When patients are seen as “The Enemy”

~ Carolyn Thomas

by Carolyn Thomas  ♥ @HeartSisters

My daughter loves her career as a probation officer. She is very good at what she does, and finds the work both challenging and rewarding. Yet her client case load includes some of the most unsavoury of individuals, found guilty by the courts of child abuse, domestic violence, sexual assault or worse, many of them  living with added complexities like addictions or mental health issues. She’s been insulted and screamed at by distraught clients. Police are sometimes dispatched to her workplace to intervene in potentially dangerous crises. Few of us could even imagine working in her office every day.

Yet whenever I ask my daughter what kind of day she’s had today, I marvel at her continuing ability to truly care about the work she does, despite the many challenges of working within the criminal justice system, dealing with an often-desperate clientele, and an almost overwhelming legal bureaucracy.

Contrast that perspective with the collective unrest among physicians who seem to hate their jobs. 

An example is well-known Chicago cardiologist Dr. Wes Fisher‘s recent online essay called “Hostile Dependency: The Real Reason For Physician Burnout”. It’s a compelling exploration of his belief that “most doctors” are turning away from medicine.

He blames this trend on the serious challenges doctors face when caring for their patients.  He blames the many layers of bureaucracy and paperwork, both electronic and manual, that burden today’s physicians. But the brunt of his blame lands on one particular target:

“As bad as these realities are, they are probably not the reason most doctors are turning away from medicine. 

“I think there’s another issue that is even bigger.

“I believe the overriding reason doctors leave medicine is because there is a growing hostile dependency patients have toward their doctors.”

Comparing the hostility of patients to what he calls the disillusionment felt by acting-out teenagers when they discover that their parents have feet of clay, Dr. Wes adds:

“Most of us understand this behavior simply as “adolescent rebellion”, not understanding the powerful issues at play.  So when we spotlight doctor burnout or the lack of patient safety in hospitals without acknowledging the realities health care workers face – like looming staffing shortages and pay cuts – we risk fanning the flames of narcissistic rage against the very caregivers whom we depend on the most.”

Thus the blame for this burnout among medical professionals is laid squarely at the feet of the very people who inspired physicians to enter the practice of medicine in the first place: the patient.  That self-absorbed misguided sod who just can’t comprehend the problems that one’s doctors are facing.

Why do some doctors blame patients for their discontent?

Dike Drummond, MD spends a lot of his time thinking about this question. He describes physician burnout as a downward spiral that has three distinct symptoms:

  • physical/emotional exhaustion
  • depersonalization
  • reduced sense of personal accomplishment

It’s that second symptom that doctors like Dr. Wes and others exemplify: depersonalization.

Depersonalization, according to Dr. Drummond, includes the development of a negative, callous and cynical attitude toward patients and their concerns (“my patients are so #%*&!”). The cardinal signs here, he warns, are cynicism, sarcasm and “feeling put upon by those patients.”

Depersonalization is not unique to doctors, of course. Whether you work in medicine or in a school classroom (teachers, for example, have the highest burnout rate of any public service job) or, like my daughter, in the world of criminal justice, depersonalization can rear its ugly head if given half a chance. 

And pointing accusatory fingers at those who need you is very, very tempting.

Dr. Wes doesn’t mention his nurse colleagues in his essay, but studies attribute burnout rates among nurses to low nurse-to-patient ratios, long shifts, and, ironically, dealing with difficult doctors who, as a British Journal of Nursing study described, “regard nurses as their hand-maidens.”(1) Another study conducted by VHA cited “disruptive physician behavior” as a contributor to the nursing shortage, after a whopping 92% of nurse respondents reported witnessing “inappropriate conflict involving verbal or even physical abuse of nurses.”(2)

If you really want to avoid getting burned out, don’t work in public accounting where juggling heavy client loads, frequent business travel, crazy tax season schedules, and relentless quarterly filing deadlines throughout the year lead to prolonged periods of extreme stress and exhaustion.

