Managing rude patientsBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5816 (Published 01 October 2013) Cite this as: BMJ 2013;347:f5816
Patients should expect high standards of professionalism in their interactions with doctors. Nishma Manek reflects on the difficulty of managing patients who do not demonstrate the same courtesy
The General Medical Council (GMC) is clear that doctors must be polite to their patients. In April, it released guidance for patients on what to expect from their interactions with doctors. The guidance states that “doctors must be polite and considerate to you and people close to you, and treat you with dignity and respect.” It also asks patients to “be polite and show respect to your doctors.”1
Emerging from medical school, full of enthusiasm for the altruistic journey I’d been preparing for, it never occurred to me that if I came across a discourteous patient I would be anything but the tolerant and compassionate doctor that I’d been eagerly striving to become. Reading the council’s guidance, however, brought back memories of occasions when I’d found it particularly challenging to uphold its advice.
Saturday in A&E
One Saturday night, like many before it, I was struggling with yet another drunk patient in accident and emergency (A&E). Helped by a nurse who, after years of watching Saturday nights unfold in the same way, was less annoyed than I was, we managed to hold him still while trying to ignore a torrent of expletives and the nauseating stench of alcohol mixed with stale vomit. Two more bays behind us were occupied by rude, shoeless teenagers in alcoholic stupors surrounded by dopy friends, both presenting us with further struggles for compliance with any form of examination.
By the end of my four month rotation in A&E, I had tarred this cohort of patients with the same brush, which led to a rather bleak picture of their use of healthcare services. I never questioned whether doctors should treat these patients at all, however. Who knew if their intoxication driven incivility was masking a genuine medical need?
A few months later I was in my next rotation and slowly getting used to the sight of daylight again in the sexually transmitted diseases clinic. I encountered a particularly odious man who requested an asymptomatic screen and refused to answer most of my questions. He looked at me with contempt on the rare occasions when he made eye contact, and kept interrupting with disgruntled insistences that I should “hurry up and get on with it.”
He became progressively more antagonistic, to the point that I began to wish I was in one of the open bays in A&E with a security alarm within reach, rather than a consultation room. I gave a quiet warning to the nurse who came to do his blood tests that he might be difficult and breathed a sigh of relief as I escaped the confrontation. Less than a minute later she returned, declaring that she flatly refused to help anyone who did not treat staff with proper respect.
Refusal to treat
I was surprised. It had never occurred to me to do the same in my consultation with him. Was that an acceptable course of action? I’d always thought that, as a medic, encountering disagreeable patients came with the territory. Even if it means forcing ourselves to bite our tongues, surely as healthcare professionals we are duty bound to rise above expressing any moral judgment of behaviour in our obligation to act compassionately and professionally at all times? This man did not have a condition that could excuse his behaviour and he had not taken any substances that might explain it. If he had been a customer in a shop, would it have seemed unreasonable for any of us to refuse to serve him?
I’ve experienced more situations like this. In general practice, a patient stormed out with a Google printout in her hand, deeply unimpressed that I wouldn’t prescribe antibiotics for her cold. On a hospital rotation, a cantankerous elderly man complained bitterly that he’d waited an extra hour for me to do his discharge letter, while I ran around on the wards struggling to manage my endless patient list. I’ve also witnessed many patients abusing nursing staff with sweeping diatribes that couldn’t be reasonably excused by their medical condition.
Politeness is a virtue
Healthcare is viewed as a basic right. Does this absolve its users from showing the common courtesy that society expects from customers in other sectors? Does the fact that no money is exchanged at the point of transaction contribute to why some patients are rude?
The patients described above represent a tiny proportion of those I’ve encountered. For every example I’ve given, there are many more times when I have felt slightly uncomfortable at the display of gratitude that seems disproportionate to the little we’ve managed to do.
Perhaps a patient’s medical condition or a doctor’s working environment is not always conducive to common courtesy. But I think that, where possible, politeness is a virtue that should be expected from both parties in the doctor-patient relationship. As the American essayist Ralph Waldo Emerson said, “Life is short, but there is always time enough for courtesy.”
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.