The Inmates Are Running the Asylum

OK; that might be a bit of an exaggeration. But if you left your clinical shift asking why you feel so depleted and frustrated and why you had that negative interaction with that patient, you should do yourself a favor and read the recent review in the Journal of Hospital Medicine entitled “When Personality Is the Problem: Managing Patients with Difficult Personalities on the Acute Care Unit“.

In this article, it notes that about 4-15% of the population is affected by at least one personality disorder and that this prevalence is thought to be much higher in those seeking healthcare services – perhaps as high as 25% of the population. This is thought to be due to in part to lifestyle factors, such as drinking and drug use, as well as the fact that individuals who possess these dysfunctional personality structures may have difficulty accessing and utilizing care adequately. These same personality disorders that create chaos within the mind and thinking of the afflicted may also impact the environment around them, creating chaos and disruption for caregivers.

But hey, you already know this! You just left a shift where a patient fired you for not giving more of the magic elixir known as “Dilaudid”; where you have given up trying to get a patient to participate in her physical therapy who is all the while bemoaning she is too weak to go home; where, despite your extensive sales experience, you could not get your isolated, but intelligent, patient to give any rational reasoning for his refusal of fairly benign but necessary interventions!

We’ve all been there. It’s helpful to realize that these patients, while deserving of our compassion and care, are damn difficult, and can suck the wind out of the most Pollyanna-ish provider. When we look at hospitalist burnout, I can’t help but feel this patient population can really degrade and decay committed providers.

So… What can we do about it? I found reading this review practical, helpful and soothing to my own chaotic mind in answering that question. The direction and suggestions to offer empathy, establish parameters and develop a consistent message within the care team is exceedingly simple but impactful. It may be beneficial to have a “mini-huddle” with all the providers to discuss the “platform” you are going to campaign on. This could not only assist with gaining cooperation from the patient, but also prevent manipulation of a single caregiver and create camaraderie within the care team.

I am going to copy this article and place it on the board in our work room, as well as talk about it with my fellow sufferers. Training and education about these personality disorders on any level has to be helpful. And I can’t help but feel that there has been a definite increase in the volume of these patients, in part due to the lack of available outpatient psychiatric and therapeutic options for this population.

Reading this article gave me and my team practical tips for making things bearable and for developing a compassionate and detached perspective. Even taking the first step toward coming up with a strategy can help providers give better care, help patients who struggle with these disorders and provide some relief to those who deal with this frustrating patient population.

Tracy Cardin

Tracy Cardin, ACNP-BC, SFHM is the Associate Director of Clinical Integration at Adfinitas Health and also serves on SHM’s Board of Directors. Prior to this, she was the Director of NP/PA Services for the University of Chicago and worked in private practice for a group of excellent pulmonologists/intensivists for over a decade. She has been a member of SHM for over ten years and has over twenty years of inpatient experience, which seems incredible as she cannot possibly be that old! Her interests include integration of NP/PA providers into hospital medicine groups and communication in difficult situations.

In her free time, she likes to run and lift, read and write and hang out on the front porch of her semi-restored Victorian house with her dear family and friends while drinking a fine glass of red wine and listening to whatever music suits her whimsy.

Leave a Comment