And those who work in retail or the fast food industry suffer significantly high burnout rates due to very low pay, monotonous tasks, extremely high staff turnover rates, job-related depression, and “not feeling valued.”

But when the depersonalization of burnout happens in the traditional hierarchy of medicine, it may feel heightened by what sociologists describe as a dominant group holding power in a given society (doctors) being disturbed by those who have historically had little power to dare question that dominance (patients).

Jackson Katz is an educator, author, filmmaker, TED talker and author of The Macho Paradox. He had this to say about those who represent a dominant group in society:

“One of the ways that dominant systems maintain and reproduces themselves is that the dominant group is rarely challenged to even think about its dominance.

“It’s one of the key characteristics of power and privilege – the ability to go unexamined, lacking introspection, in fact being rendered invisible in large measure even in the discourse about issues that are primarily about them.

“The dominant group doesn’t get paid attention to while they’re busy pointing fingers at others.”

Is Dr. Wes correct? Are “most doctors” in this dominant group actually turning away from their chosen careers? And is this where the practice of medicine now finds itself?

The times they are a-changin’, just like Dylan warned us. And as I wrote here previously, health care today from the patient’s perspective can look something like this:

  • catastrophic losses caused by medical errors.perpetrated on patients
  • the pervasive influence of the pharmaceutical industry on hired physicians willing to participate in what’s now called “marketing-based medicine“
  • stent-happy cardiologists implanting unnecessary coronary stents while fraudulently altering the medical records of their unsuspecting patients

It’s a pretty frightening time to be a patient, in fact. And if you think it’s tough these days to be a doctor struggling with the burdens Dr. Wes writes about, just try being sick.

No patient I know wants to be labelled as “difficult”, for we realize that to be so judged can demonstrably impact the quality of care received. An interesting study(3) reported in Health Affairs last year found that even though patients voiced a strong desire to engage in shared decision-making about treatment options with their physicians, several obstacles inhibit those discussions, including:

  • even relatively affluent and well-educated patients feel compelled to conform to socially sanctioned roles and defer to physicians during clinical consultations
  • physicians can be authoritarian
  • the fear of being categorized as “difficult” prevents patients from participating more fully in their own health care.

When patients do dare to speak up on medical issues that matter, we risk being shouted down for our efforts by those in the dominant group.

A small example: even in Emergency while presenting with chest pain, nausea, and pain radiating down my left arm, I was scolded by a nurse to stop asking questions of the E.R doctor:

“He’s a very good doctor, and he does NOT like to be questioned!”

The unacceptable questions I was asking that day, as I was being sent home in mid-heart attack with a GERD misdiagnosis, feeling suitably chastised and embarrassed for making such a fuss over nothing, included:

“But Doctor, what about this pain down my arm?”

Many patients who do try to speak publicly can be accused of widespread “doctor-bashing” – and now even called names like “narcissistic” and “hostile”.

Most patients are, in fact, concerned about our doctors’ professional frustrations. We hear them. We get it. We really do. We value and respect good medical care, and want to trust that the physicians who provide good care will be around for a long time. We certainly don’t consider physicians to be our enemies, and are puzzled to be considered or treated as such by any of them.

But the thing about being sick enough to seek medical care is that it’s often impossible to truly focus on the wants and needs of your physician when you’re very ill or hurting or scared. I guess that’s why Dr. Wes called us narcissistic.

Patients will not and cannot single-handedly address this burnout and depersonalization crisis.

We know, however, that not all doctors agree with Dr. Wes. That’s why we appreciate the doctors who can stand with their patients, not against them.

My daughter told me about a concept that those working in domestic violence prevention call the “bystander approach”. Instead of only seeing men as perps and women as victims, for example, their focus is on bystanders who have the power to interrupt. A bystander in this context may witness a comment, a victim-blaming remark, or any other word or behavior that might contribute to negative outcomes and then choose to interrupt the scenario. Thus, rather than silently observing a threat, bystanders dare to speak out to stop the cycle of silence. 

