Today on JailMedicine, I am happy to present a guest post by Dr. Bill Wright. As you may remember, Dr. Wright is the author of Maximum Insecurity: A Doctor in the Supermax, which I reviewed here and which you can purchase here.
Correctional medicine attracts more than its share of argumentative and demanding patients. We all feel the tightening in our stomachs when finding certain names on the clinic schedule, anticipating the disputes that are almost certain to follow. It doesn’t need to be that way.
Aikido is a martial art centered on disrupting your opponent’s balance and redirecting his energy. Unlike most other martial arts, aikido teaches that you do not have an opponent, but rather a partner. There is no punching or kicking. There are no aikido tournaments, because you can’t attack anyone with aikido. It’s purely a defensive art, but that doesn’t diminish its effectiveness. If you remember Steven Seagal movies, that’s aikido, albeit with a Hollywood twist. One of my black belts is in aikido, so I can vouch for the ability to translate aikido principles into patient encounters.
For example, try this exchange with Butch, my aggressive patient. He’s got low back pain which I’m convinced is part muscular, part bogus.
“I need stronger pain medicine. My back’s killing me, and you’re not giving me anything. I need it fixed now.”
“Tell me about your back pain. How long has it been going on?” Notice I don’t oppose his request for pain medicine, and I don’t deny his ailment. I’m on his side, just looking for more information to help him. How can he be upset with that?
“I’ve had this since the car wreck in 2002. Motrin and Tylenol don’t do anything for this. I need Vicodin or Percocet. That’s what my doctor in Denver gave me.”
“Who took care of you in Denver?” No denials or arguments. Just working with him to define the problem and gather information.
“I don’t know his name. He’s at that big hospital downtown.” So now we know he’s lying about having a regular doctor. He’s probably been hitting up ERs for the drugs or getting them from his buddies. Still, no confrontation. No arguments needed.
“Maybe we can get the records from the hospital. Which one is it?”
“I’m not sure. Maybe Swedish.”
“Terrific. I’ll send off and get their records so we can follow the plan your doctor outlined.” I’m on his side. Just doing what his doctor has outlined. Never mind that there likely isn’t any doctor or any plan, but he can’t get angry because I’m trying to help him. Just taking what he told me and moving it in the direction I want.
“But the pain. I can’t live with this.”
“Well, you know we don’t have narcotics in jail, so that option’s out.” Not my fault. I’m deflecting his demand, but not opposing the idea that he needs pain medication.
“At least I need a stronger dose of that Motrin and Tylenol.”
“You mentioned those aren’t working for you. Not much sense using something that isn’t working. I’m worried that the Motrin will make your reflux worse, and Tylenol can be toxic to your liver. We have to watch the doses of both of these.” Just feeding back what he already told me and showing that I’m not opposed to his requests. I’m concerned about the side effects of the medicines. Concern for his health is driving a denial of increasing the dose, not my intransigence.
We could go on, but you get the idea. As in aikido, you never oppose your partner’s energy, but simply redirect it. By not opposing your opponent’s strength, you give him nothing to push against. Your patient can’t confront you if you’re not confrontational.
You’ll notice in the example that I never said “no” to his requests or argued with him about whether his request was reasonable or even valid. Although we appear to be having a conversation, I’m the one who directs the flow and energy.
If I object to one of his demands, I’m opposing him. I’ve stopped the flow of energy at that point, and we’ll be going toe-to-toe about an issue that I’ve already decided isn’t relevant. Understand that I’m not gathering information by doing this. I’m past that. I’m selling the solution in a way that won’t lead to confrontation and hostility.
This doesn’t mean you can’t say “no” to a request that’s unreasonable or goes against the rules of the facility. Just couch the denial in such a way that both you are on the same side seeing the problem from the same vantage point. It’s not my desire to deny you XYZ, it’s the facility rule, e.g. nobody gets a second mattress not just you.
Is this manipulative? You bet. Just as you can deflect the question, “Do these pants make me look fat?” you can steer your dialogs with demanding patients to a happier resolution by directing the flow so both of you are cooperating instead of arguing. Everyone will leave the clinic with lower blood pressure.