It’s great when you can build a good rapport with patients and everything runs smoothly, but unfortunately, there are patients who can make your work more challenging than it already is.
Dealing with angry patients and family memberspadma puppala
Angry patients can evoke fight or flight responses in medical professionals. Inability to diffuse situation in a professional manner can lead to disastrous consequences. Here are few tips to effectively diffuse the situation
There is an evident deficiency on how best to break bad news in medicine. This is an essential communication skill that our patients expect of us. It is an essential requisite of Good Medical Practice. This presentation is part of a course held at Al Hammadi Hospital, Suwaidi, Riyadh, KSA on Breaking Bad News. 2017
A short sharing on doctor-patient communication to First year medical students in Universiti Malaysia Sarawak, to be supplemented with anecdotal accounts.
It’s great when you can build a good rapport with patients and everything runs smoothly, but unfortunately, there are patients who can make your work more challenging than it already is.
Dealing with angry patients and family memberspadma puppala
Angry patients can evoke fight or flight responses in medical professionals. Inability to diffuse situation in a professional manner can lead to disastrous consequences. Here are few tips to effectively diffuse the situation
There is an evident deficiency on how best to break bad news in medicine. This is an essential communication skill that our patients expect of us. It is an essential requisite of Good Medical Practice. This presentation is part of a course held at Al Hammadi Hospital, Suwaidi, Riyadh, KSA on Breaking Bad News. 2017
A short sharing on doctor-patient communication to First year medical students in Universiti Malaysia Sarawak, to be supplemented with anecdotal accounts.
Professionalism is the basis of medicine’s social contract with society
Professionalism demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health
Empathy is the capacity to recognize and experience feelings that are being experienced by another.
“It is the intrapersonal realization of another’s plight that illuminates the potential consequences of one’s own actions on the lives of others.” (Hollingsworth, 2003)
This presentation deals with principles of basic communication skills, importance of it for Doctors and medical students. It also addresses the basic elements Doctor patient communication skills, kalmazoo Consensus working model for Clinical interview, 5 A model guidelines for the behaviour changes.
BBN - Breaking Bad News is difficult task for Junior doctors in India as it was not in the Curriculum unlike Western countries. So this slide will give you the Facts / Methods with Description of one method & Key points.
This presentation mainly explains about the type of patients that are encountered in day to day practice as well as how each of them should be handled to improve the communication between a doctor and the patient.
Do you want bad patient relations? Do you want to lose patients? Do you want to fail your patient satisfaction surveys? Do you want a non professional image? Do you want to reduce the number of new patient referrals? Do you want to demonstrate poor quality care? Do you want to jeopardize participation in healthcare plans?
We can Help you :)
Mastering the HCAHPS by providing patients more than customer service, engage them in a customer experience. The audience was doctors and nurses, but the lessons apply to all hospital staff.
Customer care in health care industry-Manisha Singhmanishaiway
Hi All,
Attached is the presentation on Changing dynamics in customer care, it also talks about how customer care is different, yet critical in healthcare Industry.
Hope it help to you all.
The presentation covers some special situations that salespersons normally face. We will cover here how to handle objections, complaints and awkward customers.
Professionalism is the basis of medicine’s social contract with society
Professionalism demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health
Empathy is the capacity to recognize and experience feelings that are being experienced by another.
“It is the intrapersonal realization of another’s plight that illuminates the potential consequences of one’s own actions on the lives of others.” (Hollingsworth, 2003)
This presentation deals with principles of basic communication skills, importance of it for Doctors and medical students. It also addresses the basic elements Doctor patient communication skills, kalmazoo Consensus working model for Clinical interview, 5 A model guidelines for the behaviour changes.
BBN - Breaking Bad News is difficult task for Junior doctors in India as it was not in the Curriculum unlike Western countries. So this slide will give you the Facts / Methods with Description of one method & Key points.
