Resident Readiness General Surgery (70 page)

2.
Communicating with Mr. Downey may be difficult, but there are general techniques that can be used. First and foremost, a united, clear, and consistent message must be utilized when communicating with all difficult patients. Although most common in borderline personality disorder, all patients are capable of unintentionally
splitting
treatment teams so as to cause disagreements and difficulties that lead to disrupted care and poor outcomes. In addition, it is paramount that certain boundaries be clearly defined and maintained with all patients utilizing maladaptive traits.

A common technique equally useful for difficult, demanding, hostile, or dependent patients is scheduling specific, time-limited sessions that are entirely and solely treatment based (eg, seeing hospitalized patients twice at 8
AM
and 1
PM
daily for 15 minutes each, going over very specific treatment agendas). Informing the patient of the schedule up front and then enforcing it is crucial. One will need to cater the content of these sessions depending on the person’s traits. For example, obsessive–compulsive personalities often dwell on details and minutiae; it may be helpful to enlist them in keeping track of their own recovery (vital signs, labs, medication regimen) while keeping them informed when small fluctuations and insignificant changes are not to be worried about to minimize anxiety.

Considerable anxiety, worry, and stress related to medical conditions, immobility, loss of function, or pain are each very real experiences.
Empathizing
with such an experience can be challenging due to a patient’s toxic demeanor and attitude but also very powerful in creating an alliance. The principal mechanism of empathy is
validation
or acknowledgment of a patient’s concerns. Empathy is a direct recognition of what the patient is experiencing and reflection of it back in a clear, simple, and nonjudgmental language. In Mr. Downey’s example, one might recognize his concerns and confirm them with empathic statements (eg, “It must be terrifying to think about going to prison.”) rather than with less empathic questions (eg, “What are you so worried about?”). Additionally, one may attempt to
normalize
concerns expressed by a patient (“Your reaction to a prison sentence is natural.”), paving the road to a shared understanding. A patient who is validated in this manner may sense genuine concern and engage in a more cooperative dialogue, leading to shared clinical goals. Finally, depending on the patient’s values, it is important to identify others who may assist in enhancing communication, including but not limited to family members, friends, intimate partners, social work, or clergy. In some instances, consultation with a psychiatric service may be indicated.

TIPS TO REMEMBER

Personality disorders are organized in clusters according to general attributes (mnemonics of “BAD-MAD-SAD” and “WEIRD-WILD-WORRIED”).

Psychiatric consultation can assist in the management of difficult patients, especially in cases of severe aggression, behavioral outbursts, breakdowns in communication, or poor judgment suggesting a lack of decision-making
capacity. It should be said, however, that simply disagreeing with the surgical team does not mean a patient lacks decision-making capacity!

Empathic validation and normalization packaged in statements (rather than questions) can increase the therapeutic alliance when working with difficult patients.

Splitting should be reduced with unified and consistent messages. Specific and focused sessions can be useful when working with hostile, demanding, or dependent patients.

Awareness of clinician feelings and reactions to difficult patients can prevent worsening in communication and cooperation with such patients.

COMPREHENSION QUESTIONS

1.
Mr. J is a 44-year-old man who requires imminent below-the-knee amputation. He refuses on numerous accounts, reporting doctors cannot be trusted and that he generally shuns medical advice. On exam, he is oriented to time and space, reveals a flattened affect, and communicates various inaccurate thoughts, including that the infection will heal on its own. He wishes to be discharged. What is the next course of action?

A. Respect his autonomy and discharge the patient with oral antibiotics.

B. Consult psychiatry to evaluate for a psychotic disorder and capacity for decision making.

C. Override the patient’s autonomy and operate emergently.

D. Treat empirically with antipsychotic medications.

2.
A 31-year-old woman is admitted to the ICU for close observation after reportedly ingesting an entire bottle of acetaminophen as well as causing self-inflicted burns to her arms with her gas stove. These occurred in a fit of rage after her boyfriend of three months announced he would leave her. Her psychiatric history includes brief trials with antidepressants but no current treatment. She has seen literally dozens of psychiatrists. She has been admitted to psychiatric services over a dozen times since the age of 18, but she denies any serious suicide attempts. She was diagnosed with a personality disorder at age 19. Which of the following best characterizes this patient’s recurrent behaviors?

A. Paranoid personality disorder

B. Antisocial personality disorder

C. Borderline personality disorder

D. Dependent personality disorder

3.
Mrs. K, a 56-year-old retired nurse with no significant medical history, is sent to the ED by her outpatient surgeon who performed an unremarkable elective hernia repair three weeks prior. Postoperatively, she has healed poorly with numerous
bouts of fever, night sweats, and fatigue. She has not responded to trials of antibiotics, and her surgeon is perplexed. On admission, blood cultures are drawn, revealing a gram-negative bacteremia. Her surgical site is erythematous and grossly infected. She is given IV antibiotics, but after numerous days in the hospital, a nursing assistant witnesses Ms. K rubbing something vigorously into her wound site. On confrontation she breaks down but cannot explain her behavior and is very ashamed. She begins to describe numerous difficulties at home, including a tumultuous divorce, an unruly son who was recently arrested, and chronic financial struggles including potential bankruptcy. Which of the following statements would you use in approaching Mrs. K at this point?

A. “Why are you infecting yourself?”

B. “It makes perfect sense that you are overwhelmed.”

C. “Maybe you don’t need to be in the hospital.”

D. “You don’t seem to want to be better.”

Answers

1.
B
. Mr. J is refusing a presumably lifesaving intervention, and it is important to establish whether he has the capacity to refuse treatment. It is unclear at this point if he is simply uneducated about his disease, is afraid of doctors because he or a family member has had a bad experience in the past, has a psychotic illness, or is under the influence of a substance. Clarification of diagnosis, decision capacity, and whether dopamine antagonist medication is indicated may result from consultation with a psychiatrist. Although patient autonomy is an important value to uphold, discharging this patient prematurely may cause significant harm or even death.

2.
C
. This patient exhibits mood dysregulation, intense interpersonal relationships, impulsivity, a history of self-injury, and suicidal behavior in the absence of other psychiatric or medical explanations. She has had a long history or psychiatric contact and psychiatric hospitalizations since age 18, giving one a very longitudinal history, and she tells you she has been diagnosed with a personality disorder. The maladaptive traits discussed here are present in Cluster B (“BAD AND WILD”) personality disorders, with borderline personality disorder being the most likely diagnosis.

3.
B
. Patients with suspicious symptoms (in this case, symptoms of a likely factitious disorder) can become very defensive when confronted, and may continue problematic behaviors if not empathically validated at some level. Mrs. K would benefit from normalization of her feelings, but not of her behavior. Gentle confrontation of her emotional difficulties can pave the way for a therapeutic alliance. Psychiatry consultation should be obtained on most suspected cases and perhaps a referral to social work for psychosocial support would be helpful.

Section IV.
Handling Patients in Clinic