When I see patients these days, it is usually in a hospital. Most are not particularly happy to be there. They are sick, uncomfortable, frightened, or simply exhausted by whatever brought them through the emergency department and into a hospital bed. For a long time, I assumed that their frustration with being in the hospital was simply part of being sick. Of course people don’t want to be hospitalized. And, of course, they are anxious and uncomfortable. But lately, I have started looking at this from a different viewpoint.
I have begun to wonder whether some patients are frustrated not simply because they are sick, but because they don’t feel that they are being treated well. They know it, and they feel it, but they often have very little power to change it. This feeling can manifest in many different ways. Sometimes it is repeated complaints. Sometimes it is anger directed toward the nurse or physician. Sometimes it is a family member demanding to know why nobody is doing anything. And sometimes, unfortunately, it escalates into shouting, threats, physical aggression, security involvement, restraints, or medications to control behavior. We are quick to describe these patients as difficult, but I have started wondering whether we should also ask what happened before the patient became difficult in the first place.
In between slurps and bites of a meal, I was called to the bedside to evaluate a patient who was in distress. Earlier in the day, one of the specialty physicians had given me some of this patient’s backstory. There were several concerns: the patient’s condition, the possibility of a poor clinical outcome, and potential litigation. I went to the bedside and began addressing the immediate issues that could be managed on the floor and then I contacted the ICU physician because of the patient’s clinical situation. The intensivist came to the room with a very different assessment of what was happening. He was already thinking about whether the patient should transition to hospice care. I stepped outside briefly to document and had barely started typing when I heard raised voices coming from the room. I stopped typing and hopped back inside.
At that point, the conversation had escalated. My role changed almost immediately. I was no longer simply evaluating a patient; I was trying to lower the temperature in the room and get everyone to listen to one another. The escalation pathway had already been activated. After the intensivist left, the family and I talked some more and they expressed multiple grievances to me, particularly about their interactions with the nursing staff. They were angry and frightened, and they felt that no one was listening. Eventually, they thanked me for listening to them. They also threatened litigation.
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I have thought about that encounter many times since. What struck me was that despite all of the medical complexity and the concerns about the patient’s condition, what seemed to matter most to the family at that moment was that someone had finally stopped and listened. The situation had become so adversarial that litigation had entered the conversation, yet the intervention that seemed to make the greatest difference was not another test, medication, or procedure. It was simply giving them an opportunity to explain what they believed had gone wrong.
Verbal confrontations like this seem to be becoming more common in hospitals. Unfortunately, physical confrontations occur as well. Patients become agitated, families become frustrated, nurses become overwhelmed, and security is called. A patient may ultimately be restrained or physically subdued, and sometimes medications are required to control dangerous behavior. None of this is acceptable when health care workers are being threatened or injured. Nurses, technicians, physicians, and other hospital employees deserve to work in an environment where they are safe, and patients also deserve to be protected from violence.
At the same time, if we only look at the final moment (the shouting, the security call, or the restraint), we miss everything that came before it. The health care worker standing in front of the patient is often carrying an enormous amount of pressure as well. Nurses are caring for multiple patients with increasingly complex medical problems. Patient care technicians are doing physically demanding work, including lifting, transferring, and moving patients, sometimes while dealing with confused, frightened, or volatile individuals. These workers can be injured simply trying to do their jobs.
Physicians are dealing with their own pressures. They are expected to make difficult clinical decisions while simultaneously navigating staffing shortages, administrative demands, documentation requirements, patient expectations, family expectations, and the constant fear that something will go wrong. Physicians and nurses can find themselves in conflict with administration over resources, staffing, scheduling, patient flow, and clinical decisions. Eventually, some leave. Every time someone leaves, the pressure on everyone who remains becomes greater.
That is how a system starts to deteriorate. There are fewer people available to care for patients, the people who remain become more stretched, and everyone has less time. Call lights take longer to answer. Patients wait longer. Physicians have less time at the bedside. Nurses have less time to explain what is happening. Families become frustrated, staff become defensive, and the next interaction begins with less trust than the one before it.
And sometimes the breakdown is surprisingly basic. Sometimes the patient is simply hungry. A patient may be kept NPO because a procedure might happen. The procedure gets delayed, then postponed again, and eventually doesn’t happen that day. Yet the patient may still have gone most of the day without eating. Sometimes the patient is asked what they want to eat and the wrong food arrives. Sometimes nobody asks at all. To someone working in the hospital, these things may sound like minor inconveniences. To a patient who has been sick for several days, they can feel like another indication that nobody is paying attention. The same thing happens with almost every part of the hospital experience. A patient presses the call light and waits. A medication is late. A test is delayed. A procedure is postponed. A physician says they will come back and doesn’t make it back for several hours. A family member asks the same question three times because they have received three different answers.