This presentation mainly explains about the type of patients that are encountered in day to day practice as well as how each of them should be handled to improve the communication between a doctor and the patient.
Do you want bad patient relations? Do you want to lose patients? Do you want to fail your patient satisfaction surveys? Do you want a non professional image? Do you want to reduce the number of new patient referrals? Do you want to demonstrate poor quality care? Do you want to jeopardize participation in healthcare plans?
We can Help you :)
Mastering the HCAHPS by providing patients more than customer service, engage them in a customer experience. The audience was doctors and nurses, but the lessons apply to all hospital staff.
Customer care in health care industry-Manisha Singhmanishaiway
Hi All,
Attached is the presentation on Changing dynamics in customer care, it also talks about how customer care is different, yet critical in healthcare Industry.
Hope it help to you all.
The presentation covers some special situations that salespersons normally face. We will cover here how to handle objections, complaints and awkward customers.
The presentation describes in brief the patients need, expectations and how to develop the patient care and feedback system to obtain maximum patient satisfaction.
The process of using wordless messages to generate is called Non-verbal Communication. A good communicator must be able to augment his/her verbal communication with the right non-verbal communication.
Psychology is the study of human behaviour. It seeks to look at the motivational drives within an individual
and offer an explanation to the behaviour that is demonstrated
This is the Final for Dr. Bachman's Psychopathology Course for Webster University. This has been uploaded to assist with studying for the Counselor's Examination.
THE ROLE OF PSYCHIATRISTS IN RENAL TRANSPLANT UNITS.pptxAyooluwaOlaniyi
Psychiatrist role in organ transplant unit is central, as the whole structure and functionality of the team is held together by consultation liaison psychiatry team.
Personality disorders are patterns of perceiving, reacting, and relating to other people and events that are relatively inflexible and that impair a person's ability to function socially”.
Dr.Shukri and Dr.Ahmad Eid collaberated together to teach us how to tackle difficult cases and how to deal with a typical presentation to psychiatry symptoms
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Dealing with the difficult patients in the medical setting
1. Dealing with Difficult
Patients in the Medical
Settings
Ahmad Alzahrani
MBBS, ABHS-Psychiatry
University of Toronto psychosomatic medicine fellowship
2. Content
– Who are the difficult patients?
– Do All patients become difficult?
– The emotions of the treating team
– The Hateful Patients
– How to assess a difficult patient?
– How to manage?
3. The consult
– “A 40 year old male admitted with myocardial infarction calls office of the
hospital CEO to complain about his care. Assess for psychiatric disorder.”
– “A 35 year old female patient with AML refuses the second time of bone marrow
aspiration. She looks less motivated. Is she depressed?”
– “We need help with a 64 year old professional male with ESRD on hemodialysis.
He has been kicked out of all other dialysis centers due to his obnoxious
behavior. He screams at and berates the staff and may be banned from our state
operated unit. Is there anything that can be done to manage his behavior?”
5. The Difficult Patients
– Anxiety
– Agitation
– Depression
– Multiple somatic complaints
– Anger or irritability
– Excessive demands
– Noncompliance
– Wandering, pulling out lines
– Drug-seeking behavior
– Excessive requests for attention
– Physically or verbally aggressive
behavior
- Up to 15% of patients are labelled difficult by their physicians.
6. A stressful Situations
– Narcissistic Injury
– Reexamine their own self-views and address any feelings of invulnerability to illness
– Confronting the impermanence of life.
– These lead to Patient to feel “defective, weak, and less desirable”.
– Being in a hospital
– Forcing a patient to endure both body exposure, in thin flimsy gowns, and constant
personal and bodily intrusions.
– Separation
– From their normal comfortable environment and social support.
8. Psychological Responses to
illness
Behavioral ResponsesAffective Responses
Meaning of
illness
Character
Style
Life history/experience Temperament
Psychological
Defenses
Coping
Strategies
Stresses of illness
Lazarus RS: Stress and Emotion: A New Synthesis, Textbook of Psychosomatic Medicine, 2nd edition, 2011
9. Coping Styles
– A conscious effort to alter a stressful situation.
