Good evening. Thank you all for joining us for our webinar this evening. Can we change how we think about difficult patients? Before we get started, I'm just going to go over some housekeeping. And basically that simple things are that you're all all participants are muted. And if you have not taken your pre test, you must take one now to obtain your CME. And then to ask a question, please type it into the zoom platform in the q&a. And then Dr. Nairdoff will respond to your question following her presentation. And also for those of you that may be watching this on demand, should you have a question, just send it to the physician services at osteopathic.org website. And in the subject, put the title of the webinar or Dr. Nairdoff, and we will make sure to get the question to her and get you an answer. Copy of these slides are available in the course on the AOA online platform. And then to obtain your CME credit once the webinar is finished, or whether you've attended live or whether you watched it on demand. Once it's completed, take the post test and the evaluation following the webinar. Again, those are available on the online learning platform, you then will be able to print out your own certificate should you want to. AOA members, those results and that your CME credit will automatically be downloaded into your report within 48 to 50 hours. So as far as a disclaimer presentation is for educational purposes only. Dr. Nairdoff is sharing her experiences with you and her strengths and her all of that. A little bit about Dr. Nairdoff. She is an emergency room physician. She's an author and a speaker based in Alexandria, Virginia. In 2022, she published Changing How We Think About Difficult Patients, a Guide for Physicians and Healthcare Professionals. That book is available on the AOA within the AOA store. So you can purchase it should you wish. She is also one of the DO book club columnists for the DO Magazine and serves on the editorial advisory board of the DO Magazine. We're thrilled to have her here with us to share this information with you. I know I read her book and that caused me to reach out to her because I just personally, I think it's something anybody in the allied health field, every staff level should be reading this. So it's great information. So without further ado, I will turn it over to Dr. Nairdoff. It's all yours. Thanks, Cindy. Welcome everyone. And those who are going to be watching in the future, welcome. I am Joan Nairdoff. I'm an emergency physician. I'm retired from clinical practice now, but my topic is can we change how we think about difficult patients? And when I'm giving this talk live, I usually ask people for a show of hands to see has anyone ever looked at the triage board or looked at your schedule at the beginning of the day and saw someone's name or the chief complaint that they're presenting with and thought grown, oh no, I can't take this. This person is so difficult. Yeah, I think we all have. And we're going to talk about what we can do about this issue. These are some of our objectives to become aware of the negative thoughts that clinicians have towards some of their patients. Understand the stresses that the patients have. Then we're going to talk about how clinicians think. And we've fallen to, unfortunately, fallen to some really negative thought patterns. I'm going to introduce something called the think, feel, act cycle. And it's really important to talk about the way things happen in the world and how our emotions towards them are determined by what we think. And we happen to, a lot of us, when we're working in an office or emergency department tend to think the same way, but it's usually not the truth. And we can think with more intention and improve our thoughts. And we're going to learn how to change our thoughts because that causes better feelings. With better feelings and emotions, we get better actions and we get better results. There's some of the things we're going to cover. We're going to go through what makes a person difficult and who is a good patient. What are the fears and obstacles that a good patient must overcome? I'm using good in air quotes here or in quotes because it's a very subjective thing, as you will see. What does the medical literature say about this problem? And we're going to review the seminal article by Dr. Groves. I'll tell you who he was and the four different types of hateful patients he identified. The typical responses to illness and injury so that we know what's normal and what is not so normal. And I'm going to talk about what the think, feel, act cycle is and how we can leverage it to our advantage. So the question of what is a good patient and those patients who are not good are the ones that we tend to call difficult. Most of us would describe them as independent, hard-working, self-sufficient individuals who are logical and rational. And we want them to act in a mature fashion to follow our advice without overreacting. And these are the characteristics that most physicians view in themselves and the way they like to describe themselves as being logical and responding in a mature way. And this is kind of tricky in this way because I think this is where some gender, cultural, racial biases, body size biases, enter the conversation because people tend to identify more strongly with the people kind of look and act the way they do. And they naturally have some little judgment and disapproval of the way that they act. And they naturally have some little judgment and disapproval of people who look in a look a different way. So good patients are usually people who reflect what the physician views in herself as desirable characteristics. And treatment of these patients usually leads to very satisfactory interactions, very congenial, they're very effective. But the opposite can happen. And clinicians can adopt some very negative judgments about some of their patients and can