2. Think of a difficult situation…
What made it difficult?
What was the outcome you were
hoping for?
What actually happened?
What would have made it go better?
4. What makes an interaction
difficult?
Fear – of the unknown, of not knowing how the
other person will react, of hurting someone’s
feelings or of feeling hurt
Conflict – few people enjoy conflict and most go
out of their way to avoid it
Surprise – catching someone off guard can make
an otherwise smooth interaction difficult
Change – interactions involving having to make a
change often make people feel uncomfortable
5. Why we avoid difficult
interactions
We’re afraid we’ll make the situation worse
We don’t want to feel bad, and we don’t want
others to feel bad
We may hear things about ourselves that we
don’t want to hear
We, and the other person, may get emotional
We don’t know how the interaction will end,
and we fear the consequences
6. The label “difficult” is subjective
Interpersonal in nature
A function of the relationship
Based upon discomfort with:
What has happened
What might happen
7. “Difficult”: different for different
individuals
Someone labeled “difficult” by a
person may not be seen as quite so
difficult by another
Differences in expertise and
experience account for differences in
perception
8. Unfortunately… impossible people
exist.
You will encounter them.
You can’t avoid them.
You can’t fix them.
You can’t make them like you.
You can’t beat them.
They may not want your help
9. How to minimize difficult
interactions
Know your purpose
Frame your message
Use an assertive approach
Use cooperative language
Use active listening skills
10. Responding ASSERTIVELY
(DESC vs. DISC)
• Describe the situation
• Express your feelings
• Specify the change you
want
• Consequence
“I have been coming
here for PT to treat my
pain. I feel frustrated
that the pain is still
there and worse, I
have to stand in line.
May I at least have a
place to sit, so that I
can be more
comfortable as I wait?”
11. Responding ASSERTIVELY
(DESC vs. DISC)
• Describe the
situation
• Indicate problem the
behavior is causing
• Specify the change
you want
• Consequence
“I have been coming
here for PT to treat my
pain. There’s no
improvement & waiting
in line further adds to
my pain. May I at least
have a place to sit, so
that I can be more
comfortable as I wait?”
12.
13. Case Vignette 1
You have a group mate whom you notice
has always been taking advantage of
other people. During one of your
laboratory sessions, she asks you to cover
for her as she has to make an important
call. She disappears and does not return
until after two hours.
14. CASE VIGNETTE 2
In the middle of a patient encounter
activity, your “patient”, a young attractive
member of the opposite sex, grabs your
arm and tells you that she/he finds you
cute and wonders if you might meet
privately or be textmates.
16. Patient’s Needs
need to be
recognized and
treated with respect;
need to feel
important
need for specialized
knowledge and
medical expertise
PERSONAL
NEEDS
PRACTICAL
NEEDS
17. Types of Patients
There are FOUR types of PATIENTS…
1. PRAISERS (Happy & will tell you so)
2. PATRONS (Happy but won’t say anything)
3. TALKERS (Unhappy and are sure to let
you know)
4. WALKERS (Unhappy and just leave, never
to return)
18. Good physician communication
can lead to:
increased patient satisfaction
increased health care professional
satisfaction
improved patient health outcomes
decrease in complaints and lawsuits
19. Clinicians can have fewer
“difficult” relationships by:
Discovering what factors contribute to
the label “difficult”
Exploring techniques that can lead to
more satisfactory relationships
Experimenting with new skills
20. Factors that influence doctor-
patient communication
Patient-related factors
Doctor-related factors
The interview setting (environment)
21. Difficult Patients
Prevalence estimated at 15%
Patients who exhibit the following:
Repeated visits without apparent
medical benefits
Do not seem to want to get well
Abrasive personalities, demanding
Focus on issues seemingly unrelated to
medical care
Poor adherence to treatment
23. A considerable number of patients who
are labelled difficult may meet the DSM
criteria for:
Mood disorders
Anxiety disorders
Borderline personality disorders
28. When confronted with difficult
patients… take HEART
Hear them out.
Empathize.
Acknowledge/Apologize for the
inconvenience
Respond appropriately.
Take responsibility for action/Thank your
patient for bearing with the
29. Physician self-care
Ensure personal well-being
Know trigger issues
Know your limits
Bracket. Bracket. Bracket.
30. Coping with Difficult Patients
Avoid being judgmental
Be patient, tolerant
Get good history to understand
patient
Use direct communication
Humor
Selective personal disclosure
31. Counterproductive Strategies
Ignoring the problem
Accusing the patient of being
problematic
Telling the patient that there is
nothing wrong or that there is nothing
you can do for him
Attempt to solve the problem with
psychopharmacology alone
32. References
Essary AC, Symington SL. How to make the “difficult” patient less difficult.
JAAPA May 2005.
Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the Difficult
Patient. Am Fam Physician, 2005 15;72(10): 2063-2068.
Hull Skew and Broquet K. How to Manage Difficult Patients. Family Practice
Management | www.aafp.org/fpm | June 2007
Spickerman F. The Fine Art of Refusal. Family Practice Management 2004.
Feb; 11(2):80.
Editor's Notes
Angry and Resistant Patient – part of the grief reaction to the loss of health and the fear and loss of control that are part of being illGrieving Patient – mourning a loss or suffers with pain; tears are expected forms of expressionManipulative Patient – play on the guilt of others, threatening rage or legal action (or exposure to media), suicide; Demands related to bad outcome/experience of a friend or relativeFeeling that diagnostic tests/referral are being withheld to save moneySomatizing Patient – multiple vague or exaggerated symptoms, doctor shopping
Fatigued/Harried – overworked, sleep deprived or generally busierAngry/Defensive Physician – burned out, stressed, generally frustrated – more likely to react negatively to patientsDogmatic or Arrogant – personal beliefs or values may prevent the MD to assess info without bias; unable to bracket