2013 dealing with difficult patients


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  • 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
  • 2013 dealing with difficult patients

    1. 1. DEALING WITH DIFFICULT PATIENTS Aileen B. Pascual, MD, FPAFP 11July 2013
    2. 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?
    3. 3. What makes an interaction difficult?
    4. 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. 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. 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. 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. 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. 9. How to minimize difficult interactions  Know your purpose  Frame your message  Use an assertive approach  Use cooperative language  Use active listening skills
    10. 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. 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. 12. 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.
    13. 13. 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.
    14. 14. Doctor-Patient Relationship
    15. 15. 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
    16. 16. 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)
    17. 17. Good physician communication can lead to:  increased patient satisfaction  increased health care professional satisfaction  improved patient health outcomes  decrease in complaints and lawsuits
    18. 18. 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
    19. 19. Factors that influence doctor- patient communication  Patient-related factors  Doctor-related factors  The interview setting (environment)
    20. 20. 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
    21. 21. Patient Characteristics  Angry, defensive, frightened, resistant  Grieving  Manipulative/Demanding  Somatizing/“Frequent fliers”
    22. 22. A considerable number of patients who are labelled difficult may meet the DSM criteria for:  Mood disorders  Anxiety disorders  Borderline personality disorders
    23. 23. Physician Factors  Fatigued or harried  Angry or defensive  Dogmatic or arrogant
    24. 24. Situational factors  Language and literacy issues  Companions during consult  Breaking bad news  Environmental issues (setting)
    25. 25. Strategies in dealing with difficult patients
    26. 26. Psychiatric Management  Prompt assessment, treatment and referral
    27. 27. 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
    28. 28. Physician self-care  Ensure personal well-being  Know trigger issues  Know your limits  Bracket. Bracket. Bracket.
    29. 29. Coping with Difficult Patients  Avoid being judgmental  Be patient, tolerant  Get good history to understand patient  Use direct communication  Humor  Selective personal disclosure
    30. 30. 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
    31. 31. 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.