A small room
Originally submitted as a piece of reflective writing, edited for brevity and detail. There's another part of this which I didn't submit... for another day.
This was fracture clinic, and the registrar and I had a plan. The orthopaedic registrar, H, and me looked through files in an odd-shaped room. The air hung still and muggy despite cracking open the door to the side room. Today's patients had mostly been referred from the Emergency Department, and so were new to H.
“Why don't you talk to this patient, take a history, then when you're ready to present, come in and tell me what you found?”
I went out to the waiting room and spotted the first patient immediately. Not a difficult task, as he was the only patient there. I had my standard spiel ready to go: a self-introduction, asking if I could take a history. Most patients are told early on that they should expect students to do this, and most are amenable, if slightly amused. He, however, adamantly refused. I took him in to see the registrar directly, to the registrar's bemusement.
As with all other patients, the registrar started taking a history – but the patient was oddly bristly. He was vague about how he had injured himself. When asked about his occupation, the patient interrupted: “No! We are wasting time! What I do is not relevant!”
“That's fine, let's move on to the examination. Could you take your jacket off please…”
H began inspection, but narrated what he was doing, as was his habit with medical students.
The patient interrupted: “I am in a lot of pain, you are wasting time by explaining to the student!”
The patient was physically imposing, and at that moment he stood between us and the only exit. I forgot the stuffiness, the traffic droning outside; I could only focus on the space each of us was taking up. I offered to leave, but H stood his ground. He explained that students were a welcome part of the team. He explained that this kind of behaviour was unacceptable in the clinic. The patient started shouting: this was his right to have whoever he wanted in the clinic, and if he wanted me to get out, I should get out.
I never felt physically unsafe during that aborted consultation, but I did feel threatened by his aggression, even by the size of the room. However, what contributed most of all to the feeling of threat was the divergence from the usual pattern.
Placement is supposed to be a safe learning space. We are often supervised by experienced clinicians, and can get immediate feedback if we make mistakes. Placement is inherently unpredictable, though, because any clinical encounter is unpredictable. People are complex, both patients and staff. While I initially treated events such as cancelled clinics and over-running ward rounds as nuisances, I realised that this stemmed from an understaffed system with many moving parts. These were, at least, benign, something we would laugh off.
This unpredictability meant that there were occasions during placement that genuinely made me feel threatened or fearful. Fear sneaks in during the seconds between approaching an intimidating nurse or consultant to ask for a favour. Fear sneaks in, in the moments before doing a procedure – hitherto only practiced on mannequins and anatomical models – on a real patient. Fear sneaks in when encountering a completely new situation with no clear solution, with no clear way out.
In that stuffy fracture clinic, fear snuck in, in the seconds between realising something was wrong and this patient being aggressive, because there was no telling what he was going to do. What if I had been in one of the side rooms alone, or H had gone out to run an errand, or if I had misunderstood the patient's intentions?
H never managed to calm the patient down. Instead, he got myself and then himself to leave the clinic room because he realised the conversation was going nowhere. The nurses got the other consultants in clinic – all as imposing as the patient – to talk to the patient.
When we returned to the now-empty clinic room, the patient had left with a new appointment with a new consultant. H did not immediately move on to the next patient on the list straight away, though: we talked about what had just happened. H spoke about the times that he had to disengage because he knew he was going to lose control. We discussed tactics for recognising when it was time to leave. We talked about de-escalation, from using non-verbal communication to choosing your physical position in the room carefully. It was humbling to realise that, with the same communication skills drilled into us from first year, a potential heated argument could at least be cooled down enough for myself to leave and escalate to someone more senior.
I realise now that our conversation was a form of debriefing. It helped separate the fear and perceived threat from the actual event history, and it was a chance for me to ask questions about why H did what he had done. More importantly, it was a space for me to formulate an approach if I ever found myself in a similar situation.
In an overstaffed, underfunded system fraying at the seams, there is reason enough for patients to be anger, justifiably so. I know meeting angry patients is inevitable. So when I next step into a room with the atmosphere electrified with hostility, I think I will see the same stuffy room again, and I hope I remember the gentle but firm way H tried to talk the situation down. If I find myself with a student encountering the prickly end of clinical unpredictability for the first time, I hope I remember what H did, and help them navigate these situations with grace and good humour.