当医生不喜欢他们的病人时会发生什么？

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Healthcare providers have a responsibility to care for all of their patients equally, but not all doctors and nurses like their patients. In a recent article for The Washington Post, Dr. Joan Naidorf discussed what it feels like to take care of a difficult or unruly patient and how these negative feelings can be detrimental for both patients and providers.

Naidorf recalled being asked to treat a female patient with severe pain that she had already seen twice before.

“She was always crying out in agony. She would inject drugs into her legs leading to multiple deep infections. There was poor intravenous access, and once we established an IV, she accepted some medications and signed out against medical advice. I resented that she did not fill any prescriptions and did not see a primary care physician outside the ER,” the physician wrote.

Naidorf explained that the patient was struggling with substance abuse and an undiagnosed psychiatric disorder, which couldn’t be adequately addressed in an ER setting.

“It seemed to me like she was purposely making herself sicker while frustrating me and our nurses further,” she noted.

According to a study in the Archives of Internal Medicine, internal medicine physicians find around 15% of their patients to be “difficult.” Interactions with these patients can leave providers feeling frustrated, resentful, defeated or inadequate.

If a physician sees around 25 patients a day, they will likely encounter these feelings between three to four times per shift.

Naidorf argues that many providers ignore these feelings, believing them to be contrary to the oaths they took to provide the best possible care to all patients.

Psychiatrist James E. Groves addressed these concerns in his article, “Taking Care of the Hateful Patient.”

“When the patient creates in the doctor feelings that are disowned or denied, errors in diagnosis and treatment are more likely to occur,” he wrote.

Groves found that providers caring for “hateful” patients were more likely to feel helpless, to unconsciously punish the patient, to punish themselves, to inappropriately confront the patient, or to avoid or remove them from the clinical setting.

If the patient believes their provider is unconsciously judging or punishing them, any sense of trust quickly breaks down. A study in the British Journal of Medicine found that patients who believed their doctor had compassion for their plight were more likely to take their medication, follow through with treatments, experience better outcomes, rate their physicians higher, and file fewer malpractice lawsuits, even when a mistake was made.

Rana Awdish, medical director of Care Experience for the Henry Ford Health System in Detroit, recently wrote about the problem with branding patients as difficult in her memoir, “In Shock: My Journey From Death to Recovery and the Redemptive Power of Hope,” after one of her nurses labeled her as “difficult” while she was being treated for a critical disease.

“We label patients. We label them as cooperative, or drug-seeking, realistic, or difficult,” Awdish wrote. “It functioned as an abridged report to our colleagues of what to expect. ‘Difficult’ was shorthand for ‘The patient is not going along with the plan. I have a good solid plan, and they weren’t on board.’ … We insisted on creating a dynamic in which one person wins and the other loses.”

Naidorf argued that medical providers are just as susceptible to “negativity bias” as other human beings. We all have a tendency to judge one another. It’s an instinct our ancestors used to detect and avoid imminent danger.

Medical providers are also trained to look for what’s wrong in any given situation, even if it means blaming the patient for their life decisions.

Naidorf wrote that she heard plenty of teachers and colleagues using derogatory language toward patients that were seen as difficult, disagreeable, or just non-compliant. They referred to patients that return to the ER regularly as “frequent fliers” and “drug seekers”, but she believes providers don’t have enough information about their patients to make such sweeping generalizations.

“We generally do not have all the information we need to formulate an accurate assessment. Because of confirmation bias, we tend to interpret new information as being supportive of the opinions we already hold. We search for things in the world that support the negative beliefs we already have. We also ignore evidence that disagrees with or does not confirm our preconceived beliefs,” she wrote.

When it comes to combating negative bias, Naidorf encouraged providers to imagine what their patients are going through, including how terrifying it would be to have a symptom or disease they don’t yet understand.

She also suggested that providers should look for common truths about the patient. For example, is this patient someone’s son or daughter? Are they suffering from an undiagnosed mental health disorder that may be contributing to their difficult or combative behavior? Providers should think about what may be causing this behavior and whether they should give the patient the benefit of the doubt.

Every provider knows what it feels like to care for a difficult patient, but these labels often do more harm than good. Keep these ideas in mind to avoid the trap of confirmation bias.