The bystander effect can work both ways, however. We know, for example, that:

  •  the greater the number of bystanders who do nothing to interrupt a specific action, the less likely it is that any one of them will help
  • studies on altruism show that all helping behaviour is more likely when there are similarities between the helper and the person being helped
  • when “us-vs-them” accusations begin, the resulting wedge widens the gap between the two

For examples of this phenomenon, just visit any physician post on KevinMD to read the toxic comments left there by docs whose burnout seems both palpable and contagious.

I wonder if it’s possible to get the doctors who don’t hate being doctors to speak up as bystanders, to be interrupters as this “downward spiral” accelerates within their profession?

There are many of them out there. I know this because I so often hear from them, meet them, read their words and best of all, I’m lucky enough to have three of the very best of them on my own team as my GP, cardiologist and pain specialist.

Another such interrupter is internist Zackary Berger, PhD, MD, who teaches at Johns Hopkins and is the author of the excellent book, Talking To Your Doctor. He chose to respond directly to Dr. Wes Fisher’s essay on “hostile dependency” and “narcissistic rage” like so:

“I confess I have difficulty with this piece. 

“First, I am not sure what the author means by the term ‘hostile dependency’. It seems to mean patients who criticize doctors too much. But iatrogenic error and its attendant morbidity and mortality are real.

“Patient criticism of providers’ failures and shortcomings should not be reflexively dismissed.

“Perhaps the ‘growing hostile dependency’ is a projection onto patients of our increasing realization that something is amiss with healthcare in this country. 

“If we doctors blame patients for pointing out what we all know to be the case, we will be shooting the messenger – pretty hostile, I think.”

Yet another interrupter is physician Rick Lippin, MD, whose essay My New Adult Relationship With My Patients manages to avoid name-calling entirely:

“My approach with my patients has evolved over 35 years of medical practice. The excesses of paternalism in my practice of medicine have been replaced by a much more rewarding adult-to-adult relationship with my patients. Not shaking my finger at them or scolding them as ‘children’ has helped them and me more than you can imagine.”

When my daughter first set her sights on working with criminal offenders, many of us worried about her career path. But very little of her current workplace reality has come as any surprise to her. Like all of us, she experiences good days and bad, but she knew what this life would be like right from the get-go, and has been well-trained to cope.

Eric Van De Graaff, MD has expressed similar observations in his KevinMD column called Why Are So Many Doctors Total Jerks?  (NOTE: I know from having my own articles picked up by KevinMD that titles are not necessarily created by the author, so it’s entirely possible that Dr. Eric found his column title’s word choice as unfortunately cringe-worthy as I did).  Another potential interrupter, Dr. Eric is, like Dr. Wes, a cardiologist – yet one who doesn’t feel the need to compare his patients to acting out adolescents. He warns his colleagues:

“We doctors have chosen professions that are inherently filled with stress, deadlines, and treading in deep emotional waters.  None of that grants us a free pass to behave like spoiled toddlers.”

There well may be “narcissistic rage” boiling up out there, but sadly, much of it appears to be coming from physicians, not from patients.

♥

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(1) Dealing with difficult doctors. Castledine SG. Br J Nurs. 2008 Nov 13-26;17(20):1305.
(2) Nurse-physician relationships: impact on nurse satisfaction and retention. Rosenstein AH. Am J Nurs. 2002 Jun;102(6):26-34.
(3) Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making. Dominick L. Frosch et al. Health Affairs. May 2012 vol. 31 no. 5 1030-1038

This was also picked up as a guest post by KevinMD.com

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Q:  Are patients responsible for physician burnout?

See also:

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Published by Carolyn Thomas

30 thoughts on “When patients are seen as “The Enemy””

  1. Pingback: Hopeful Doc

  2. Carolyn,
    What a shock, but not a surprise, to see the name of one of the doctors I saw during my heart journey this year. Dr. Wes was one of the doctors I gave a try, but have since moved on from.

