Teacher’s Guide: Common characteristics and circumstance of patients perceived to be difficult by providers: Emotional and expressive of emotions Certain personality features or disorders Personal characteristics viewed negatively by provider (different moral or ethical view points, non-English speakers, disheveled or unkempt appearance) Specific clinical problems Places extra demands or stresses on the clinician
Teacher’s Guide: Literature supports notion that most learners can be taught awareness of negative responses and harmful behaviors. Communication skills training can improve an individual’s ability to communicate in difficult situations. Pay special attention to the final point -- physicians often have negative emotional responses to patients that are not fully recognized and lead to unconstructive behaviors. Some examples are listed below. Have the learners reflect on these patterns. Do they recognize these behaviors in themselves or others?
Teacher’s Guide: Have the learner(s) read through the scenario. Ask for a volunteer to describe how they would approach a conversation with R.D’s parents. Ask and discuss: What is the goal of communication with the patient and parents? (build trust, gather data, give information) What are the challenges of communicating with patient and parents in this situation?
Teacher’s Guide: Some challenges to effective communication with patients and parents while in the night float role are listed here. Are there others? Some others to consider: Less time to spend with each patient due to higher patient load at night On call physician may have limited information about the patient available Exhaustion (patient, parent, physician, etc.)
Teacher’s Guide: There are three basic components to physician-parent-child communication, listed here. “informativeness” refers to the quantity and quality of health information provided.
Teacher’s Guide: Have the learner(s) read through the scenario. Ask learners to share (quickly) personal experiences with a “difficult patient or parent,” and/or consider offering an example from your own experience. Ask the learners to. For example, the parent is reportedly upset/angry/emotional and demanding; The provider has a negative perception/energy in advance of the meeting and is demonstrating avoidance behavior. Facilitate a discussion around the following questions: What additional information do you need to know before meeting Mrs. S? What approach would you use when talking to Mrs. S?
Teacher’s Guide: Ask the learners how they would feel in this situation. Facilitate a discussion about possible approaches and/or responses to Mrs. S’s concerns. What is the goal of the interaction and how is that goal best accomplished? Goal: Approach: and more… see following slides
Teacher’s Guide: The NURS mnemonic can provide a framework for approaching communication with an angry or difficult parent.
Teacher’s Guide Ask the learners to think back to Case Two. Ask them to use the NURS mnemonic to generate possible responses to Mrs. S. One example of a response, using the NURS mnemonic, is given.
Communication ppt final
Dr Nehal Mehta
Recognize and describe the patient and provider roles
in difficult relationships
Describe a framework (mnemonic) to improve
communication with patients and overcome challenging
What is a difficult patient?
Raises negative feelings within the clinician
Causes the clinician to experience self-doubt
(threatens clinician’s competence or control)
Has beliefs, values, or characteristics that differ
from those of the clinician
Does not assume the role expected by the health
A difficult patient is one who impedes the clinician’s
ability to establish a therapeutic relationship, but…
… It Takes Two!
The difficult patient must be viewed in context of the
clinician and the clinician-patient relationship.
Receive biomedical training, focused on
identification and treatment of the disease
May not receive adequate psychosocial training,
focused on communication and relationshipbuilding
Often have negative emotional responses to
patients that are not fully recognized and lead to
If the clinician feels threatened leads to over
control of the interview or situation
If the clinician has discomfort with psychological
issues leads to avoidance
If the clinician dislikes the patient leads to
The most common element of an adversarial
clinician-patient relationship is
Obstruction in communication
•Multiple symptoms involving multiple body systems
•Vague and shifting complaints
•Undue concern about minor symptoms
•Poor response to usual methods of treatment
•Hostile, demanding, dissatisfied
•Manipulative, exploitative, controlling
•Unrealistic expectations of care
•Raises new problems as visit ends
•Resistant to physician’s recommendations
The “ANGRY Patient”
Pay attention to pre-visit signs: long waits and staff
Is it true anger, or just pain and frustration?
Anticipation of Bad News?
DO NOT GET DRAWN INTO THE CONFLICT
KNOW YOUR TRIGGERS!
Strategies to Defuse Anger
Allow the patient to vent their anger.
Acknowledge the anger “I can see you are really
angry about this.”
Validate the anger “understandably you are very
angry as this is a very frustrating situation you are
Offer to explore the situation in more depth – it is
often found that there are many layers to the anger
and frustration the patient is experiencing.
During the interchange keep calm
Use a neutral tone of voice, adopt an open body
Do not become defensive (do not take it personally)
Non-Compliant Patients Defined
The patient deviates significantly from most patients (with
similar medical problems) in degree of compliance with
medical advice, treatment, or follow-up in a way that
directly or potentially jeopardizes the patient's health or
quality of life.
The patient's medical problem is potentially serious and
poses a clinically significant risk to length or quality of life
At least one treatment exists that if followed correctly, will
markedly reduce this risk
The patient has easy access to the treatment or
“The most helpful things I have ever done with
noncompliant patients have been to ask questions,
not to lecture, and to be willing to listen to what
These activities are often very difficult to do within
the time constraints of clinical practice.
Sometimes I have to "suspend" the clock and my
usual clinical approach and just tell the patient that
I'm frustrated and concerned and that I need to know
what he or she understands about the disease
process and problems being faced. And then I'll just
be quiet and listen as nonjudgmentally as possible. “
The “Seductive” or The “Manipulative”
The “Seductive Patient”
Even non-psychiatric care involves “transference”
Transference=feelings experienced by the patient toward
the physician that recapitulate other important
relationships within the patient’s life
Caring and compassion misinterpreted as sexual
Innocent flirtations NEVER appropriate
Emphasize that this is a strictly professional relationship
Utilize chaperone throughout interactions
Obtain consultation/referral if needed
Institute and enforce written office guidelines
The “MANIPULATIVE” Patient
These patients often play on the guilt of others,
threatening rage, legal action or suicide.
