The Patient Who Records You
During a busy shift, a 34-year-old man with chronic abdominal pain is being evaluated for the fourth ED visit in 6 weeks. Workup to date has been repeatedly unremarkable. He requests 'the good stuff' (IV hydromorphone) and becomes loud when you explain a plan of oral analgesia and outpatient follow-up. He pulls out his phone and begins recording, saying, 'I'm documenting how you're refusing to treat my pain.' He refuses to stop recording. A nurse tells you he 'has a reputation' in the department. You are aware that other clinicians have flagged him as drug-seeking in the chart. The waiting room is full, and you have two critical patients.
1. How do you handle the recording and the encounter in real time?
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Recording: Policies vary by state and institution; in many one-party-consent states the patient may record. Do not grab the phone or escalate physically - that creates a battery/assault risk and a spectacle. You may ask him to stop, state that you will continue to provide care, and, if your institution permits, continue the visit professionally. If institutional policy forbids recording, involve security and hospital administration rather than physically intervening. Assume anything you say may be heard by others and keep language clinical.
De-escalation: Lower your voice, sit if possible, use his name, acknowledge the pain ('I hear that this has been awful for six weeks'). Set a clear boundary: 'I will treat your pain. I am not going to give IV hydromorphone today, and here is why and what I will do.'
Avoid the trap: Do not let the recording or the 'reputation' change the standard of care. Do not make disparaging comments - they will be on the recording and in the chart.
Exam point: The correct behavior is calm, boundary-setting, patient-centered, and policy-driven. The wrong answers are retaliatory (refusing all care), coercive (demanding the phone), or capitulating to demands to end the conflict.
2. How do you approach the pain complaint and the 'drug-seeking' label in a way that is both safe and fair?
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Reframe 'drug-seeking' as a clinical problem to be managed, not a character judgment.
- Screen for genuine emergencies first. Chronic abdominal pain does not exclude an acute cause; document a focused exam and targeted testing based on today's presentation, not the prior visits.
- Use a structured, transparent plan. Explain that IV opioids are not indicated for a chronic pain flare without an acute surgical cause, and offer a multimodal plan: non-opioid analgesics, a defined reassessment interval, and a clear escalation pathway if symptoms change.
- Set expectations explicitly: 'If your pain is not controlled, I will reassess you. I am not sending you away untreated.'
- Address substance use with compassion: If opioid use disorder is suspected, offer resources (e.g., harm reduction, treatment referral) rather than moralizing.
- Check the PDMP where available and document your reasoning.
Exam point: The fair, safe answer treats the patient's report seriously, avoids stigmatizing language in the chart, and uses shared decision-making. The wrong answer is either reflexive opioid administration or reflexive dismissal.
3. The encounter ends with him leaving angrily, and a colleague later says, 'Just flag him so we don't waste resources next time.' What do you do about the chart and the system?
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Chart: Document objectively - his stated concerns, your exam, your shared decision-making, the plan offered, his decision to leave, and return precautions. Avoid labels like 'drug-seeking,' 'frequent flyer,' or 'noncompliant,' which bias future clinicians and can be discoverable. If you have a genuine safety concern (e.g., agitation, threats), document behaviors, not inferences.
System: A 'flag' that exists to warn staff of violence is legitimate; a flag that exists to discourage care is not. If your institution uses behavioral flags, ensure they meet defined criteria, are reviewed, and are not used to ration care.
Improvement opportunity: Repeated visits for the same complaint are a signal. Consider a care-management referral, a pain plan documented in the chart for continuity, and a team debrief about how the encounter was handled. Measure whether future visits go better (e.g., documented care plans, reduced conflict events).
Exam point: Professionalism includes how you write about patients and how systems treat them. The strongest answer protects the patient's future access to care while keeping staff safe.