really dislike interacting with some of our patients. It's almost as if we've formulated an instruction manual for our patients. And I call it a virtual instruction guide. Of course, we think the patients know what they're supposed to do, but they don't. And I've written a few articles, some appear on medium.com and on my website to talk about what the instruction should be or what I feel they should be for to be a good patient. But it's one of the things we need to tell people how to act. And the more we tell them, the better it would be. What can a good patient do? Patients have to go through a lot. They've got a lot of fear. They're fearing for their base of integrity, their fear of strangers, fear of separation for their loved ones. They, especially in children, are very afraid of separation and even some of our elderly. They're afraid of the loss of love or approval from their loved ones, possibly loss or injury to their body parts. They don't know if they're going to lose something, a part of their body, if they have some sort of traumatic injury. The loss of their basic functions. Sometimes people have some intermittent incontinence and they're wondering if this is going to continue. And people can handle their fear of pain and they can relate what their pain level is and try to get that relieved. The adaptations that a good patient make, they have to maintain their relationship. They have to function with some level of disability. We have to send people home from the emergency department, from the office with splints on their arms or legs. They can't get admitted to the hospital with that. So they have to be able how to function. And some people don't know what some new diagnosis means that this, so they're afraid of the unknown. They're also afraid of the variety of providers that they see. They see a lot of people in different uniforms, people who are wearing scrubs. They don't know who's the doctor. And then if they're there over a shift change, they have like twice as many people. They have to figure out who they are. And then the factors affecting a patient's emotional responses have to do with the nature and severity of the illness. And a lot of times our patients have no idea how severely ill they are. Their characteristic personality and coping patterns and their past experience with illness or even their family's past experience with illness, the type of experience that the patient has in their family or perhaps their parents or grandparents. So in 1978, Dr. James Groves was a consulting psychiatrist at Massachusetts General Hospital, and he wrote a seminal article. It's worth reading. You can still get it. There are ways to bypass the paywall on the New England Journal of Medicine. It's actually available through Washington University of St. Louis. It's called Taking Care of the Hateful Patient. And in that article, it's only about four pages long, he talks about four stereotypical types of patients. And I think it's really worth looking at these type of patients so we can understand what we're up against and the reasons why they're acting that way. Of course, this is like the perspective of a psychiatrist, of course. And the first are dependent clingers. Clingers are always requesting our reinsurance, our cries for explanation, affection, analgesics, sedatives. They want attention and they use flattery and sometimes childlike behavior to seduce, not actual seduction, but to get the doctor to like them. It could be actual seduction. They want endless medical attention and reassurance. So dependent clingers are usually do it by being nice. So when you have patients who are really laying on the flattery and the kindness more than seems appropriate, sometimes they're dependent clingers and these people are very afraid of having the doctors withdraw any attention. The second type are entitled demanders. And I think this is one of the most common types that we see. People who are demanders use intimidation and guilt induction to try to place the doctor in the supply role. They may try to threaten or control the physicians by withholding payment or threatening litigation. They're usually impatient and arrogant and very condescending. Some of these people have narcissistic personality traits. They feel like they're entitled to special treatment. And when you tell them that we treat everybody equally, or we try to treat everybody well, which I think is the way to answer these people, they may react with anger or rage because they don't understand why they're not being treated as special. Usually these people are the type who announced that there are some sort of VIP or they're on the hospital board, or they're somebody really important. And usually underlying this type of person's personality issue is that they're unaware that they've got a deep dependency and they're afraid of being abandoned. Manipulative health projectors are the people who insist that nothing will ever help them, but they keep on seeming to follow the doctor's advice. They're kind of poor with their compliance and they may actively even thwart their own treatment. It seems like when one symptom is relieved, another kind of magically appears. And these people, they're not necessarily looking for relief of their symptoms, but they want a secure and unique relationship with the physician. So in turn, the physician can feel guilty and inadequate because they seem to never be able to kind of cure the people or make them happy. An example of these type of people are certain diabetics, some chronic pain patients, and renal dialysis patients. Sorry. The last one is the self-destructive denier. These patients display conscious or unconsciously self-murderous behavior. They seem to take no responsibility for themselves or seem ungrateful or hostile to the caregivers who saved their lives. Some examples are alcoholics and drug users and people who smokers can't seem to stop smoking. They