She also warned hospitalists to recognize when they become a “magnet” for difficult patients, as many times the expert in the group will become the “go-to” doc. “I don’t think anyone can take care of a large panel of these patients; it’s just too much,” she said, noting you have to negotiate some limits or you will “burn out and lose perspective.”
Many doctors are very uncomfortable with scared or crying patients, Dr. Block said, explaining these are some of her most difficult patients. “Show me a patient in the hospital who isn’t scared,” she said. “Even it they aren’t, they are scared of dying.”
Other sources of workplace discomfort include the dependent or “needy” patient, the suspicious patient, and the extremely pushy patient. Dr. Block suggested setting clear boundaries with patients; she also noted physicians should be ready and willing to identify and reflect on your own emotions so that “you have the capacity to get perspective on the problem and keep yourself from being part of the problem.
“Limit-setting is one of the most therapeutic things you can do with difficult patients,” she said. “It feels to us as a form of sadism, as though we are punishing patients. But for many patients, the most dangerous, scary, and dysfunctional thing you can do for patients is not set limits.”
CLINICAL
The Art of Clinical Problem-Solving: Mystery Cases
SPEAKER: Gupreet Dhaliwal, MD, University of California at San Francisco
Humility, patience, and practice: Those are the keys to improving one’s clinical diagnostic skills, according to Dr. Dhaliwal, an acclaimed educator and clinician at UCSF who walked a packed room through two blind cases and encouraged hospitalists to work hard at their craft.
“If you want to reach your maximum potential, you have to view it the same way we do other things, the same way a great musician rehearses and a great soccer player scrimmages,” he said. “All of us are busy, but you either have to increase the number of cases you put your mind through, or you take the cases you have and you analyze them, you seek feedback, you try to improve the process around the diagnostic.
“The message isn’t always fun, because both of those things equal more work, but there is no way to hide it because there is no field in which people get better without more work.”
Dr. Dhaliwal says hospitalists should be “humble about diagnosis.” He explained that the more experienced people become, the more we shift from analytical reasoning, “thinking hard like we did when we were students and residents,” to intuitive reasoning, which “is basically saying, ‘I recognize a pattern, this is an old friend, I’ve seen gout before.’ I think any of us can be guilty of forgetting that it has pitfalls. And there is a whole list of cognitive biases that are associated with moving fast and building patterns.”
He also believes hospitalists who dedicate themselves to clinical greatness can parlay such improvement in the quality realm. “Every one of us has used diagnosis as a core part of our identity, but in terms of getting the community or other stakeholders behind improving diagnosis or improving judgment, I think the umbrella of quality and reducing diagnostic errors is the most appealing and most logical,” he says. “I think we start to take for granted we are good at it, but I think there are ways many of us, especially if we work at it, can become great at it.”