Navigating stressful situations in residency

Congratulations on moving on to the next stage in your professional career. This article is part of a series called "Transition to residency", which is designed to help new interns and sub-interns adjust to their new responsibilities. The other articles in this series include:

• “Communication during residency”
• “Daily life of the intern”
• “Logistics of US health care and hospitals”
• “Life outside of the hospital”

This article discusses strategies for navigating some of the stressful situations that you may face during your residency training. This includes anger and threats from patients and familiy members, patients who want to leave against medical advice, medicolegal issues, patient death, workplace conflicts, harassment, and clinical uncertainty.

Faced with the stresses associated with a major medical event and hospital stay, patients and/or their family members may be angry or frustrated. While anger will be expressed verbally in most situations, physical threats may also arise. For all cases, it is important that you are familiar with deescalation strategies (see also “Approach to the agitated or violent patient”).

Management of an angry/threatening patient

• Always ensure the safety of yourself and those around you.
  • Maintain a safe distance from the patient.
  • Position yourself between the patient and the door/exit.
  • If possible, contact hospital police/security so that they are nearby in the case of escalation.
• Try to control your emotions and stay calm.
• Acknowledge the patient's emotions.
• Try to identify why the patient is angry.
• Work with the patient to devise possible solutions. If their anger is due to:
  • Fatigue and being overwhelmed from being in the hospital or from their underlying medical issue (e.g., pain, lack of sleep)
    • Explain the importance of the evaluation to date and why continued management in the hospital is necessary.
    • If possible, provide a timeline for the diagnostic and treatment plan.
  • Delays in care (e.g., long wait times for evaluation or testing):
    • Explain the reasons for the delays.
    • If possible, propose alternative options.
  • Medical error: Apologize, be honest with the patient about what happened, and explain the steps you are taking to manage the error and prevent it from happening again (see “Medical error” and “Patient safety” in “Quality and safety”).
• For patients who use aggression and intimidation to demand certain tests or treatments: ^[1]
  • Acknowledge their right to receive the best care possible.
  • Explain that you need them to calm down so that you can provide care without feeling threatened.

Follow-up of encounters with angry/threatening patients

• Consider convening a debriefing session with peers or others involved in the encounter.
• Talk to your support system.
  • In the hospital: peers, supervisors, and mentors
  • Outside of the hospital: friends, family, mental health providers
• Reflect on the patient encounter and adopt strategies for managing subsequent patient encounters.
• Find an outlet for personal feelings of frustration and anger.
• Remind yourself of recent positive patient encounters.

Leaving against medical advice (AMA) refers to when a patient wishes to self-discharge from the hospital despite the medical team's recommendations for continued in-hospital care.

Patient assessment

• Assess the patient's decision-making capacity.
• Determine the clinical urgency and severity of the patient's condition.
• Identify the reason(s) for wanting to leave the hospital, which may include:
  • Personal or family obligations outside of the hospital
  • Long wait times
  • Dissatisfaction with care

Management

• Try to identify alternative solutions for care.
• Arrange appropriate follow-up. ^[2]
  • If patients require further medical therapy, e.g., antibiotics, provide them with a supply of medication to continue after leaving the hospital.
  • For patients with outpatient primary care or other providers: Contact the outpatient providers to arrange for close follow-up.
  • For patients without outpatient providers: Arrange for them to establish primary or specialty care as needed, and/or provide them with a list of potential providers.

• Medical errors are common and can occur at any stage of one's career. If you have made a medical error or are being accused of committing a medical error, know that you are not alone.
• Medical errors can elicit a variety of emotions, including fear, guilt, and embarrassment. They can also impact self-confidence and trust in one's own judgment.
  • Reach out to others in your residency program (peers, senior residents, chief residents, or attendings) to discuss these emotions and to ask for advice managing them. Many of the people around you have likely had similar experiences.
  • If you are having trouble performing your regular duties after an error, consider a consultation with an employee assistance program or mental health provider.
• Consider the opportunities for personal and professional growth.
  • Understanding what went wrong can help you manage similar situations and avoid similar errors in the future.
  • The situation may allow you or others to identify opportunities to improve system-level factors.

• Situations in which you may face patient death include:
  • Patients assigned to your care during their hospital stay or visit (e.g., emergency department, ward, ICU, perioperative settings)
  • Responding to a code/cardiac arrest
  • A cross-coverage service/shift
• See the article “Death” for more information about pronouncing, addressing loved ones, coping and processing death, and documentation.

• Clear and effective communication can often help to prevent conflicts in the workplace (see “Communication in residency”).
• Various types of conflicts may arise in the hospital setting, including with members of:
  • Your team (e.g., medical students, senior residents, attendings)
  • The patient's care team (e.g., nurses, consultants)
• People vary in their conflict management styles (e.g., avoiding, accommodating, competing, compromising, or collaborating), and different styles may be suited to different situations. ^[3]
• Consider the appropriate setting for conflict resolution.
  • Assess the urgency of the issue.
  • Find an appropriate location to discuss the issue privately with the other party. Avoid having these conversations in patient rooms or public settings.
• For conflicts that you are unable to resolve on your own, consider involving other neutral parties, e.g., senior faculty not involved in the situation, your program director or division chief, or an ombuds office.

Experiencing harassment

• Sources
  • Patients
  • Hospital staff (including superiors and other members of your medical team)
• Forms
  • Verbal harassment: comments on physical appearance, background, or personal life; use of humiliating or degrading language
  • Physical harassment: inappropriate touching or hitting, or excessively close contact with an individual
  • Sexual harassment: unwelcome verbal or physical advances of a sexual nature
• Consequences
  • Negative impact on mental and physical health
  • Difficulty performing responsibilities at work

Addressing harassment from patients

• Ask the patient's nurse or another staff member to accompany you when evaluating patients.
• At the time of the encounter, consider telling the patient that their comments made you feel uncomfortable and set appropriate boundaries (e.g., “I am not comfortable with your comments. Let's keep this discussion professional and focus on getting you the best care.”).
• If you do not feel able to address the harassment with the patient, consider excusing yourself from the patient's room to talk through the situation with a senior resident or attending.
• After the encounter, take time to talk to those in your support system, colleagues, and senior residents/faculty about the episode.

Addressing harassment from superiors or colleagues

• Fear of retaliation may keep you from addressing harassment, particularly from superiors. Explore ways in which you can safely report concerns that arise at your institution.
• Access available institutional resources:
  • Ombuds office
  • Chief residents, mentors, and other trusted program faculty
  • Anonymous feedback
• Try to use concrete descriptions of the incident(s). Consider keeping a written record.

• Many patients present with atypical symptoms, and diagnoses may be unclear even after a thorough workup.
• When unable to rely on traditional knowledge from textbooks or medical literature:
  • Consider basic principles and biological plausibility to help guide the diagnostic and therapeutic directions.
  • Review what diagnostic steps have already been taken before going through a more extensive workup.
  • Consult with others prior to ordering testing that is not strongly supported by evidence.
  • In some cases, watchful waiting for a short period of time may be appropriate before ordering additional testing or providing additional treatment.
• Clinical uncertainty can cause frustration for patients as well as providers. When discussing the clinical uncertainty with the patient:
  • Explain what testing has been completed to date and what diagnostic role it plays.
  • Review the ongoing diagnostic and treatment plan, and engage the patient in shared decision-making regarding next steps.
• For management of symptoms that persist after a thorough workup and are thought to be due to a somatic symptom disorder, see “Somatic symptom and related disorders.”

• One-Minute Telegram 52-2022-1/3: Mistreatment and discrimination contribute to physician burnout.

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