seem to want to damage themselves or unable to quit. And the challenge for physicians and other caregivers is to not mirror the hatred and the anger in these patients, but try to engage the patient in a compassionate, constructive way. The five most common emotional responses in patients are important to realize because we see them in almost everybody in one form or another, and it's normal. So we shouldn't be surprised when we see it. Now, regression is when the person, I think, regression is when a person acts in a childlike manner, and we see this all the time. Someone who seems like a perfectly well-functioning adult comes in with some sort of illness or injury and suddenly starts behaving like a child. Now, some level of regression is helpful because our patients do typically look up to us as a father or mother figure, as their physicians, and we want them to listen to our advice and take our advice and follow our instructions. Some children aren't always so compliant. I'm sure some of you know that from your own experiences with your own children. So this is expected to see some regression. The other is denial, and denial is a totally normal emotional response we see in our patients with some illness or injury, and some denial is good. We call it suppression. We want people to be able to kind of forget about their ankle fracture so that they can function in the rest of their life or perhaps go back to work after it gets set, but we don't want people to be in total denial where they try to go out and start running again even though they've been instructed not to. We want people who know they have some form of coronary artery disease to take it seriously when they have some sort of chest pain and not just write it off as heartburn. Anger is another common emotional response. Some patients, particularly with chronic illness or people who haven't found their way totally to a diagnosis that they find satisfactory, come in with anger, and that is very challenging because we tend to get our back up and get defensive as soon as someone comes at us in anger, and the real challenge for us is to not mirror their anger. There is sadness in people who have some sort of diagnosis that is troubling or life-changing or some sort of chronic illness like, say, dialysis or chronic kidney failure where they have to go in and get dialyzed and they don't think it's fair and they're kind of sad and they have this sort of attitude. The last is anxiety. Lots of our patients are anxious. I would say a lot of our patients are anxious that they're reading their medical record before we have a chance to talk to them, or they're getting very anxious and they have some symptom and they go to Dr. Google and they read that the first thing they worry about or sticks in their mind is that it's cancer, so it's troubling and some people get so anxious they start to have panic attacks, and this is a real challenge in some of our patients to kind of separate that out and to try to reassure them. So, why the deep dive into thoughts and emotions? And the answer is because our thoughts cause our emotions. Now, emotions are not created by what we, by the event or circumstances, like that, like the patient coming into the emergency department or the patient coming into your clinic. Your emotions are caused by what you're thinking about them, and we can have wildly different thoughts about them. You know, you may see a cranky old lady coming in, that person coming in may be my mother. So, these are different thoughts we're going to have about the very same person, and our thoughts can be chosen in a more intentional way to create more useful feelings, thoughts, and actions. So, I'm going to show you an example of a patient walking through the door. So, I'm going to show you a graphic in a moment to help you visualize this better. The situation that we're talking about in this talk is an episode or event, just the facts, like a patient walks through the door or a patient is brought in by an ambulance. This is the situation. It's a totally neutral situation. In other words, we could think either good or bad things about it. Of course, when someone's injured, most of us feel terrible about that. But we wanna have some of those thoughts. And then a thought is just a sentence in your mind. And depending on what that sentence is, that thought creates feelings that you have. This usually happens so quickly that we forget that there is a period where we form a thought in our mind. Now, it's usually not just one thought. We might have about three or four or 10 at a time. Depending on what you're feeling and your level of curiosity, concern, these are all feelings that we have, there are certain actions that you take, what you do and don't do in response to your feelings. In this setting, we're talking about ordering lab tests or doing procedures, things like that, and or ordering consultations. And then based on those actions that we take, we get results. So what we wanna do is kind of guide this towards we have more productive thoughts so we get better feelings, better actions and better results. Let me show you. This is the cycle in action in an emergency department or a clinic. At the top, you see that the patient arrives. A clinician, this is a doctor, a nurse, a tech, a paramedic has a thought about the person. They have feelings or emotions. They order the labs or the imaging or the meds. They decide to go in and talk to them more. They do a physical exam. They take the history. If this feeling or emotion here is that I can't stand this person or I'm afraid of this person or this person smells bad, we may not spend that much time talking to them or being in the room with them. And then we're gonna possibly, when we have those negative feelings, our results, which are here, that the patient feels better and hopefully goes home or gets admitted to the hospital or leaves our office in a satisfied