Managing an Unhappy Patient

A clinical study has noted that one out of six patients is perceived as “difficult” by clinicians. Not surprisingly, patient dissatisfaction has to do with multiple factors, both within and outside the control of the surgeon. In the present times of electronic information and ratings, managing difficult patients is a critical skill—a patient's dissatisfactory review could adversely affect a practitioner's reputation built over years of meticulous practice. Patient expectations are often more pronounced in case of elective medical procedures such as hair transplants. The subject of managing an unhappy patient in the context of hair transplantation is, therefore, one that requires due enquiry and is the subject that this article seeks to explore.

Outcomes of Endoscopic Ultrasound-Guided Biliary Drainage in a General Hospital for Patients with Endoscopic Retrograde Cholangiopancreatography-Difficult Transpapillary Biliary Drainage

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been developed as an alternative treatment for percutaneous transhepatic biliary drainage for patients with bile duct stenosis. At specialized hospitals, the high success rate and effectiveness of EUS-BD as primary drainage has been reported. However, the procedure is highly technical and difficult, and it has not been generally performed. In this study, we retrospectively examined the effectiveness of EUS-BD in ERCP-difficult patients with distal bile duct stenosis. We retrospectively examined 24 consecutive cases in which EUS-BD was performed at our hospital for distal bile duct stenosis from October 2018 to December 2020. EUS-guided choledochoduodenostomy (EUS-CDS) was selected for cases that could be approached from the duodenal bulb, and EUS-HGS was selected for other cases. In the EUS-CDS and EUS-HGS groups, the technical success rates were 83.3% (10/12] and 91.7% (11/12], respectively. An adverse event occurred in one case in the EUS-CDS group, which developed severe biliary peritonitis. The stent patency period was 91 and 101 days in the EUS-CDS and EUS-HGS groups, respectively. EUS-BD for ERCP-difficult patients with distal bile duct stenosis is considered to be an effective alternative for biliary drainage that can be performed not only in specialized hospitals but also in general hospitals.

What Causes the Most Stress in Breast Radiology Practice? A Survey of Members of the Society of Breast Imaging

Objective The objective of this study is to determine the major stressors affecting practicing breast radiologists. Methods All members of the Society of Breast Imaging within the United States received an email invitation to complete an anonymous survey evaluating stressors that may contribute to physician burnout. Stressors evaluated included pace at work, work–life balance, care of dependents, job security, financial strain, decreasing reimbursement, new regulations, delivering bad news, fear of getting sued, and dealing with difficult patients, radiologists, and administrators. Results The overall response rate was 13.5% (312/2308). For those who opened the email, response rate was 24.6% (312/1269). The most prevalent stressors reported were working too fast (222/312, 71.2%), balancing demands of work with personal life (209/312, 70.0%), fear of getting sued (164/312, 52.6%), and dealing with difficult administrators (156/312, 50%). Prevalence of stress related to new regulation requirements, job security, financial strain, decreased reimbursement, dependent care, call, delivering bad news, and dealing with difficult patients, difficult referrers, and difficult radiologists were present in fewer than 50% of respondents. Conclusion The most prevalent sources of stress in breast imaging radiologists relate to working too fast and balancing demands of work with time needed for personal life.

Super Difficult Patients with Mental Illness: Homelessness, Marontology and John Doe Syndrome

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196 The effect of affect: what we teach our learners about the role of patient induced emotion in clinical reasoning in the ED and why?

Aims/Objectives/BackgroundFew empirical studies explore the contribution of non-clinical factors to perceptions of patient difficulty in EM. Fewer have investigated what students placed in EDs learn about ‘difficult’ patients or what, if anything, clinicians teach about the topic. We looked to address this. Considering these questions is imperative: patients perceived as frustrating report lower satisfaction with their clinical encounter, experience worse health outcomes and seem to be at risk of medical error secondary to faulty clinical reasoning.Methods/DesignWith ethical approval, we undertook three interrelated, qualitative studies to conduct a case study of the undergraduate EM module delivered at Edinburgh University. In the first two, focus groups were used as the method of data collection; five clinician (n=25) and four medical student (n=21) groups were facilitated. In the third, semi-structured interviews with clinicians (n=12) were conducted. All groups/interviews were audio-recorded and transcribed. The data were analysed inductively using reflexive thematic analysis.Results/ConclusionsFrequent attendance, demands, pre-existing relationships and unrealistic expectations contributed to perceived patient difficulty. These were modified by personal and circumstantial factors. Although rarely told, students were aware who these ‘difficult’ patients were through observing behaviours. Critically, clinicians and students alike believed frustration adversely impacted aspects of clinical reasoning. Students struggled when witnessing what they considered ‘bad’ behaviour as it contradicted their previously held ideals of how physicians should act.It seems we teach students to try to internalise emotion yet that it is acceptable to let it negatively impact patient care. To combat this, students sought greater emotional transparency from physicians as well as advice on self-management strategies. Clinicians recognised the benefits of being candid but were afraid of being so. Contributing to this is the culture in medicine being one that mistrusts emotion. Further, both groups desired a formal curriculum addressing emotion in clinical reasoning thus suggesting one is needed.

An Alternative Loop Snare Technique with Many Loops Using a Simple Guide-Wire for Removal of a Double J Stent: A Case Series

Background: Removal of a double J (DJ) stent has been conventionally performed with conventional snare wires, tissue forceps, or stone baskets under fluoroscopic guidance. However, if the lumen is collapsed, is very wide, or if the tip of the DJ stent is lodged in the bladder wall, the procedure becomes difficult. Patients and Methods: We retrospectively reviewed four patients who had undergone retrieval or replacement of their DJ stents by interventional radiologists with an alternative loop snare technique using a guide-wire after conventional attempts using a snare catheter had failed. Results: Five DJ stents were completely removed without any complications. Conclusion: The loop snare technique using a guide-wire could be an alternative and inexpensive approach for difficult DJ stent removal.

Altruism and the Difficult Patient

Background For some nurses, providing altruistic care to difficult patients is a challenge, leading to the use of negative coping strategies such as anger or avoidance, leaving the nurse frustrated and patients feeling rejected. Yet other nurses can deal positively with difficult patients. Purpose To study how the stress of caring for difficult patients affects the level of altruism and use of negative coping strategies in their care and to find out what positive coping strategies and interventions could be used. Design/Method A mixed-methods design was used. A survey tested the level of altruism, the use of negative coping strategies, and several demographics. Thematic analysis examined narratives generated by participants to three questions regarding how to provide altruistic care to difficult patients. Findings A purposive sample of 67 registered nurses (RNs) participated. The average level of altruism used by RNs with difficult patients was 99.7/120 points. An inverse relationship was found between the level of altruism and use of negative coping strategies ( r = −0.577, p < .001). Qualitative analysis of narratives identified three themes—Developing Psychological Hardiness, Bearing Witness, and Fending for Oneself. Conclusions This study provides insight into the experiences of RNs caring for difficult patients and how to ensure altruistic caring.