A 27-year-old woman is admitted to the hospital for evaluation of abdominal pain that has intensified over the past 3 months. She describes the pain as severe and has been unable to work due to her symptoms. Medical history includes lower back pain, irregular menstrual cycle, depression, and borderline personality disorder. The admitting senior resident physician obtains a detailed history, after which the patient remarks, "You're a great doctor, and I can tell you really understand what I'm going through." Vital signs are stable. Physical examination shows mild, diffuse abdominal tenderness and is otherwise unremarkable. The next day, the patient is seen by the first-year resident physician who explains her role on the treatment team. She performs a brief physical examination, explains that an abdominal CT scan and laboratory tests have been ordered, and offers to answer any questions. The patient refuses to undergo testing and angrily says, "You're not good at your job. I know a good doctor when I see one. You just order tests without even knowing anything about me." Which of the following is the most appropriate response by the resident?

Question

A 27-year-old woman is admitted to the hospital for evaluation of abdominal pain that has intensified over the past 3 months.  She describes the pain as severe and has been unable to work due to her symptoms.  Medical history includes lower back pain, irregular menstrual cycle, depression, and borderline personality disorder.  The admitting senior resident physician obtains a detailed history, after which the patient remarks, "You're a great doctor, and I can tell you really understand what I'm going through."  Vital signs are stable.  Physical examination shows mild, diffuse abdominal tenderness and is otherwise unremarkable.  The next day, the patient is seen by the first-year resident physician who explains her role on the treatment team.  She performs a brief physical examination, explains that an abdominal CT scan and laboratory tests have been ordered, and offers to answer any questions.  The patient refuses to undergo testing and angrily says, "You're not good at your job.  I know a good doctor when I see one.  You just order tests without even knowing anything about me."  Which of the following is the most appropriate response by the resident?

Quizplus · Accepted Answer

Patients with personality disorders often display challenging behaviors, which can result in problematic interactions with providers and negatively impact care (eg, patient distrust and refusal of recommended treatments, demands for special treatment). Patients with borderline personality disorder frequently use the defense mechanism of splitting, in which they experience the self or others in extremes, either all positive or all negative. This patient's polarized views of the admitting senior resident as "good" (eg, "You're a great doctor") and the first-year resident as "bad" (eg, "You're not good at your job") has led to an impasse in treatment and potential division within the treatment team. The optimal approach to manage splitting in the inpatient setting is for all providers to see the patient jointly as a team. This allows the team to present a united front, providing clear and consistent information, preventing miscommunication, and minimizing the potential for splitting to divide the team or interfere with treatment. (Choice A) The first-year resident's assurance that the tests are indicated is unlikely to defuse the patient's anger and elicit her cooperation because she already perceives this physician as incompetent and "bad." (Choice B) This statement is defensive, and having the perceived "bad" team member tell the patient that her chart has been reviewed is unlikely to reassure her or reduce splitting. Arranging a team meeting with all members present would be more helpful. (Choice C) Promising to spend more time with the patient after the tests are completed does not address her accusation that these tests were ordered without the resident knowing anything about her. It would not help to reduce the patient's tendency to split the team. Educational objective: Patients with borderline personality disorder use the defense mechanism of splitting, which can result in polarized views of team members as "good" and "bad" and create division within the treatment team. Seeing the patient jointly as a team can help provide clear and consistent information and minimize the tendency for splitting to interfere with treatment. References: Difficult physician-patient encounters. (http://www.ncbi.nlm.nih.gov/pubmed/20646098) Borderline personality disorder. (http://www.ncbi.nlm.nih.gov/pubmed/29795363) Social cognition and borderline personality disorder: splitting and trust impairment findings. (http://www.ncbi.nlm.nih.gov/pubmed/30447728)

A 27-Year-Old Woman Is Admitted to the Hospital for Evaluation