manner, it's not gonna happen if we have really poor feelings and emotions in this area. So why does it matter what we think? We get poor results. We miss diagnoses. It's not ethical. I'm gonna talk a little bit more about that in a moment. But we get patient complaints, we get bad reviews, inquiries to the board of medicine and or possibly malpractice suits. And on a more important level, having bad emotions at work, like being cynical, feeling burned out, feels terrible. Disliking our patients feels terrible. And we all know how good it feels when somebody gives us a warm handshake and a thank you at the end of one of our patient interactions. We all feel warm, fuzzy, and say, this is why we went into this field. But when things don't go well, we feel terrible. We think about changing our jobs and we think about even leaving medicine. So by remembering the thought line, we can pause in that cycle and reconsider our thoughts and try to think with more intention. These are the four core ethical principles of medicine. It's important to remember this because like I said, if we're not acting, if our thoughts aren't so good, we tend to get away from these core principles. Our patients have autonomy. Competent patients have the right to accept or reject our advice for medical care. And so our patients who are capable have the capability to make what we consider unwise decisions. People decide they don't wanna get vaccinated for some reason because something they heard at the barbershop or they saw on TV. We can't force them to. If they're capable because they have autonomy, some people don't wanna accept our advice for admission. They decide to leave against medical advice. We have to respect that. The second principle is beneficence. We're expected to do what's best for a patient. And that definition of what's best should derive from the physician's judgment and the patient's wishes. Non-maleficence, first do no harm. We are fallible and we're capable of harming and we have to try not to harm our patients. And then the fourth principle is justice. And that is the expectation for the fair allocation of resources that patients in similar situations should have access to the same care. So that's the first part of this talk where I have discussed mainly from the patient side, what's going on with them, what their fears are. And from the second half of this talk going forward, we're gonna look at the physician's thoughts about difficult patients and discuss our strategies to change those thoughts. I think the question is valid. How have we acquired such negative thoughts? Because it's natural and normal and not any individual's thought. What are five unhelpful thought patterns that physicians fall into? What are some strategies that we can use to change those thoughts? And to remember, we can decide how we wanna feel and then start thinking the thoughts that will produce those feelings. So that's a little bit different approach. We'll talk about that in a few moments. And why bother? We can just power and do things and we do things we don't wanna do all the time, but our object here is to feel better about some of these difficult interactions. So, how have we acquired such negative thoughts? We all wrote this beautiful essays to get into med school, nursing school about why we wanted to be there. And then we got out into the wards and the clinics and we found out that things weren't always going that way. It's absolutely normal for us to have negative thoughts and kind of fear what's going on. We have a natural negative thought bias. It's kind of evolutionary thing. It's normal for us to scan nature. I mean, our caveman forebears had to scan the horizon and look for bears and tigers so that they weren't in danger. And modern doctors are looking for the most dangerous diagnosis. And so, we're always looking for the worst. Patients are saying things, we're kind of not trusting them. We have a negative thought bias and it's only natural. So, I don't think anybody should beat themselves up because they feel this way. We are literally taught this. Our senior residents and some of the professors and teachers in medical school talk this way. They use kind of disparaging labels for people. The pulmonary critical care doc where I went to school called the people toads, totally obnoxious alcoholic derelicts. Not a kind way to refer to a lot of his patients. So, this is the language that we were using and using other kind of negative words. And then, everybody's talking that way in the nurse's station and in our lounges. And we kind of all go along with the group thing because we think, well, everybody thinks that way. And part of it's gallows humor. I know if we didn't laugh about it, sometimes we would be crying. So, it's totally natural for us to have acquired these negative thoughts, but we can shake them. And I think the way to start to change them is to be aware that we're having them. I mean, we can't even start to think about changing our negative thoughts about our patients if we don't kind of fess up that we're having some of them and become aware. These are six unhelpful ways that we think, and it's all kind of compounded by confirmation bias. In other words, if we label people early in our transaction that there are a certain way, we tend to look for evidence that will confirm our initial thoughts. Personalization is when we take too much blame or too much credit that something going on with our patient. It's lovely when our patients get better and they thank us or send us a thank you note. And we take, you know, it's usually something really small that we did. We threw a short course of antibiotics at them when they were probably at the end of a viral illness anyway and gonna get better in two days, but we take too much blame. But sometimes we take too much credit, but sometimes we take too much blame and all of our patients are going to die at some time. And one