They tend to exhibit impulsive behavior directed at
obtaining what they want, and it is often difficult to
distinguish between borderline personality disorder and
The keys to managing encounters with manipulative
patients are to be aware of your own emotions, attempt
to understand the patient's expectations (which may
actually be reasonable, even if his or her actions are not)
and realize that sometimes you have to say "no."
R.D. is a 5 year old girl with lobar pneumonia and effusion,
hospitalized with respiratory distress and hypoxia. You are called
to her bedside because of worsening respiratory status. On exam,
she appears ill and uncomfortable. She is febrile, tachypneic, with
diminished breath sounds on the right base and both subcostal and
intercostal retractions. Her parents, whom you have never met,
are at the bedside and appear worried.
What is the goal of communication with the patient and parents?
What are the challenges of communicating with the patient and
parents in this situation?
Unique challenges to effective
Inherent stress of high acuity situation
Lack of established relationship with patient and parents
Potential for frequent interruptions
Informativeness: quantity and quality of health information
provided by doctor. It directly addresses the cognitive needs of
the patient and/or parent, and forms the foundation for the
physician’s task-related behavior. The physician may say, “She
may have respiratory distress because her effusion has worsened,
so I am going to get a chest x-ray.”
Interpersonal sensitivity: affective behaviors that reflect the
physician’s attention to, and interest in, the patients’ and
relatives feelings and concerns
Partnership building: the extent to which the physician invites
the parents (and child) to state their concerns, perspectives, and
Interpersonal sensitivity and partnership building
address the affective needs of the patient and/or the
relative-that is, the emotional need to feel heard and be
These two components inform the physician’s relational
behavior – showing concern and respect. The physician
may say, “I can see that you are worried. What worries
you the most?”
Some nonverbal ways to show concern and
respect include maintaining eye contact, using
appropriate gestures, and using active listening
The literature overwhelmingly supports direct
communication with the child, provided that the
communication is done in a developmentally
appropriate manner, taking into account the
parent-child relationship and the family’s cultural
You finally have a moment to eat dinner. Your
phone rings and the nurse on duty says: “Patient
J.S.’s mother is here. She is upset and asking to
speak to the doctor. Please come ASAP.”
You groan in response. Mrs. S has become
notorious on your team, a so-called “difficult
relative,” because she is always upset and
demanding of the provider’s time. You have been
dreading receiving this page. You decide to eat your
dinner quickly, and then go to the bedside.
Which characteristics of the patients relative and provider
contribute negatively to this situation?
What approach would you use when talking to Mrs. S?
Case Two- Continued
You review your sign-out: J.S. is a 4 month old with
bronchiolitis. Parents were not present or reachable by
phone during day. You learn from the nurse that Mrs. S is
upset because J.S. was placed on oxygen and she was not
When you walk into the room, Mrs. S has her arms
folded across her chest. You introduce yourself, and
she responds by complaining about her son’s care and
how no one is talking to her. You listen for a minute or
two, and end up having to interrupt her to get a word in.
You mention that your colleague called during the day
but no one answered. Mrs. Smith just gets more upset,
saying that there was no message and no one is
keeping her informed.
What is the goal of the provider’s interaction with
Alleviate parent concerns, provide education
about condition and what to expect, establish
better method of communication
How is this goal best accomplished?
Active listening, validation of concerns
Goal: Elicit the patient’s emotions and address them.
Naming: recognition of emotion
Understanding: acceptance and validation of emotion
“I can understand why that was frustrating for you.”
Respecting: respect their experience, praise their efforts
“You are angry.” or “That was sad for you.”
“You’ve been juggling a lot.” or “You did a great job recognizing that
he was getting more sick.”
Supporting: express support, create partnership
“Let’s work together to come up with a better way to address this.”
Case Two- Revisited
Using the NURS mnemonic, craft a
response to Mrs. S.
“Mrs. S, I can see that you are upset and I can understand why. It must be
difficult to arrive at the hospital and learn that your son is now requiring
oxygen. You’ve been juggling a lot, with having to go to take care of your
other children and be here at the hospital with J.S. What questions can I
answer for you now?
I am sorry that we were not able to communicate better during the day.
What would be the best way to make sure this type of thing doesn’t
Coping Skills that help…
Allow patients to vent their feelings: Listen long
enough to show your empathy, but set practical time limits.
Strengthen your communication skills: Remember
that as a physician, you're also a teacher and a coach.
Tailor your explanations and guidance to each patient's
needs and ability to absorb information.
Become a more effective history taker: They may also
provide you with clues about what the patient is skipping
over or not saying.
Avoid becoming an enabler: Know when to set limits on
patients' demands in order to protect yourself from burnout
Try not to judge: View patients' disruptive actions as
opportunities to learn more about their concerns, beliefs and
Remain calm and confident: Stay in control while working
with patients who are angry, depressed, manipulative,
seductive or overly dependent.
Understand your own strengths and vulnerabilities:
Know when to set limits on patients' demands in order to
protect yourself from burnout
Be patient & Respect your patients: Know when to set
limits on patients' demands in order to protect yourself from
Protect patients' confidentiality, keep promises and show that
you respect their feelings.