– Hundreds of coping strategies have been identified.
– Problem-focused coping
– Seeking information, planning, and taking action.
– Emotion-focused coping
– Involve focusing on positive aspects of the situation, mental or behavioral
disengagement, and seeking emotional support from others.
10. Coping Styles
Coping Style Description
Confrontative Hostile or aggressive efforts to alter a situation.
Distancing Efforts to mentally detach self from a situation.
Self-controlling Attempting to regulate one’s feelings or actions.
Seeking social support Attempting to seek emotional support or information from others.
Accepting responsibility Accepting a personal role in the problem.
Escape-avoidance Efforts to escape/avoid a problem or situation, both cognitively and behaviorally.
Planful problem solving Attempting to come up with solutions to alter a situation.
Positive re-appraisal Re-framing a situation in a more positive light.
11. Coping Styles
Healthy copers
- Use a combination of problem & emotion
focused coping.
- Optimistic, practical, flexible, and composed
- Consider possible outcomes and emphasize
immediate problems.
Poor copers
- Often are unable to make decisions.
- Hold rigid and narrow views.
- Passive and deny excessively.
- Moments of impulsivity and unexpected
compliance.
12. Defense Mechanisms
– Mental operations that remove some component(s) of unpleasurable affects
(emotions) from conscious awareness—the thought, the sensation, or both.
– Largely unconscious.
– A coping strategy or defense mechanism may be relatively maladaptive or
ineffective in one context but adaptive and effective in another.
14. Defense Mechanisms
– Defenses most often used by “difficult patients”
– fall under the immature category.
– characteristic of the cluster B personality disorders.
– Often are irritating to others as this defense style transmits patients’
“shame, impulses, and anxiety to those around them”
– Neurotic defenses, which can also be maladaptive
– experienced more privately and usually do not annoy others because they do
not distort reality as much.
15. Meaning of Illness
Personality Type Characteristics Meaning of Illness
Dependent Need, demanding, unable to reassure self
Seeks reassurance from others
Threat of abandonment
Obsessional Meticulous, orderly, likes to feel in control, dichotomous Loss of control over body/emotions/impulses
Histrionic Entertaining, dramatic, seductive Loss of love or attractiveness
Masochistic “Perpetual victim” Ego-syntonic, conscious or unconscious
punishment
Paranoid Guarded, distrustful, sensitive to slights Proof that world is against patient
Medical care is invasive and exploitative
Narcissistic Arrogant, devaluing, vain, demanding Threat to self-concept of perfection and
invulnerability, shame evoking
Schizoid Aloof, distant Fear of intrusion
Adapted from: James Levenson, Textbook of Psychosomatic Medicine, 2nd edition, 2011
17. Countertransference
– Classically reactions to a patient that represent the past life experiences of
the clinician.
– For example,
– A frail elderly woman is given extra attention by a physician because she reminds
him of his mother.
– A young diabetic patient is scolded for non-compliance because the nurse’s own child
is diabetic and non-compliant.
– Recently, countertransference has come to encompass all feelings and attitudes
of clinicians towards the patient, both physician- and patient-originated.
18. Countertransference
– Often result in negative reactions (aversion, fear, despair, or even malice).
– Positive reactions should be watched also.
– May predict later devaluation.
– May Potentially lead to significant boundary violations on the part of the
clinician, in an effort “to do everything possible” for the patient.
