In the middle of a very busy day at the hospital, the phone rings. A highly agitated doctor asks for my help: a patient went mad, is menacing the hospital staff and demands to go home against the medical advice. It’s the doctor on duty for the night shift who’s telling this to me; the patient’s personal doctor has finished his work day and went home. And, given the situation, the doctor on duty needs a psychiatric assessment before deciding what to do with the agitated patient. Having understood the situation, I leave my office in a hurry and I take the elevator up to the hospital department where this story is developing.
I arrive in the department and the first thing I do is listening. Are there any loud voices quarreling or objects being smashed? Everything seems calm so I infer it might not be a psychiatric case after all. If it were for a schizophrenic or a bipolar maniacal patient, things would have been different. I walk in the nurses’ office and introduce myself, while trying to perceive the “energy of the place” or what is the current collective mood. I find 2 angry nurses and the doctor who seems irritated but, on a second look, seems rather frightened as well. I ask for the patient’s papers so as to get a better view of the situation, while the nurses show me the patient who’s staying defiant outside his room. I take the time to rapidly check the medical papers, knowing that if someone’s angry, its anger vanishes with time. The doctor explains to me that the patient wants to be discharged because he has an appointment in 2 days’ time and he can’t understand why he didn’t arrange this with his own doctor and now wants to go home late in the afternoon when a normal discharge procedure can no longer be performed. This makes me think the patient is either a psychopath or has a really big problem, since it’s logical to leave in a scheduled manner and not in a hastily and potentially dangerous manner, after an incomplete treatment.
I get into the room of the patient, I say my name and my professional title and, as usual, ask what the problem is.
– This staff is full of idiots, doc! I want to get the hell out of this hospital as soon as possible! I came here for some tests, I told to my doctor that I have an appointment planned within 2 days, yet everybody treated me like the last man. And you know why, doc? Because I didn’t bribe them! I said that I’m already paying for my insurance which covers the hospital time and everything else, so I’m not giving them extra money so as to do their job properly! They neglected me in every possible way and I’m fed up with this! I will complain to the manager of the hospital and publish everything in the local newspapers and the social media! This is not acceptable! I worked my entire life, paid my insurance, and now I have to give extra money only to be taken into consideration and be provided with basic care?! I don’t know why they sent you to me because I’m not crazy! I just want my rights to be respected!
– Okay, but what exactly happened, I ask the patient, in the calmer possible manner. Can you explain it a bit to me? I’m not working here on this department and I want to understand.
– Well, I wanted to talk to my doctor today, since the only thing left to do in the hospital was to wait for the result of an X-ray. I can continue my treatment at home, there is no need to stay any longer in the hospital. The nurses told me that the result from radiology arrived in the morning but my doctor was busy in the ambulatory all day and nobody cared to give me the result of the X-ray and explain me what is all about. In the end, my doctor went home without coming to visit me and talk to me about the result. Doc, I’m really frightened about the result of my X-ray. So I went to the nurses asking for my doctor to come to me before he goes home. And the nurses answered aggressively that “the doc has left”. So I asked for the doctor on duty to come and at least explain me the X-ray result and tell me if it’s bad or not, but the nurses told me on the spot that the doctor has no time for me. So I asked where I can find the doctor and they told me that the doctor can be found in his night shift room, which is in the other corner of the hospital. So I left how I could, struggling with a lot of pain, until I arrived at the doctor’s door but there was nobody inside. Then I returned to my room, and on my way back I crossed somebody in a white coat, somebody who was talking to the nurses when I asked them about the doctor on duty, and asked him where I can find the doctor. And to my surprise, it was him that doctor I was searching for. So I understood in a blink of an eye that the nurses made fun of me, while the doctor was with them, and have sent me to his door, knowing very well that he isn’t there and walking was painful for me. So they basically couldn’t care less about my suffering, mocking me in the lowest possible way. So I exploded. I told them all to go to hell and asked for my immediate discharge. Nurses are supposed to be caring and helpful, not abusive because I refused to pay them.
In general, there is no smoke without a fire. The story of the patient is too full of details to be the product of his own imagination. I feel I’m getting angry myself because of the injustice caused to the patient. But then I remember that patients can lie as well and some of them might seek ways to harm the reputation of the hospital. But anyway, my role in the entire story is not the one of a policeman or a judge. My role is firstly the one of a psychiatrist and second, since the department and the doctor on duty have failed to communicate efficiently, the role of a leader. As a psychiatrist, my assessment was that the patient was in an acute reaction to stress. I couldn’t find any other psychiatric disorder. He simply reacted to a situation, be it an abuse or a misunderstanding. As a leader however, I had to do something.
First, I informed the patient that he is free to go and nobody will hold him against his will in the hospital. Generally this calms everyone, because a person who feels that is free and in control is a person who gives up rapidly any intention of pursuing a fight. Then I informed the patient who was constantly menacing me with his right to complain to the management of the hospital that he is completely free to do just that. This calmed the patient even more and provided him the much needed power position, hence partly removing his fear of consequences (the patient was menacing basically because he was also afraid).
Second, I knew that pursuing a game of “whose fault is” will lead to the further escalation of the conflict. There was appetite for judgment and punishment in the air; this was the local “energy” of the place, so my job was to change this atmosphere. Then, I had to listen to the “other part”, namely the nurses and the doctor on duty.
The nurses denied any wrongdoing. They said that the patient is talking nonsense and they wouldn’t mock someone this way, since they are true professionals. But my psy eye saw them nervous; they were defensive, not calm. They even began a game of “how dare he say that”. All in all, it was basically their word against the patient’s word.
In situations like this, it is unproductive to play the judge. Even if there is a problem of injustice, you need to focus on finding a solution and seeking a compromise. It is not profitable to go on with many questions and create an ad-hoc court. Both sides are “right” and both think they hold the truth. So you have to manipulate the situation, to “bend the energy”. So I took the doctor on duty with me and went to the patient’s room so as to… negotiate.
Leadership involves finding a compromise and avoiding a damaging war between several parties. And this is done by negotiating with the leaders. In this story, the leaders were the patient and the doctor on duty, since during the night shift the doctor acts like a manager by interim.
I began by explaining to the patient that my concern in this story, as an outsider, is his own interest. It is better to leave the hospital in a proper manner, during the next morning, after having the occasion to speak with his personal doctor who can properly prescribe a treatment. On the other hand, a sudden discharge means no immediate treatment and a discontinuation of the treatment procedures already in place in the hospital until the next day, including the painkillers. This convinced the patient half-way. Then, I offered to him the possibility to ask the doctor on duty about the result of his X-ray, which he did right away. The result was good but, to my utter surprise, the doctor on duty began to blame the patient for being impolite, trying to protect his team of nurses. This had the effect of throwing gas into a fire that was on its way to being contained. It was again my job as a leader to calm the doctor on duty and explain that blaming each other wasn’t productive at all. In the end, we left the patient a couple of minutes to decide whether he wants to stay or not in the hospital. The result? He stayed until the morning to talk to his personal doctor. And he didn’t complain to the hospital manager either.
In medicine there are, just like in other jobs, hard skills and soft skills. Taking a blood sample is a hard skill; everyone can do it and the medical staff is expected to have this skill. However, soft skills are about the way we interact with people, about how we deal with confusion or conflict, about communication and about common sense. It matters if you’re good on hard skills but it also matters if you’re having common sense. Especially when living in a deeply imperfect world, where it is difficult to draw a line between good and evil…