    It was one of the strangest appointments I’ve ever had. At my one and only appointment he came in the room, sat directly at the computer, didn’t introduce himself, questioned me thoroughly and didn’t make eye contact for the first 15-20 minutes. Seemed to listen somewhat, changed the settings on my pacemaker and sent me on my way. His social skills were so strange, I have just moved on… Detached.

    I have two cardios that listen and I’m grateful. So hard to find.

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    1. I think it’s imperative to begin some burnout prevention strategies in med school – particularly before you start your clinical rotations with Real Live Patients.

      A study of over 2,600 med students reported in the Journal of the American Medical Association (Dyrbye et al, 2010) found that 52% of med students reported burnout symptoms, that students with med school burnout were more likely to report engaging in one or more unprofessional behaviours than those without (e.g. 3rd & 4th year students reporting a physical examination finding as normal when they had not performed the exam), and that students suffering from med school burnout were less likely to hold altruistic attitudes about a doctor’s role in society including a lower likelihood of wanting to provide medical care for the underserved. Check out Dr. Dike Drummond‘s post on burnout in medical school.

      You might even want to address this issue for your own blog readers! Best of luck to you in your med school experience.

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      1. Thank you so much for your encouragement and reply. There have been a couple of informative sessions whereby professors scare us with greater suicide and alcohol abuse and divorce rates among physicians.

        While I haven’t directly addressed burnout on my blog, I did write recently on wallowing, ideas of depression or perfectionism woven in. My biggest challenge at the moment is writing too much and not studying enough! But I will certainly check out the link if I haven’t already found it on google!

        Last year, I tried my darndest to find good resources against preventing burnout as well as keep up exercising and eating well. My friends and I feel challenged to study adequately and feel prepared while remembering to chill out, to see family etc. But I’ve heard that taking care of yourself is of great importance when caring for others!

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  4. Thank you for another excellent article, Carolyn.

    I too have experienced the distress and great harm caused by depersonalisation, and I wrote here recently about a few of my encounters with it.

    Some descriptions I have seen used of iatrogenically damaged patients by their medical oppressors are ‘disgruntled’ and ‘heartsink patients’. In my country, health professionals are almost completely unaccountable for the avoidable suffering and deaths they cause.

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    1. Your dental experience reminds us that far too often, symptoms of pain can be mistakenly dismissed as anxiety or depression. Studies in heart patients have shown this is also distressingly common in female patients. Some of it may be due to the depersonalization of burnout, but I suspect much of it is ignorance on the part of the diagnostician. When the AHA surveyed physicians in 2005 to find out how many were aware that more women than men die of heart disease each year (a stat that’s been true since 1984), the results were shocking: just 8% of family doctors knew this fact, and – even worse! – just 17% of cardiologists were aware of it.

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  5. Many thanks for this very informative piece and showing what a complex issue this is. I’ve always tried to approach interactions with my doctors in as informed and professional a manner as I can, and have been fortunate in most cases to have excellent doctors who are very responsive to my concerns. I once had to go to the emergency room in a lot of pain. I learned how difficult it can be when you’re in pain to think clearly and to perform such cognitive tasks as remembering the precise details/dates in your medical history. It seems that the emergency room is one scenario where patient vulnerability combined with the possibility of doctor burnout poses particular risk.

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    1. Hi Lisa – you’ve raised such an important distinction here between an Emergency visit and an ongoing relationship between a patient and regular care provider. The former is fraught with complex issues for the patient that can make us particularly vulnerable.

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  6. The word “depersonalization” in any profession makes me sad and reflective about the world today. Yet to hear it in association with healthcare shows a lack of human kindness and compassion – both of which are basic qualities in medicine as I know it.

    No human being should be depersonalized. I have a hard time seeing “hostile dependency” in any patient. Certainly the lives of physicians are stress-filled with long days and overwhelming emotional situations, but ultimately it is the human component that makes a doctor become a doctor. Burnout has to be a real and existing component to their lifestyles, but not because of the patient . . . or so I would hope.

