized staffing—especially in high-risk clinical settings—strengthened training for health professionals, expansion of resources in underserved communities, and more intentional collaboration with government agencies are a few of the approaches that have been identified as bringing some benefit in addressing the problem.14 I am sharing this story of my mom’s experience to illustrate some of the emotional impact for patients and their families who are in need and who may feel vulnerable and unsafe in the very place that is entrusted with restoring health and providing security. Similarly, health care professionals and trainees also may feel vulnerable and unsafe in the places where they spend long hours, performing very difficult work, and they too deserve to feel secure and supported. Along with others in society, the members of the health professions workforce have been suffering.15 The problem of aggression in clinical settings appears to be worsening. It is clear that the pandemic increased the hardships and complexity of frontline work.16 Repeated negative interactions with patients may further contribute to emotional exhaustion and diminished resilience amongst health care workers.8,17,18 The formative impact of such interactions on trainees is yet to be fully understood, as noted by Hu et al, but certainly threatens individual and workforce wellbeing.1 Thus the story of my mother’s experience also serves to underscore the importance of safety in the health care and learning environment and also the importance of mutual support, respect, and gentleness amongst colleagues. Reaffirming our commitment to our professional values may go far in restoring trust in the health professions on a societal scale.5,19 Among the many strategies we undertake in addressing aggression in health care settings should be our intensive efforts to create a sense of belonging and respect in those settings. No one should deal with hardships alone. We will be more effective in our service to others as we, together, respond therapeutically to individual patients’ needs, no matter how they are expressed, and stand with one another to support a society—our society—in its distress.