There are a few things from residency training that resonated so profoundly for me that they permeate everything I have done since. I will never forget my first delivery, not because I thought I would ever deliver babies in my practice, but because of the emotional and enduring collision of medicine and nature it represented for me. And who can forget the 36-hour shifts (now extinct) that I am quick to recount for young clinicians with the perfunctory “back in my day….”
There were, of course, specific patients whose stories stick with you or whose diseases you will only see once in a lifetime. But there is one experience, above all the rest, that changed the way I approach patient care, and that just might do the same for you: One of my clinical professors, a Birkenstock-clad hippie with a philosophical persona, developed a model for understanding common maladaptive patient behaviors that were previously unclassified or lumped into generic categories like “immature coping mechanisms.” He described patterns of inappropriate behavior that are associated with a “loss of control,” often triggered by stress, fear, pain, and vulnerability. He termed this new clinical entity, “Expectations Disease.”
Here’s what it means:
When expectations are negative or disabling, people feel a loss of control. But instead of choosing behaviors that might help them regain control, these patients have a tendency to choose destructive behaviors that they would not otherwise deliberately choose. Examples include substance abuse, anger, binge behaviors, panic, hysteria and somatization (patients with medical symptoms, often pain, but without an identifiable cause). These maladaptive behaviors allow these patients to temporarily shift their focus away from the real problem or stressor while providing them with a paradoxical sense of relief.
It’s a fascinating construct when you think about it, and one that likely underpins a lot of presentations we see in the urgent care setting. This makes sense when you think about the spectrum of problems we see and the ease with which patients can access our care. These are often desperate cries for help, hidden behind distracting and unrelated behaviors. In order to ensure we deliver the right care for these patients, we have to get good at identifying Expectations Disease and responding appropriately.
Needless to say, it can be quite challenging to hold our own emotions in check when someone is acting out in destructive or offensive ways (those of us with children at home have had to learn the hard way). So, here are a few practical tips:
The front office staff is usually to first to be impacted by these behaviors, so it can be helpful to be aware and prepared with a de-escalating response. First, always acknowledge the problem and demonstrate a genuine resolve to help. For example, you might say, “I can see that you are in pain, let’s get you checked in so we can see what we can do to help.” Substitute any of the following for pain: angry, upset, concerned, sick, etc. You get the idea. Remember, no one ever wants to be told to “calm down” or have their concerns dismissed. It’s best to actively reassure these patients that we “have their back.”
For physicians and advanced practice providers, these patients can feel exhausting and the task can seem daunting in our setting. My advice for you is simple: Don’t feel like you have to “fix” everyone; just make a dent in the armor and get these patients better oriented for getting the care they need. If done with empathy, compassion, and advocacy, your patients will understand and appreciate it. And you can avoid unnecessary work-ups or medications.
For all of us, regardless of our position or role, let’s never forget that a cry for help is a gift, regardless of how misdirected or disruptive. Being there for our patients when they are in distress is important. And helping them is what brings us joy. It’s what we do.
Lee A. Resnick, MD, FAAFP
Editor-in-Chief, JUCM, The Journal of Urgent Care Medicine