    Your writing has great depth and certainly makes me rethink medicine and physicians.

    I applaud your daughter in her profession and the difference she makes in the lives of those less fortunate or those who have not made good choices in their lives. We need more people like your daughter in this world! Thank you for this most thought provoking writing.

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    1. You’re so right, Sharon – it is the human component that draws people into medicine in the first place, so doubly sad when docs start blaming that very element for their own despair. Read Dr. Drummond’s spot-on comment below for more on physician burnout. Thanks so much for your observations here. PS: I’m very biased, I know, but I agree that we need more people out there like my daughter…

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    2. Sharon, If you’re so worried about depersonalisation by doctors, you should maybe put yourself through med school and experience it yourself. When doctors tell their patients to lead healthy lifestyles and they don’t listen, where are you to preach those patients?

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  7. Great post based on the battlefront of Kevin MD. Weary burned out docs? I can imagine your pain, but try being a patient.

    In the last couple weeks I have added yet another medical error to my list. For those who extol “pro-active patients”, it’s hard to be more pro-active than researching one’s own symptoms, finding a diagnosis that covers everything, and offering it to a series of docs, who reject the suggestion with tolerant smiles and: “Highly unlikely.” “Yet another rare condition.” “So much of what you describe is just from getting older.”

    At one point I went down the protocols of a test, point by point, and explained the various ways in which they did not follow the protocol with me, and why, even if they had, the result did not mean what they said it did. When they can’t come up with a better reply, I’ve heard “Dr. X is excellent and he thinks otherwise. I am entirely satisfied.” from a series of docs.

    Patients should not have to fight for appropriate care as though waging a military campaign, but time after time that is exactly what I have been forced to do. Pull back when faced with extraordinary resistance, work a while on another front, return to the campaign when there’s an opening (or when life is getting noticeably worse and it becomes top priority again.)

    And, time after time, I eventually find the doc in our HMO who takes me seriously, does not agree with the others, and is willing to stand up for his/her diagnosis, that happens to be the one I have been raising (to tolerant smiles and outright denial) for years.

    Just since changing to another primary care doc last year (see Anxious Female), 2 more serious conditions have been verified.

    In the first case, for over 6 years I was denied screening and risk assessment for a cardiac condition notorious for causing sudden death. Very recently I began a simple medication for an endocrine condition (another effect of radiation) that has made my life difficult and saddled this never-smoker with a cardiac risk equivalent to smoking 2 packs a day. I battled on this latter front since 2007, and have proposed the explicit diagnosis, down to the sub sub subset, since 2011.

    In this recent case, after both listening and talking, the doc finally said, “Well, what’s the worst case scenario? Say you’re making every bit of this up. What are you going to do? Pass the spray to your cousin who sells on the black market?” He shrugged at the absurdity of that, and observed that my behavior during the appointment supported yet another thing I had been reporting for years. Put the way he did, it’s even harder to understand or justify those years of resistance.

    On the one hand, I’m glad to be feeling so much better in such a short time. But it confirms that all those years of struggle to put one foot in front of the other, sometimes barely able to to put a phrase together – they were entirely unnecessary, may have shortened my life, and I will never get them back.

    Obstacles erected by docs who view patients as demanding moochers and malingerers. Perhaps even worse when the patient dares to be rather well informed, but without MD after her name.

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    1. Hello Kathleen – at my women’s heart health presentations, I urge my audience to become the “world expert” on their own particular health care diagnosis and treatment. You are indeed the poster child for savvy patients who have spent years learning as much as they can about serious conditions that seem to have eluded their diagnosticians. The difference: patients shouldn’t have to research their condition for pure survival reasons as you have. I’m very glad you’re feeling better these days.

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      1. That’s what my husband says. Great to learn about and study one’s own condition, but not everybody can do that, and none of us should have to in order to survive.

