Dealing with Difficult Consultations

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Dealing with Difficult Consultations
Introduction to Primary Care a course of the
Center of Post Graduate Studies in FM
PO Box 27121 Riyadh 11417 Tel [phone] Fax
4970847
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Objectives

• Objectives
• be able to define difficult patients
• be able to list types of difficult patients
• be able to explain how the problem can effect
  patient-physician relationships.
• be able to define causes for difficult patients
• be able describe the strategies on how to cope
  with difficult patients.

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Not all difficult encounters can be blamed on the
patient side of the interaction
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Definition

• Difficult patient is the one with whom the
  physician has trouble forming an effective
  working relationship.

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Types of Difficult Patients

• Somatic fixation
• (patients who express personal distress in the
  form of somatic symptoms)
• Dependent Patient
• (Dependent on prescription drugs).
• Demanding Patient
• (frequent visit for minor things requesting
  medications, tests, referrals ) .
• Manipulative help rejecter)
• (Do not follow doctor instructions)
• Self destructive patients
• (Diabetic patients who induce frequent attacks of
  keto-acidosis)

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Cont

• Seductive patients.
• Angry patients.
• Patients who are shopping from one doctor to
  another for the same problem.

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Difficult Consultations

• Patient with Hidden Agenda
• (Patient Reluctant to Talk Freely)
• Talkative Patient
• Angry Patient
• Demanding Patient

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Patient Reluctant to Talk Freely

• Causes
• Patient Factors
• Dr. Factors
• Circumstances

• Examples
• The topic
• Cultural barrier
• Social class barrier
• Dr. authority
• Time constrains
• Presence of 3rd party

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Patient Reluctant to Talk Freely

• Non - verbal Com.
• Showing sympathy empathy
• Showing real interest
• Unhurried manner
• Touch for reassurance
• Use of physical examination

• Verbal Communication
• Giving reason for the question.
• Comments on the patient attitude
• Generalization of the problem
• Asking at the right time
• Reflection
• Mirroring
• Confrontation

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Talkative Patient communication skills

• Verbal Communication
• Summarization
• Prioritization
• Behaviors which brake the
• Interruption
• Close ended question

• Non - verbal Comm.
• Use of touch
• Sympathy empathy
• relationship

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Angry Patient Communication Skills

• Empathy
• Legitimation
• Non-judgmental attitude
• Respect patient autonomy
• Support
• Flexibility

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Even Angry Customers Are Always RightMarsha L.
Miley and Thomas J. Weida, MD

• 7 steps for satisfying angry patients
• Handle problems privately
• Listen to patients' complaints
• Disarm anger with kindness
• Delegate up when necessary
• Follow through on promises
• Involve the patient in prevention
• Be grateful

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Dealing with Demanding Patient
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Negotiation Skills (think win-win)
Set limit Reinforcement
Compromise Be flexible
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Dealing with Demanding Patients

• Negotiate agenda goals Set limit
• Reinforcement
• Compromise Be flexible
• Avoid argumentation,
• Explain your rationale,
• Pay attention to the way you say no, and,
• If all else fails, breathe deeply and start over.
• Exceptionally, for some patient
• firm boundaries are the rule

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Cues for the physician

• Difficult patients evokes a feeling of anxiety,
  pressure, boredom, or frustration

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Management

• Acknowledge his/her feeling
• Frequent short visits
• Background
• what is going on, life history, expectation ?
• Affect
• how do you feel about that problem
• Trouble
• what about the situation trouble most ?
• Handling
• how are you handling the problem ?
• Empathy

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Coping Strategy for the Doctor

• Recognize your true feelings. Difficult patients
  evoke a feeling of anxiety, pressure, boredom, or
  frustration
• Ability to use resources .
• Be alert for countertransferance reaction in your
  self.
• Recognize alternative medicine e.g religions,
  herbal .
• Involve colleague in your management plan.
• Improve yourself .

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Respect for persons

• 1- Respect for patient autonomy (can be reduced
  but never absent people must be allowed to
  control their health)
• 2- Informed consent
• 3- Truth-telling
• 4- Respect for confidentiality

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Prevention

1. Preventing patient from dropping out from the
   care is of primary importance
   a- keep patient waiting
   time to a minimum b- a system for
   follow-up, ensuring that the patient leaves
   clinic with a specific time for future
   appointment.

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Prevention

• Simplify the treatment regimen
  a- eliminate unnecessary medication.
  avoid narcotic as pain killer.
  
• b- medication should be prescribed as few times
  daily as possible e.g. tricyclic antidepressant.
  c- prescribe the least amount of
  medications that is needed to achieve the
  therapeutic goal.

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Prevention.

1. Try to protect patient from harm in medical
   field(e.g. unnecessary tests, medications or
   surgeries)
2. Patient should be actively involved in their own
   carea- Studies have shown that negotiating care
   with patient results in better compliance.
   b- encouraging patient to take
   greater responsibility for their care by asking
   more questions of their physicians results in
   improved attendance

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Suggestions for Better Practice Management
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Suggestion Activity
Promote continuity of care Educate patients that the involvement of multiple health care professionals may result in conflicting or confusing approaches help the patient maintain a primary care provider.
Schedule appropriately Length of visits should fit patients perceived needs and expectations. Modify scheduling systems to allow more time for certain patients at the request of the physician.
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Suggestion Activity
Access community resources Develop on-site or community-based links to mental health and social work professionals
Ensure adequate follow-up Schedule regular follow-up visits at two- to three-week intervals, especially if high dependency needs are suspected. Educate the patient in appropriate use of telephone or e-mail contact as an alternative to more frequent visits.
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Suggestion Activity
Set firm limits Discuss and enforce your policies regarding abuse of staff, insistence on immediate telephone access, or obstruction of the process of care. Terminating the relationship with the patient is a last resort and should be done with care.
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• Thanks