Challenging Patient-Physician encounters in the Emergency Room

Nov 09, 2014 News

…a physician’s perspective

(With Dr Zulfikar Bux, Head of GPHC’s A&E; Asst. Prof. of Emergency Medicine)

The emergency room is a crucible for the medical encounter. Life-threatening illness and trauma are more likely

Dr Zulfikar Bux

to appear here than in the office or clinic, hence, decisions often must be made quickly. Patients’ physical distress and fear push them to extremes of behaviour.
Crisis, fear, strange behaviour, and the opportunity for heroic success or failure—the elements on which drama and melodrama thrive—are common place in the emergency room. These are occurrences in all emergency departments and will vary according to the setting.
It makes sense that these high-pressure conditions turn up the heat on the patient-physician interaction also. The personalities of individual patient and physician and the range of personal, social, and professional expectations that each brings to the interaction always have the potential to turn the medical encounter into a difficult one; they are almost certain to do so in the emergency department where patients are frequently hostile, angry, combative, or abusive if special care is not taken to avoid potential problems.
This week we will discuss reasons that may contribute to difficult patient-physician encounters in the emergency room and we will look at solutions to these issues in next week’s article.

LACK OF A HISTORY BETWEEN THE PARTIES
Perhaps the most consequential characteristic is that the patient who walks or is brought into the emergency department and the physician who is there to treat that patient are generally meeting each other for the first time. There is no prior relationship and no patient history to refer to. Neither party knows what to expect. Or either or both may be suspicious.

PRE-DETERMINED EXPECTATIONS
Patients usually come with expectations to emergency departments that can’t always be realistically met. Patients or their representatives may come with pre-determined expectations such as having a specific test done, the right to be seen immediately no matter the situation, not wanting to wait for investigations or not being able to have full control of their movement in the emergency room. These expectations are not always in line with the plans of the emergency physician who has to make the correct diagnosis and treatment plan based on the patient’s condition and not often on their wants. These differences in opinions between the patient and the physician may lead to tension, building a possible confrontation.

PATIENTS BROUGHT AGAINST THEIR WILL
Patients may have been brought to the hospital against their wishes, by friends, family members, an emergency response team, or police. If so, they may be hostile, combative, or abusive and attempt to refuse treatment or to leave the hospital.

CULTURAL BARRIER
Some of those whose only medical care comes through the emergency department are homeless or otherwise outside the community’s safety nets of care. These patients, whose numbers are greater in urban areas, may have become dependent upon street survival behaviours that don’t rely on the open exchanges of information and discourse expected in the patient-physician relationship. Their lack of manners may be off-putting to the clinician.

FRUSTRATED PATIENTS WITH CHRONIC CONDITIONS
There are patients who receive routine medical attention, have no psychiatric diagnosis, are compliant, but have recurrent acute relapses in their chronic condition that may require frequent emergency room visits. These patients develop frustrations about their conditions and sometimes vent their anger on the emergency physician who they have to see whenever they have an acute exacerbation. They are often upset, perhaps fearful, and maybe unable to process information in their characteristic rational manner.
In a rapidly evolving fast-paced world, there is a gradual change in the patterns of behaviour we have come to expect from all in society. Everyone is becoming more time-sensitive and their needs and wants are gradually increasing. Society now demands more to be done in shorter durations. When these expectations cannot be met, tensions will build and difficult encounters will occur. The emergency physician is expected to attempt to maintain calm when these encounters do occur.

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