It's Not Just on 'The Pitt': Real-Life Emergency Doctors are Stressed Out—And Patient Irritation Plays a Significant Role
UMass Amherst-led research finds physicians with peevish patients were more likely to become disengaged in the patients' care
AMHERST, Mass. — HBO's emergency-department drama "The Pitt" has become a smash hit in large part because it shows the deeply human toll that emergency medicine exacts from those who practice it. While researchers have long known that real-life ER doctors are affected by many of the stresses that "The Pitt" has so effectively captured, a recent study led by the University of Massachusetts Amherst and published in the BMJ: Quality & Safety is the first to design an interactive and controlled experimental method to test how irritable patients—those displaying frustration or anger—affect the emotions of those treating them, and thus, potentially, the effectiveness of care they receive.
The emergency department has always been one of the most stressful places to work in any hospital—one never knows what sorts of injuries, or how many of them, each shift will hold. Additionally, these spaces have increasingly been on the frontlines of various economic and social crises, including the lack of health insurance and skyrocketing medical costs, immigration and law enforcement and increasing needs for mental health and addiction services. One of the results of all of this is that patients are increasingly irritable, and too often take their frustrations out on caregivers.
"Emotions are an inherent part of our lives—they're what makes us human," says Linda Isbell , Feldman-Vorwerk Family Professor in Social Psychology at UMass Amherst and the paper's lead author. "But for too long, the medical culture has expected doctors to leave their emotions at the door. This is just unrealistic."
It seems reasonable to conclude that when physicians experience stress in response to patient irritation, the quality of patient care suffers, and there is good anecdotal evidence to support that. But until Isbell and her co-authors, including emergency medicine doctors from the UMass Chan Medical School and the Harbor-UCLA Medical Center, began their study, there were no reliable controlled experiments that had rigorously studied how patient behavior affects physicians' emotions and patient care.
The team designed a novel approach that began with professional "standardized patients"—people who are specially trained to play patients with realistic, specific medical conditions. Four standardized patients were each trained to perform in one clinical case that corresponded to one of four different diagnoses. Each "patient" was trained to perform two different roles: someone calmly seeking medical care, and someone behaving irritability with their physician.
"What's most important here is that each standardized patient, no matter whether they were playing their calm or irritable role, provided the same exact medical details," says Isbell. "The only thing they changed was their emotional condition."
Isbell and her colleagues video-recorded these patient encounters and then recruited 134 emergency medicine physicians from 46 U.S. states. Each physician was randomly assigned a set of four recorded patient encounters, two of which were from calm patients, two from the far more irritable group.
The physicians were then asked to order clinical tests, for which they received results, and continuously assess their patients, just as they would do in a real-life setting.
Finally, Isbell and her team asked the physicians to report on their emotional state and engagement with each patient. With this information, researchers examined whether or not physicians' emotional responses, clinical assessments or clinical behaviors shifted when they were assessing irritable patients versus calmer ones.
What they found is that irritable patients make physicians feel worse. Those physicians reported increased levels of anger, anxiety and fatigue. Doctors were also less engaged in their irritable patient's care, and much more likely to find their patients unreliable in terms of reporting their own symptoms. Physicians with irritable patients were more likely to interpret their patient's pain as exaggerated, find them less cooperative, less engaged in their own care or willing to adhere to a treatment plan, and less likely to return to work.
Furthermore, those physicians who were more susceptible to finding medical uncertainty stressful experienced a greater emotional toll when their patients were difficult.
More research is needed to better understand how all of this affects patient care, but, as Isbell put it, "the interaction between a patient's behavior and a doctor's ability to tolerate stress associated with medical uncertainty is critical." Doctors who are especially vulnerable to stress are likely to experience their difficult patients as more challenging and emotionally taxing—fueling a cycle that could lead to worse patient outcomes.
"Medicine is inherently uncertain and emotional," says Isbell, "especially in the ER. We need a systemic shift that acknowledges the human reality of uncertainty and emotions in medicine and supports both doctors and patients as they work toward a common goal: health and well-being for all."