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  8. Thanks for this piece Carolyn. It is important to notice that when a doctor or any other helping professional starts to blame, belittle or dishonor the ones they serve .. that is a symptom of burnout.

    It is symptom number two of the Maslach Burnout Inventory … “Depersonalization” and commonly called compassion fatigue.

    This is a SYMPTOM … and not the core problem. Unfortunately compassion fatigue is so common in some workplaces that it is thought of as “venting” and as a healthy activity. It is not.

    Blaming your patients is a dysfunctional coping mechanism to attempt to stop the drain of burnout. The only reason it seems “normal” is some workplaces have burnout rates approaching 100%.

    This seeing the people you serve as the enemy is common to all helping professions … any job where you learned along the way that someone else’s needs are more important than yours. The spectrum runs from the hospitality industry, through teaching, therapy, nursing, healthcare, to law enforcement and the military. This “others before you” dynamic is impossible to maintain though for the simple reason that you must take care of your own needs in order to have ANYTHING available for others.

    When your tank is empty and you have little to give … that is when compassion fatigue kicks in.

    I work as a coach to burned out doctors all around the country. The recovery from burnout is always multifactorial and must involve more than just taking a break. You can learn a LOT more at my website, The Happy MD.

    Dike
    Dike Drummond MD

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    1. Thanks so much for sharing your unique perspective here, Dr. D and for the important work you do in caring for those who care for us. Your Physician Burnout Prevention guide (“117 different ways to lower stress
      and prevent burnout”      ) is a useful free resource for docs.

      It’s a relief for us patients to hear from somebody like you who confirms that blaming, belittling or dishonoring one’s patients is a symptom of burnout, and is not identifying the core problem.

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  9. Excellent column today. Burnout is possible in ALL walks of life which is why it’s so important for us to practise balance between our working and private lives and be responsible for maintaining a healthy lifestyle.

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  10. Carolyn, thanks for this thought-provoking post. I find it sad to see doctors lashing out at patients. It seems to me that a big part of the problem is the system in which we practice.

    Unfortunately, that system was designed in a time in which patients DID tend to sit quietly and not ask questions. Even back then, the time doctors had for patient visits was on the brief side for certain types of problems. Now that we’re finally making the needed shift to a more collaborative approach, the time is even shorter 😦

    It should never be the responsibility of an individual patient to take care of the physician.

    But as a society, we need to think about just what it is we are asking providers to do, and then make sure they are provided with reasonable resources to do so. There will always be exceptional people who manage to do a great job despite poor support (I’m not one of them btw; left a community clinic because the job stress was affecting my marriage & kids), but it’s a bad idea to design a system that relies on sustained exceptional efforts by the front-line.

    Separately, there is the issue of helping 1-2 generations of practicing physicians make the shift to a new model in which they can’t play top dog any more… challenging to be sure.

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    1. Thanks Dr. K for such a thoughtful response. So many important points! I’m glad you brought up this need to adapt to a new model of practice. You’d think that current medical school students would have a head start in learning this new model, so it’s disheartening to read of studies showing declining empathy starts even in med school, for example, such that researchers warn this may ultimately “threaten health care quality”.

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  11. I am fortunate to be treated with kindness by my doctors. But I note that I am not informed of my test results unless I call. Thinking this means an attitude of “as long as I (the doctor) know what’s going on, that’s enough.” I also must ask for my numbers: BP, lipids, etc.

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    1. Hello Pauline – Patients used to think “no news is good news” if they don’t hear about our test results. Not necessarily! Good for you for keeping track of ALL your numbers as all patients should.

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  12. Yes, I am responsible for the burnout of a few doctors! I dared to show up ON TIME, with a list of questions, a stack of research, and I refused to leave until I understood. It takes a special type of medical practitioner to handle such a patient.

    JG

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    2. You are exactly right! Speaking from personal experience, some of them explicitly dislike patients who do research. Whenever possible, that’s a cue to change docs.

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