of us is going to be the last physician or nurse taking care of them. And we need to be confident enough to know that we've done everything and not take the blame for it. A lot of us have, excuse me for changing that. We have arbitrary inference or bias, which means that we make assumptions about people. We make assumptions about people based on the size of their bodies. If they're obese, we may make some sort of inference based on how they're dressed, the color of their skin, where they're from, whether they're speaking the same language that we speak. And these are all biases that we can't help. We're raised in our society and we try to be as nonjudgmental and as unbiased as we can be, but we're raised in this society and there are biases that creep into our thinking. A lot of us have all or nothing thinking. We tend to think that there is only one way to get things done. There is only one solution. There is either my way or the highway. And when you notice yourself getting into all or nothing thinking, you start thinking that there's only one solution for a problem and this is not true. There's never only one solution, there are others. Now, some of our colleagues in our various specialties are literally taught to think this way. I did a podcast with a surgeon and he told me that the surgeons think that there is only the way that they offer to the patient is the only way. So that'll get you into a little bit of some uncomfortable, difficult interactions with patients because there certainly is not just one way and very frequently our patients don't wanna do things our way. The mirroring of emotions is a normal thing. It starts when people are infants and they mirror the emotions of their parents. And when our patients come in and they're very kind and courteous, it's very easy to be courteous in return and to mirror their emotions. But when they're sarcastic or they're angry or impatient or yelling, it's very easy for us to get defensive and to start mirroring those emotions and acting back in the same way. And if you feel yourself starting to yell or get angry, you're probably mirroring emotions and you need to kind of get ahold of that before things get a little bit out of hand. A lot of our colleagues and ourselves are kind of mired in victim mentality. And a lot of the things, we tend to feel that a lot of the things going wrong in medicine or in medical practice or in the emergency department are happening to us and we are the victim of them, that the lab tests are taking too long, I can't get the readings from radiology, that the nurses haven't started the IV yet, stuff like that. People who are in victim mentality feel like are always kind of shifting the blame to other people. There has to be a villain, they're the victim. And these are people, and I'm sure you have noticed some of them in your work environments who are always complaining. And when they're always complaining, they're always kind of blaming their unhappiness or the way things are on somebody else. And it's a totally disempowering way to feel and think. And when we feel this way in our daily interactions, we're not able to take the power and make the changes and fix some of the things ourselves. The other thing we tend to do in our offices and particularly in the emergency department, of course, I'm an emergency physician, so this is my bias here, is resisting reality. And what I mean by that is we tend to think right away, as soon as we see a patient's chart, what their chief complaint is, we tend to think that they shouldn't have come. What they have really isn't an emergency. Why didn't they see their primary care doctor? Probably the primary care doctors are seeing how come they didn't see their specialist? How come they didn't go to the emergency department? Why did this happen? Why did you do that? We can't change the past. The patients can't change the past. Anything that happened before is the past. You can't change the past five years ago and you can't change the past 20 minutes ago. Now, we feel like, of course, we feel bad that something like an accident happened, a car accident or someone falling down. But it's much better for us to accept reality and work from there. And in terms of the patient being in the right place, I like to say that the patient is exactly where they need to be. There's no one better to take care of this problem than me in my emergency department, where I can get all the lab tests and all the things right away. So the negative thoughts that you have can cause your negative emotions and they can range. There's a continuum, of course. We all get a little annoyed from time to time. Excuse me. And that can go all the way to rage and sadness. Our negative reactions can be bodily symptoms like sweaty palms and tachycardia or impulsive actions. We can yell at people. Tendency when we're having unpleasant interactions with people is to just walk away from them. We don't wanna spend any time with them. It's so unpleasant. And the first step to interrupt this cycle is awareness, is to say, okay, I'm feeling sad or frustrated or defeated or angry, and basically allow yourself to feel it. Usually some sort of negative feeling to feel defeated or sad or angry. It only lasts a couple minutes, it passes. And then you can kind of get ahold of it and redirect yourself to what you wanna think and how you wanna feel. So how can we start to change our thoughts? It sounds easy, but when you're in the thick of it, it isn't so easy. But the place to start, I think, is to ask better questions. And one of the most useful questions you can ask yourself, especially if you are kind of stuck in some all or nothing thinking or black and white thinking is, could I be wrong about that? And if you're willing to think about whether your plan or your diagnosis or what you thought would be the best thing to do might be the wrong thing, then you can ask the patient or the patient's