Editors' Note

Abstract

Editors' Note James M. DuBois, Ana S. Iltis, and Heidi A. Walsh Approximately 15% of adult patient encounters are with patients described as "difficult" by healthcare providers. These encounters often evoke feelings of dread, frustration, and anger in healthcare professionals. Verbal or physical abuse of staff, repeat hospital admissions due to self-injurious behaviors, and unusual beliefs about health may make care difficult. In other cases, patients may lack the resources or social support to follow treatment protocols. Additionally, healthcare providers may bring biases, personal triggers, or inaccurate assumptions to patient encounters. David Vilanova, a cardiac and intensive care nurse, writes: No guidelines truly exist when it comes to the management of a patient that you simply do not like. The result can be a near-instantaneous dread each time you must answer that patient's bed alarm, call light, or most basic needs. A negative bias takes over, and it would be an understatement to say that this affects the quality of care. Patients in situations like this—with providers who judge them as I have been guilty of—can easily become subject to derogatory remarks, health inequities, and biased labeling in charting that follows them from one hospital visit to another. […] We often cannot control our initial thoughts. The knee-jerk reactions we have toward people, places, and things or the judgments we make about the patients that cross our paths, but what we choose to think and do beyond that is up to us. Through self-care before work and active reflection throughout my shift, especially in times of stress, I can ensure I am doing my best to provide high-quality care to my patients regardless of their circumstances. In this issue of NIB, 12 healthcare professionals including physicians, nurses, and social workers who have cared for "difficult" patients describe their experiences and offer constructive responses to these challenging situations. Eight additional stories are available in the online supplement. The symposium editor, Autumn Fiester is an Associate Professor and Associate Chair for Education in the Division of Medical Ethics at the Perelman School of Medicine at the University of Pennsylvania. She is the Executive Director of the Penn Program in Clinical Conflict Management. Much of her work focuses on the "difficult" patient. Fiester also provided a commentary article for the symposium. Aliza M. Narva & Erin T. Marturano and Yolonda Y. Wilson provided two additional commentaries. The commentary authors have expertise in conflict management, building ethical competence among clinical teams, ethics consultation, nursing, and racial justice. All three commentaries offer important insights into the authors' stories. Reflecting on how healthcare providers can change their approach to working with so-called "difficult" patients, Narva and Marturano surmise, "Good care may not mean recovery, healing, or a patient's return to a former, healthier self. It may mean relinquishing control and focusing on the patient's story rather than the clinical outcome, or apologizing, connecting and learning." This issue of NIB includes two case studies. In "The Right to Be Childfree," Andrea Eisenberg & Abram L. Brummett describe a situation in which [End Page vii] Eisenberg's 23-year-old patient requests permanent sterilization. "I know I'm young, but I know I never want kids. I've never wanted kids. My whole life, I've never wanted kids." The patient, whom Eisenberg has never treated before, explains, "I've struggled my whole life with mental illness. I know I could never take care of a child. I have read articles about the risk of regret, but I won't ever regret this." A growing number of individuals are identifying as members of the child-free movement. They desire or have undergone permanent sterilization, do not have biological children, and never want to have them. But as Eisenberg learns, many of these individuals have undergone "bingoing"—a phrase used by people who are child-free to describe when a physician attempts to convince them that their decision is wrong and dismisses their choices. The authors state that this is an outdated model of the doctor-patient relationship and instead the physician and patient should exchange reasons for their choices and engage in shared decision-making. "It is appropriate to offer...