全文翻译（仅供参考）

医疗保健提供者有责任平等地照顾所有患者，但并非所有医生和护士都喜欢他们的患者。在华盛顿邮报最近的一篇文章中，琼·奈多夫博士讨论了照顾一个难相处或不守规矩的病人的感觉，以及这些负面情绪如何对病人和提供者都有害。

奈多夫回忆说，她曾被要求治疗一名患有严重疼痛的女性患者，她之前已经看过两次。

“她总是在痛苦中哭泣。她会把药物注射到她的腿上，导致多处深度感染。静脉通路很差，一旦我们建立了静脉通路，她就接受了一些药物治疗，并拒绝接受医疗建议。我很不满她没有开任何处方，也没有在急诊室外看初级保健医生，”医生写道。

Naidorf 解释说，患者正在与药物滥用和未确诊的精神疾病作斗争，这在急诊室环境中无法得到充分解决。

“在我看来，她似乎是故意让自己病情加重，同时进一步让我和我们的护士感到沮丧，”她指出。

根据《内科医学档案》的一项研究，内科医师发现大约 15% 的患者是“困难的”。与这些患者的互动可能会让提供者感到沮丧、怨恨、挫败或不足。

如果医生每天看大约 25 名患者，他们每班可能会遇到 3 到 4 次这些感觉。

Naidorf 认为，许多提供者忽视了这些感受，认为它们违背了他们为所有患者提供最佳护理的誓言。

精神病学家 James E. Groves 在他的文章“照顾可恶的病人”中解决了这些问题。

他写道：“当患者在医生身上产生被否认或否认的感觉时，更容易出现诊断和治疗错误。”

格罗夫斯发现，照顾“可恶”患者的提供者更有可能感到无助、无意识地惩罚患者、惩罚自己、不恰当地面对患者，或者避免或将他们从临床环境中移除。

如果患者认为他们的提供者在无意识地评判或惩罚他们，那么任何信任感都会迅速瓦解。《英国医学杂志》的一项研究发现，认为医生对他们的困境有同情心的患者更有可能服药、坚持治疗、获得更好的结果、对医生的评价更高、提起医疗事故诉讼的次数更少，即使在犯了一个错误。

底特律亨利福特医疗系统护理体验医疗主任拉娜·奥迪什（Rana Awdish）最近在她的回忆录《震惊：我从死亡到康复的旅程和希望的救赎力量》中写到了将患者标记为困难的问题。她的一位护士在她接受重症治疗时称她为“困难”。

“我们给病人贴上标签。我们将它们标记为合作的、寻求药物的、现实的或困难的，”Awdish 写道。“它的作用是向我们的同事提供一份关于预期结果的简短报告。“困难”是“患者不遵守计划”的简写。我有一个很好的可靠计划，但他们没有参与。......我们坚持创造一个人赢，另一个人输的动态。”

奈多夫认为，医疗提供者和其他人一样容易受到“消极偏见”的影响。我们都有一种互相评判的倾向。这是我们的祖先用来发现和避免迫在眉睫的危险的本能。

医疗服务提供者也接受过培训，可以在任何特定情况下寻找问题所在，即使这意味着将患者的生活决定归咎于患者。

奈多夫写道，她听到很多老师和同事对被视为困难、不愉快或不顺从的患者使用贬义语言。他们将定期返回急诊室的患者称为“飞行常客”和“药物寻求者”，但她认为医疗服务提供者没有足够的患者信息来做出如此全面的概括。

“我们通常没有制定准确评估所需的所有信息。由于确认偏差，我们倾向于将新信息解释为支持我们已经持有的观点。我们在世界上寻找支持我们已经拥有的消极信念的事物。我们也忽略了不同意或不能证实我们先入为主的信念的证据，”她写道。

在打击负面偏见方面，奈多夫鼓励提供者想象他们的患者正在经历什么，包括出现他们还不了解的症状或疾病会有多可怕。

她还建议提供者应该寻找关于患者的共同真相。例如，这个病人是某人的儿子还是女儿？他们是否患有未确诊的心理健康障碍，可能导致他们的困难或好斗行为？提供者应该考虑可能导致这种行为的原因以及他们是否应该让患者受益于怀疑。

每个提供者都知道照顾困难患者的感觉，但这些标签往往弊大于利。牢记这些想法，以避免陷入确认偏差的陷阱。