family what they're thinking, and you can find some common ground that you can work with and find some common solution. For example, if a person cannot be admitted on the spot for some reason, they have to go home and take care of a pet or a family member, we can usually allow for that, find some sort of plan and tell them when to come back in to get more testing. Another useful question to ask is what else is true about this person? Especially when you have some really difficult patients to deal with, someone like an alcoholic who comes in as nearly passed out drunk, it helps to think about this person in their other role. Is this someone's son? Is definitely, any man is definitely someone's son. And that kind of conjures up more empathy and more caring because you can put yourself in that person's role. You feel sorry for the parent. If you're a parent yourself, if you kind of wish, I would hope that if something happens to one of my children, or if my son showed up in your office or emergency department, I hope that you would give them the benefit of the doubt and try to treat them with kindness. Is that lady someone's mother? In other words, it's a nice, another way of saying, can you consider this person the way you would a member of your own family? Can you give this person the benefit of the doubt? The person that says they're in pain and needs some sort of opioid, and you're kind of concerned that they might be stretching the truth or lying, could it be true? Can you extend them the benefit of the doubt? Can you imagine the person's problem or issue as though it were your own? That's a little easier when you have some, as you get a little older and you have some of the problems that your patients come in with, it's a little bit easier to identify with them for sure. Can I be more curious? Can I find out why they're not following my instructions? Why they decided to show up on a certain day? Perhaps I'm not asking enough questions to know the particular situation. And if I've made some assumptions that were incorrect, I need to get more curious and ask more questions. Basically, what I'm asking is to drop some of the judgments and the negative judgments and work towards accepting people as they are. The person who is still smoking or is still taking some sort of drugs or left themselves in a bad way with skin infections because of drug use, drop their judgment and just work with where they are and how you can start to get them better. Sorry, I lost my picture for a moment. A lovely gentleman wrote me a letter after seeing one of my articles in a family practice journal. He asked, is there an understanding deficit on the part of the physician? I think this is a great way to put it because we don't understand what's going on with our patients. I know we think we do, but I adapted this graphic from the internet and our patients have very complex lives. We ask them a lot of questions, but there's so little that we actually know about it. And someone's life is so complex. We should work on accepting our patient's difficult behavior so we can understand it. And if we understand a little bit more why they're not taking the medicine or why they can't make the follow-up appointment, perhaps we can change it to a better prescription or get them some social services, get them some transportation, but we will never know unless we ask. The other thing you can do is decide in advance how you want to feel. Now, what I like to say is I want to feel confident in all my interactions with every patient. And I think to myself, what would I have to be thinking to feel confident? I would have to remember how well-trained I am. I would have to remember that I know who to ask for help and when to ask for help. I would have to remember that I've been trained in all the procedures. I have all the equipment I need. And if I don't know how to do one of the procedures or I don't feel comfortable, I know who to call to ask to do it. If I fail in one of the procedures, like for example, if I'm doing an LP and I don't get it on the first pass, I know how to redirect or reposition the patient to kind of fail forward and learn from what I did incorrectly so I can correct my course of action and feel more confident in doing the procedure. One of the reasons that, another reason that we feel terrible in some of our patient interactions are the way that we feel about ourselves and we're too self-critical. And one of the ways, here's an example of some of the self-critical thoughts because we tend to be perfectionists but we can never really reach perfection but there are always gonna be some things that are tough for us. We think, I don't know that much about rashes. I'm not that good. It was always tough for me when someone came in with a really brisk nosebleed. We didn't always have the right equipment. The people were really anxious. They were spewing blood all over the place. I just kind of hated it. And I had to get over it. When we don't think that we can help a person anymore we might kind of not feel good about our interactions with them but we can always help someone. We can't always cure them but we can always help them and provide some healing care. Every human being wonders at some point whether or not we're good enough and extreme self-criticism has gotten the name imposter syndrome. It's another thing I like to write and talk about. And it's just a lacerating form of self-criticism. It's normal, but we need to kind of give ourselves a break. There are really no such thing as difficult patients. They're only people who challenge us and elicit negative thoughts. And we are responsible for creating our own thoughts and we can choose better thoughts. We can ask better questions. Our negative thoughts cause the negative feelings and our actions, and they also cause our results. And somehow our results always serve to reinforce our negative thoughts that, you know, that these are