20. The Hateful Patients
The Hateful
Patient
Associated
Personality
Defense
Mechanisms
Coping Styles Countertransference
Dependent
Clingers
Dependent
Histrionic
Regression
Passive aggression
Idealization
Excessively
seeking social
support
Power and special
Depleted, exhausted
Wish to escape
Entitled
Demanders
Narcissistic Self-idealization
Devaluing
Projection, Splitting
Confrontational Fearful of reputation
Enraged about demands
Ashamed, inferior
Manipulative
Help-Rejecters
Borderline Splitting
Projective identifying
Idealizing/devaluing
Escape-avoidance
Seek social
supports
Anxiety overlooking illness
Irritation/frustration
Depression/self-doubt
Self-Destructive
Deniers
Antisocial
(or any cluster B)
Primitive denial
Acting out, Devaluing
Distancing
Escape-avoidance
Enraged/malice
Wish the patient were dead
21. Dependent Clinger
– A forty-five year old male with a history of peripheral vascular disease who
recently underwent a below the knee amputation is now crying and sobbing on
the unit. He becomes highly anxious and despondent when there is not
somebody in the room with him, calling for the nurses unnecessarly. When
family is present, he requires their constant attention, requesting they feed him,
help him drink liquids, and even blow his nose, despite full upper extremity
mobility.
22. Entitled Demander
– “A fifty-six year old male is admitted to the hospital secondary to AIDS
complications.
Through out the hospitalization, he is belligerent and belittling to the staff and
physicians, including the junior members of the psychosomatic service. He is
pleased to hear that his case is ‘unique,’ requiring the director of the
psychosomatic service to meet him personally. Upon arrival of the director, the
patient immediately comments, ‘you have a lot of guts wearing that outfit. How
much is it worth? $100? $1000? You could feed a hundred starving children in
Africa for your one outfit. I hope you can live with yourself.’”
23. Manipulative Help-Rejecters
– A sixty-eight year old female who recently left AMA from another hospital
presents to the emergency department for worsening edema of her lower
extremities. Upon further evaluation, she is found to have significant congestive
heart failure and is admitted. During her admission, she is initially cooperative
with the primary team, but as her condition improves, she becomes belligerent
and hostile with the staff, complaining that her water has too much ice in it, the
coffee is not served on time, and the nurses are not looking at her properly.
Indignant, she demands to leave the hospital AMA, stating that she will get
better care elsewhere. When records are obtained from the other hospital, it is
discovered that a similar scenario occurred there.
24. Self-Destructive Deniers
– A thirty-six year old male with end-stage liver disease has frequent re-
admissions to the hospital for altered mental status. Despite his worsening
status, he continues to drink heavily and uses other illicit substances. With each
admission, he requests a liver transplant but then angrily reacts when he is
advised that abstinence is a requirement for transplant consideration.
He is hostile and belligerent with the staff, threatening them on multiple
occasions.
26. Assessment of the Difficult Patient
Awake and Alert?
Yes
NoYes
Yes
Yes
Yes
No
No
NoNo
Confused?
Mood, Psychotic, or
Anxiety Disorder?
Intoxicated?
Supportive Care
Monitor for withdrawal
Manage agitation
Delirium or Dementia
Assess acuity
Search for cause
Manage agitation
Personality Disorder? Psych tx
Educate & help staff
Scared? reassure
Angry? Explore; patient rep
In Pain/discomfort? meds
Jerk/Criminal? security, police
Reassure
Explore patient’s experience
Educate & help staff
Set limits; Prn meds
Reassess when awake
Search for cause of impaired arousal
Hold sedating meds for evaluation
Manage agitation if recurs
Mary Jo Fitz-Gerald, MD, The “Difficult” Patient, Academy of Psychosomatic Medicine 2013
29. Behavioral Management
– Ensure that the basic needs of the patient (privacy, food, etc.) are being met.
– Attempt to maintain consistent staff.
– Attempt to understand and empathize with the patient.
– Acknowledge the real stresses in the current situation.
– Accept the patient’s limitations by not directly confronting immature defenses
or poor coping styles.
30. Behavioral Management
– Set firm limits on unreasonable expectations by consistently declaring that “in
order to provide the best medical care possible ...” However, reasonable
requests, or approximations thereof, should not be refused.
