Medical Examiner

How a SHPOS Is Born

The acronym doctors use for the very worst of the worst patients.

It is usually young female clinicians who bear the brunt of trying to care for angry misogynists.

Photo by Thinkstock

A medical acronym, SHPOS, helps a doctor summarize a patient’s history in just five letters. But unlike emotionally neutral acronyms doctors use, such as LOL—little old lady—SHPOS is a derogatory term that describes a hospitalized patient who is felt by his doctor to be a “subhuman piece of shit.” The acronym has been around since at least 1980, when it was first mentioned in print, but must have existed long before it was memorialized in the journal Man and Medicine. Some doctors drop the SH prefix, going straight for POS, but the phrase “subhuman” is really where the expression gets it power. What makes a patient, formerly known as a human being, a SHPOS? A SHPOS becomes a SHPOS when a health care worker hates him.

The term is known to physicians everywhere, passed by word of mouth from resident to intern to medical student. Psychiatrist Abbey Strauss described the phenomenon in a 1983 paper: a patient who is “childlike, unreliable, occasionally arrogant, demanding, insensitive, self-centered, ungrateful, non-compliant, and wrongly motivated.” Strauss describes a type of SHPOS who might be called a “difficult patient.” His paper focused on the way physician and patient narcissism create the SHPOS interaction. As a psychiatrist with an interest in antisocial personalities, I would add to his description the words abusive, threatening, racist, misogynistic, and rageful.

Not surprisingly, the SHPOS is often alone in the world. He may have just been released from jail, or his loved ones may have refused to take him in. He may have been fired from his job or banned from seeing his children. On top of that, now he is ill. The SHPOS comes to the hospital in a state of social despair, isolated and unhelpable, and the only person left to absorb his rage is the health care worker who must care for him, no matter how hateful he is.

One doesn’t get called a SHPOS for nothing. Walk the hallways of a hospital in a tough neighborhood and you will see security officers, some of them armed, on every ward. Some patients require two officers to control their violence and threats—and these patients are not under arrest. Patients throw feces and full urinals at staff. They cut themselves with IV needles to express their disgust with the hospital diet. They prey on other patients who are too ill to defend themselves, stealing their cash and even the food from their trays.

Recently I was one of two doctors in a team meeting with a patient, a physician assistant, and a social worker. The purpose of the meeting was to clarify treatment goals, as the patient seemed unwilling to accept the medical staff’s recommendations and had announced he would not leave the hospital if his needs were not met. The patient was addicted to cocaine and wanted to be admitted to a rehab program, a laudable goal. Unfortunately, the patient’s insurance refused to pay. The patient found this difficult to accept, understandably, but rather than make the best of what he had to work with, he lashed out at the women in the room, the social worker and myself. He spoke to us with absolute contempt. He attacked me particularly as an unethical, uncaring, and lazy psychiatrist whose only agenda was to save the hospital money. His remarks were so unexpectedly and inappropriately hostile that the team was taken aback and took several minutes to collect itself and terminate the meeting.

While being berated, I was aware of my heart pounding, and of the effort it took not to retaliate verbally and physically for this assault. I maintained my self-control, but at a cost. For days I ruminated over the event. I imagined that my struggle to contain my own anger had damaged my cardiovascular health. I felt humiliated in front of my colleagues and unmasked as a weak person not competent to manage difficult patients. I thought of my parents’ pride when I became a doctor, and imagined what they would think if they knew about my actual daily experiences.

Thus a SHPOS was born. Prior to that meeting, he was a man with a serious drug problem who had come to the hospital for help. When he and I entered a dyad of mutual hatred, we lost ourselves. He was subhuman, and I was the doctor who loathed him.

These demoralizing encounters are commonplace in hospital medicine. Less often, but more dramatically, SHPOS behavior leads to serious injury. On one nursing unit at my hospital during the past year, a patient broke a nurse’s arm, and another ripped out a hunk of a physician assistant’s hair.

After the hair-pulling incident, which was unprovoked and terrifying to all who witnessed it, the outpouring of distress was shocking. Most of the physician assistants at my hospital are women in their 20s, many in their first jobs. Many are nonwhite. All described an atmosphere of continual sexual harassment and disrespect by patients. Many had been touched inappropriately, and all had been subjected to comments about their appearance. Most described feeling afraid to enter some of their patients’ rooms, and many would not enter a patient’s room alone.

More women than ever before are physicians. In addition, women are disproportionately represented in lower-paying, less prestigious “physician extender” positions, such as physician assistants and nurse practitioners. Nurses and nurse’s aides, at least at my hospital, are mostly female, as are social workers, care coordinators, and clerks. When a female clinician interacts with an angry misogynist who is now ill and vulnerable, dependent on women for lifesaving treatment, food, water, comfort, and company, the climate is ripe for the development of SHPOS behavior.

One thing that stands out about SHPOS behavior is its pointlessness. It doesn’t solve anything for the patient, and he doesn’t appear to derive pleasure from humiliating others. He expresses a bottomless need for care that can never be met, and punishes the health care worker in advance for failing him.

He lashes out, or clings to the caregiver, angrily refusing to leave. When he is finally escorted out by security, or escapes in the middle of the night with his IV still in place, he leaves the staff shaken. No one is proud to call another person subhuman.