hen I go to work each day, I hope to build doctor-patient relationships based on mutual respect. As a new doctor, I believe that this foundation helps us deliver safe and satisfying medical care.
Mutual respect doesn’t always happen.
Several weeks ago, I was assigned a patient who was admitted overnight after fainting due to dehydration and low blood pressure. As I was digging through her chart the next morning, a nurse told me that she was demanding her anti-anxiety medication ahead of schedule and was leaving at 8 a.m., no matter what.
With few exceptions, patients can leave the hospital against medical advice — what we refer to as AMA —whenever they want. It’s their right. But they often don’t do well. In a recent study of 150,000 hospital discharges, about 2 percent of people left AMA. Within 30 days, however, the AMA group was twice as likely to be readmitted — about 25 percent, compared to about 11 percent of patients who were properly discharged. Worse, they had a twofold increased chance of death compared to patients who were properly discharged by their doctors.
Ms. X, as I’ll call her, wasn’t my only patient, but I put my work aside and went to her room to see what was going on.
After we talked for half an hour, she calmed down and told me she wanted to leave. She felt fine and was tired of being in the hospital. I told Ms. X that we needed more time, and that I would greatly appreciate her patience.
I laid out how we wanted to treat her. Even though I had examined her, the senior doctor still had to evaluate her, and all of our other patients, during our morning rounds that started at 8:30. After that, we would discuss her diagnosis and treatment and come up with a game plan. Finally, the senior doctor and I would prepare the discharge paperwork, which would be reviewed with Ms. X and a nurse.
Safety first. Why rush it?
It was only with the promise of coffee, breakfast, and Klonopin that she agreed to wait.
Patients who leave AMA get labeled as difficult. It’s a dark mark that can affect the way we feel about our patients, challenging us to be as thorough, as thoughtful, as human as we would be with someone more willing to collaborate with us. The first patient I cared for in this hospital was a homeless man struggling with alcoholism. I tried to connect with him, to learn about his life, to give him the kindness and compassion he deserved. He left AMA. Two weeks later, he was back, even worse off than he was before. Again, I reached out. I tried to connect. But when he started threatening to leave again, I began to feel like I was just going through the motions in treating him.
Unfortunately, many patients who leave AMA are the most socioeconomically disadvantaged. I pursued my residency at the Cambridge Health Alliance because I wanted to practice mission-driven medicine, and serve patients who wouldn’t have access to care otherwise.
And here I was trying not to resent my patient for rebuffing my efforts. This realization was hard to stomach. I knew he was sick and suffering, but when you have a million things to do, it’s emotionally taxing to care for someone who won’t be cared for.
By 8:40 a.m., Ms. X was clamoring to nurses that she wanted to sign her papers and leave. My team had prioritized rounding on other patients who were more ill and required immediate attention. Once again, her demands disrupted our workflow. I dropped everything to address Ms. X and her concerns before she left without a treatment plan.
Now she wasn’t feeling well, and demanded a headache medication that is used only occasionally because it is addictive. Taken too often, it can have miserable side effects, including a rebound headache. Her chart told me that she popped it like candy, and as my attending physician tried to explain the risk of taking it too often, she started screaming.
“Are you going to give it to me or not? If not, I’m out of here right now!” she screamed. As the attending began explaining why he couldn’t, she cut him off, vigorously pointing at him again, “It’s a simple question — YES OR NO?”
This soft-spoken and thoughtful man conceded, and left. I’d never seen a patient treat a doctor that way. I felt disrespected on his behalf, and embarrassed at having been one of four people watching him fail at negotiating with an emotional extortionist. We were simply trying to give her the best possible health care.
The team concluded that Ms. X suffered from low blood pressure because she had taken too much of her high-blood pressure medications. While she was waiting for her headache medication to arrive from the pharmacy, it was my responsibility to review our assessment with her. I carefully went over the reduced dosage of each of her three blood pressure medications, and assured her that I would spell out these changes in her discharge paperwork to avoid any confusion at home. Again, I asked for her patience as I prepared her paperwork and got it checked by a senior doctor.
As the senior doctor was editing the paperwork, I saw the patient transport staff wheeling Ms. X down the hall. She had taken her headache medication and decided then and there that she was leaving.
I felt my blood begin to boil. This woman had thrown a grenade in my entire day. She not only stole time from my other patients, but also compromised my education — I was bargaining with her instead of benefiting by rounding with the rest of the team.
“Whatever,” I thought, “I’m not the one who is going to suffer when she drops in the streets.”
But the problem is, her health is my concern, and if she comes back, I still have to do my best to help her. It’s frustrating.
Some doctors look at AMA discharges as liability protection, a means of protecting themselves from discharges we don’t agree to. This patient did not technically leave AMA, but I definitely did not agree to this discharge. As I documented this in her chart, I wondered if I tried too hard to protect her from the stigmatizing impact of the AMA label.
I turned to my attending. “I’ve bent over backwards to help this woman have a safe discharge and I feel like she sabotaged the whole thing. How do you deal with patients like this?”
“It never gets easier,” he said.
Maybe I learned something after all.