actually difficult patients. So if we can think with more intention, work with our thoughts to get to a better place we will kind of naturally feel more empathy and more curiosity. It's important to remember that life is 50-50. The 50% of our experiences are going to be terrible and 50% are going to be good or happy. And that's going to happen at work and it's going to happen at home. So when things aren't going right, there's actually nothing wrong here. This is the way it's supposed to be. For most of us, we don't even feel like it's 50-50. We feel like things are usually going right. It's probably more like 70-30 or 80-20. So we forget when things go wrong, it feels so terrible. We forget that that's a normal part of life. Having things go wrong and feeling terrible, having our kids talk back to us, all this stuff, it's normal. And why does it matter? Why do we even bother to give this lecture, write this book? Because feeling angry or resentful or impatient with our patients feels terrible. And there are so many of our colleagues who are thinking about leaving the profession already because of some of the negative interactions that they have with patients. And they're tough. You can actually do better. Sometimes all this stuff doesn't even work. But what I like to remind people is of that, it's a very small percentage of our patient population and our patient interactions. It's only some studies of an internal medicine practice. So the only 15 to 20% of the patients are considered difficult. So that's enough to make us feel bad, but we need to remember that most of our interactions with patients and their families are going really nicely and are very satisfying. I like to remind people to say to themselves and believe that every person is going to be better off today after seeing me. I may not always be able to cure, but I can heal. I like to ask people to practice the thought that they are amazing. You are amazing. You've chosen this profession. You go in there and slug it out with people every day. You have the greatest of intentions. For a shining moment, we were the heroes of our society. And I think we still are, but people forget and their thoughts have moved on. We will feel more satisfied with our work and more accepting of treating some of our challenging patients. And it's just kind of part of the deal. If you try this, the shift in your thinking, you're gonna feel much better about this valuable work that you're doing. My talk has kind of scratched the surface of this. Now, this is a picture of the book that I wrote. It's available through the AOA in a paperback form. It's a short book. It's also available through Amazon and other platforms, but Amazon has it as an audio book, which is narrated by a woman. And it's a short book. It's an audio book, which is narrated by a professional actress, not me, actor. And running time is under four hours and it's also available in a Kindle version. My dream would be that more people would be sharing it, maybe buying a copy, sharing it with the office, because I think that all the medical, all the clinicians, everybody dealing with, everybody has some difficult interactions and we could do so much better with them. I am available. That's me holding my French poodle, who is a very anxious little girl. And I have a website where I write about stuff. I'm not really selling anything. I write about travel. I do a lot of book reviews for the Dio magazine and for myself because I don't, not all the books that I read, I review for the Dio, but I've been fortunate to read quite a few. And there are some wonderful books out there to kind of enhance our experience and some patient memoirs also that give us some insight to what our patients are feeling. I love it. And if any of you have written books and want me to read some and possibly review them, you can reach me through the website or through, through the AOA. You can reach out to Physician Services and we welcome that. Reach out to Physician Services. So thanks. And I don't know if anyone has had any questions or wants to talk to me about the, any challenging interactions that they had or stories. I'm always anxious to hear some good cases and discuss them with people and possibly feature them in a future talk. Yeah. Well, it does not look like any questions have come in. If anybody has a question, we'll give you a minute or so to raise your hand and, or type a question into the Q and A. If not, then as I said in the beginning, the slides are available and we will be able to have those on the AOA website. And then you also will have the Physician Services email address should you have a question. You can send it in or as Dr. Nierdorf said, a book, anything that you'd like her to read to put out there on the DO platform. That would be great. But thank you very much, Dr. Nierdorf. Your book blew me away and I know that I'm sharing it with my friends. So I think it is definitely something that all people in the healthcare field should read. It's a little bit, it reads a little bit like a self-help book for all the doctors and nurses, kind of a little bit of confidence boost. One resident wrote me and told me that he would read a chapter before he would go in for every shift in the emergency department. That made me happy. So I hope more people can find it and get something for it. I really want the message to get out there because now we are doing such a valuable service for our community, for our fellow citizens. And we don't have to suffer quite as much while we're doing it. We can really feel good about it. Yeah. All right. Well, thank you all for joining us. And again, thank you, Dr. Nierdorf. Wealth of information, really appreciate it. Thank you. And that concludes our webinar.

difficult patients

clinical settings

negative thought patterns

think feel act cycle

empathy in healthcare

patient stereotypes

self-reflection

burnout reduction

Joan Nierdorf