– Gently discuss any irrational fears about the illness or treatment that the
patient may have, and assess his ability for reality testing (i.e., ensure that a
transient psychosis is not occurring).
31. Helping the treating team
– Acknowledge the reactions of the treaters and empathize with their
countertransferences.
– Acknowledge universality of their feelings
– Model non-sadistic behavior and appropriate limit setting
– Arrange team meetings to prevent splitting
– Develop clear behavioral management strategy
– Ally with staff- DO NOT interpret staff’s pathology
– Explain patient’s reality to staff
– Give permission to say no to excessive demands
– Recommend interventions needed for safety
32. Pharmacotherapy
– May be of benefit in treating Axis I Disorders such as mood, anxiety, or
psychotic disorders
– Impulsivity and anger may respond to mood stabilizers and antipsychotics
– Avoid agents with addictive potential due to the propensity for substance
abuse in these patients
34. References
– James Amos, Psychosomatic Medicine an Introduction to Consultation-Liaison
Psychiatry 2010.
– James Levenson, Textbook of Psychosomatic Medicine, second edition 2011
– Mary Jo Fitz-Gerald, MD, The “Difficult” Patient, Academy of Psychosomatic
Medicine 2013
– Jerome S. Blackman, 101 Defenses, 2004.
Editor's Notes
When students are asked why they enter medicine, a common answer will be helping others and contribute to the welfare of humanity. However, after even a few years of clinical practice, many physicians will readily admit to experiences of anger, frustration, inadequacy, and, occasionally, strong negative reactions towards patients. (James Amos, Psychosomatic Medicine)
Narcissistic Injury self view injury… self concept injury.
Separation from family and their comfortable environment may lead to conscious or unconscious feeling of abandonment (not only in children.. It can occur in adults…).
E.g. of separation newly diagnosed AIDS pt may fear rejection from community and abandonment by family. An advanced cancer pt may elect to undergo another course of chemotherapy despite the low likelihood of success rather than seek palliative and end of life care because the latter would signify giving up. The pt might fear that his oncologist who had worked with him for a decade would abandon him. (Textbook of Psychosomatic Medicine).
Character style develops from both life experience and temperament (inborn).
The 3 factors: coping strategies, meaning of illness and psychological defenses affects the psychological responses to illness and these appear in the form of mood and behavior.
Does the flowchart stop here?... One important factor is the psychodynamic interaction with the treating team and their countertransference toward the patient. The ongoing psychodynamic interaction between the patient and the team is an important period of time to manage the patient condition.
For example Maladaptive denial A lung cancer patient continue smoking thinking he has a mild lung condition.
Adaptive denial Use of denial in an advanced pancreatic cancer patient might enable him to maximize his quality of life in the months before his death.
Healthy individuals usually use different defenses throughout their lives, whereas pathological use occurs when persistent use of certain defenses leads to maladaptive behavior that affects one’sphysical and/or mental health. (James Amos, Psychosomatic Medicine)
* Simply stated, immature defenses make others suffer, while neurotic defenses cause the self to suffer. (James Amos, Psychosomatic Medicine)
A central task of the psychiatrist working with the medically ill is to understand patients’ subjective experience s of illness. (ask questions like: what do you know about your condition? What was your first response when hearing about it? Any current symptoms and how do you manage? How did it affect your life? What do you know about the prognosis and future plans?)
It is important for the consultant to understand not only the underlying causes of the patient’s behavior, but also the emotions generated in the treating staff, if a successful resolution is to be achieved. (James Amos, Psychosomatic Medicine, 2010).
Being aware of these emotions allows the clinician to attain better understanding to and provide better care for the patient.
Will need to speak with nursing staff and family; get thorough medical, psych and substance hx, thorough physical exam, incl neuro/cognitive exam
Nature of precipitants, envt in which agitation occurs.
* Keeping in mind that comorbidity often present but we have to treat the most serious condition/s first.