I began the follow-up visit with Dan (not his real name), my middle-aged diabetic patient, with an open-ended question: “What’s on your mind today?” This usually helps me get a sense of a patient’s priorities, whether they are concerns about health or life in general. That day, I was surprised and dismayed by what I heard right from the start.
“Doc, this rotten, corrupt election is going to ruin health care. We’ll be like sheep under socialized medicine! You know it’s coming.” Dan gripped the arms of his chair tightly and looked at me like he was desperate for my approval.
I have encountered this kind of situation — as I’m sure many others have — more times this year than ever before in my career. With the pandemic surging, political tension lingering, and a country very ideologically divided, it is understandable for some emotion around these issues to spill over into the exam room. However, these discussions often feel like they can consume too much of our limited visit time. And when the opinions expressed are opposite my own, it is often unnerving and distracting.
So what is an effective way to navigate through these verbal storms? The first thing I remind myself to do is to stay in the “role” of physician. If I receive these comments personally, I may feel inclined to react. But in my professional role, I can view them as components of the patient narrative and consider how they might influence other health matters, like blood pressure or diabetes control. These tirades may also be symptoms of anxiety and depression, which seem to make up a growing proportion of what I have been seeing and treating in my primary care practice this year.
I reflected back on Dan’s statement and proceeded to weave it into a discussion about setting the visit agenda. “Dan, it sounds like you are worried about the election’s impact on the health care system. Many people share your feelings. What additional issues would you like to discuss during your visit today?”
This allowed me to acknowledge my patient’s concern without having it eclipse other important health matters that needed attention. Depending on what else was on the agenda, we could negotiate a plan for how to allocate our time together, including leaving more time for open-ended expression of his feelings about current events. What may have seemed like a search for approval through harsh comments may simply have been a desire to be heard and have his feelings recognized.
My office may be the only place where some of my patients feel safe expressing their views without fear of reprisal, especially if we have developed good rapport over time. Preserving that safe space is important to our therapeutic relationship. Keeping this in mind helps me to be resilient when divisive issues arise.
I also find it helpful to listen carefully for factual errors that might be mixed into my patients’ emotional comments, especially when they may contribute to risky health behaviors. This has been especially important during the COVID-19 pandemic. When offering patients a correction, I’ve had the most success using questions that show genuine curiosity about their views and through sharing stories. Curiosity steers me away from anger and helps me find even the most preposterous things somewhat interesting. For instance, a patient recently bemoaned all of the “hype” over COVID-19 precautions, describing the disease as “just a cold.”
“Have you been sick or known anyone who has been infected with COVID-19?” I asked Dan.
“Everyone I know either had a mild cough or no symptoms at all,” he said.
“I’m glad you haven’t had anyone close to you get seriously ill. We’ve had a number of our patients hospitalized for COVID this week, and the hospital was so full of COVID patients that they were kept in a hallway for a full day waiting for a bed to become available!”
I’m not sure if I changed his mind, but he did not continue his rant.
By staying in my “role,” leveraging curiosity, and working on setting the visit agenda, I’ve been able to reduce my stress level when patients interject controversial opinions during our visits. As a physician, I am there to provide emotional safety and stay focused on listening for clues concerning the diagnosis and ways to help my patients heal.
When I get home at the end of the day and put on the national news, well that’s another story.
How do you manage care for trying patients? Share your approach in the comment section below.
Jeffrey Howard Millstein, MD, is a practicing internist and serves as physician champion for the patient experience initiative at Clinical Care Associates of Penn Medicine. He leads initiatives and serves as a resource for clinicians and staff to help improve patient-centered communication skills. You can follow him on Twitter @millstej.