Individually, these things may seem small, but collectively they become the patient’s experience of the hospital. Even something as simple as getting a patient from the emergency department into a room is dependent on an enormous number of people and processes. There has to be an available bed. The previous patient has to leave. Transportation has to be arranged. Environmental services has to clean the room. The environmental services worker may already be dealing with an enormous number of rooms and not enough people to clean them quickly. The patient waiting in the emergency department does not see any of this. They don’t see the staffing shortage, the bed-management system, the environmental services schedule, or the nurse trying to care for several other patients at the same time. They see the person standing in front of them, and that person becomes the face of the problem. The nurse becomes the delayed medication. The surgeon becomes the delayed procedure. The technician becomes the transportation problem. The hospitalist becomes the discharge plan the patient doesn’t understand. The person standing directly in front of the patient is often being asked to absorb the frustration created by a system that they did not create.
This is where I think we have to be careful about how we use the term “difficult patient.” Sometimes patients are genuinely difficult. Sometimes they are verbally abusive. Sometimes they are threatening. Sometimes they are physically dangerous. Those behaviors cannot be excused simply because someone is sick, and health care workers should not be expected to tolerate threats or violence as part of their jobs.
But sometimes anger is communication. A patient who is repeatedly asking questions may not understand what is happening. A family that appears demanding may be a family that believes no one is listening. A patient who is yelling may have been waiting for hours, may not have eaten, may not understand why a procedure was canceled, may have received conflicting information, and may have no idea when someone will return to explain what happens next. Understanding that pathway to escalation does not make threatening or violent behavior acceptable. It does, however, give us an opportunity to prevent some of it.
I also think we underestimate how much patients notice. They notice whether someone remembers their name. They notice whether someone sits down. They notice whether the physician looks at them or only at the computer. They notice whether someone explains why something is delayed. They notice whether the nurse comes back after saying, “I’ll check on that.” They notice whether someone seems genuinely concerned when they say, “Something doesn’t feel right.” Most importantly, they notice whether they feel like a person or a problem or a commodity.
We spend a tremendous amount of time talking about improving health care through technology, efficiency, artificial intelligence, quality metrics, throughput, and financial sustainability. All of those things might matter to different people. But there is another element of health care that is much harder to measure: trust.
A patient who trusts the health care team is more likely to ask questions, tell us when something is wrong, and participate in the plan of care. They may also be more willing to accept that a test has to be delayed or that a particular treatment isn’t appropriate. When that trust disappears, every subsequent interaction becomes harder. A delay becomes evidence that nobody cares. A mistake becomes evidence that nobody is paying attention. A different answer from a different clinician becomes evidence that nobody knows what is happening. By the time the patient becomes angry, the argument may no longer be about the meal, the medication, the call light, or the delayed procedure. It may be about everything that happened before it.
That is what I think happened with the family I encountered. Their anger did not begin when voices were raised in that room. It had accumulated over time. By the time I walked back into the room, I was dealing with the accumulated frustration of everything they believed had gone wrong. Listening became an intervention. It wasn’t a medical intervention. I didn’t give a medication, order a test, or perform a procedure. I listened. And for that family, at that moment, it mattered.
Of course, listening does not mean agreeing with everything a patient says. It doesn’t mean allowing abuse. It doesn’t mean compromising clinical judgment because a family is angry. It doesn’t mean asking health care workers to tolerate threats or violence. We have to protect health care workers too. But protecting health care workers and listening to patients are not opposing ideas. In fact, they are connected.
Health care workers need adequate staffing, reasonable workloads, safe working conditions, and institutional support. Patients need timely communication, basic dignity, food, attention, and the feeling that someone is actually paying attention to what is happening to them. Perhaps we need to stop thinking of these as separate problems.
The patient who is angry and the nurse who is exhausted may actually be experiencing two sides of the same broken system. The patient feels that no one is listening, while the nurse may feel that no one is listening to them either. The physician is trying to care for increasingly complex patients while being asked to do more with less time. The technician is trying to safely move patients while working in an environment where staffing and patient acuity continue to increase. Everyone is stretched, and the consequences are often felt most acutely at the bedside.
The patient is not a burden, and the health care worker is not an unlimited resource. If we want patients to have better experiences and, ultimately, better outcomes, part of the solution has to begin before we ever talk about the diagnosis. It begins with how we interact with patients from the moment they enter the hospital: whether we explain the delay, whether we make sure they have something to eat when medically appropriate, whether we answer the call light, whether we tell them when we don’t know something instead of pretending that we do, whether we come back when we say we will, and whether we listen when they tell us something is wrong.
Every interaction contributes to the patient’s perception of whether the hospital is a place where they are being cared for or simply a place where things are being done to them. That distinction matters. Patients come to hospitals because they need help. They shouldn’t have to spend their hospitalization wondering whether they are welcome there.
Perhaps before we ask why patients are becoming more difficult, we should ask ourselves what we are doing that makes people who came to us for help feel like they are a burden. Maybe the answer isn’t that patients have suddenly changed. Maybe some of their frustration is telling us something about the environment in which we are asking them to heal. So, before we order another test, call another consultant, or activate another escalation pathway, we should remember that one of the most basic interventions in medicine will always be available to us: listening.
Dalia Saha is a nocturnist.
