As many as 15 percent of patient-physician encounters are rated as “difficult” by the physicians involved.1 Patient characteristics that suggest the likelihood of difficult encounters include the presence of depressive or anxiety disorders, more somatic symptoms, and greater symptom severity, according to the study. Not all difficult encounters can be blamed on the patient side of the interaction. Physician attitudes about care, fatigue, stress, and burnout can create circumstances in which physicians are responsible for the difficulties. Language barriers, cross-cultural issues, and the need to relay bad news can also make for challenging encounters.
Using a framework adapted from Adams and Murray,2, we present some common scenarios you may encounter in your practice, along with strategies for dealing with them. In this model, patient characteristics, physician characteristics, and situational characteristics contribute to difficult clinical encounters.
Patient factors
It can be hard to have productive encounters when patients exhibit the following characteristics. Here's how to identify them and respond appropriately.
Angry, defensive, frightened, or resistant patients. Clenched fists, furrowed brows, wringing of the hands, restricted breathing patterns, and warnings from the office staff that something is wrong can help identify these patients. When you see these signs, try to uncover the source of difficulty for the patient and pay attention to the way their emotions relate to the medical issues at hand. Don't get drawn into a conflict. Instead, define your boundaries and recognize when your “triggers” are invoked. This will help you modulate your response to the situation and allow you to empathize with the patient. Use reflective statements such as, “I can understand why you might feel that way,” and follow with a discussion about what it might take to resolve the situation2,3
For example, a patient in pain and has been waiting for an hour because you have been tending to a hospital emergency might be quite angry when you finally get to the room. He may say, “My time is as valuable as yours. I don't understand why I had to wait.” Your sense of being harried and running late may trigger an angry reaction from you, but simply taking a deep breath and offering a sincere apology would be a more constructive response than having your meltdown. A statement such as, “I can understand why you are upset, and I appreciate your waiting for me,” would go a long way toward easing the patient's frustration. If you can confidently say that you'll handle the situation differently next time, for instance, by instructing your office staff to tell your patients that you are running late and offering alternatives to waiting, such as rescheduling, then tell the patient what you intend to do.
If you sense that a patient is fearful about a diagnosis or treatment, encourage the patient to talk about it and assess whether the fear is appropriate in proportion to the situation. This may help establish a context for the fear, allowing the patient to deal with it more constructively.
Of course, if at any point during an encounter with an angry patient you sense a potential for harm to you or your staff, ask for assistance from law enforcement and remove those you can from harm's way.
Manipulative patients. 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 manipulative behavior. 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 be able, even if their actions are not), and realize that sometimes you have to say “no.”
Somatizing patients. These patients present with a chronic course of multiple vague or exaggerated symptoms and often suffer from comorbid anxiety, depression, personality disorders. They often have “doctor-shopped” and likely have a history of multiple diagnostic tests. Keys to productive encounters with somatizing patients include describing the patient's diagnosis with compassion and emphasizing that regularly scheduled visits with a primary physician will help to mitigate any concerns. Be sure to manage any comorbid psychological conditions as well effectively. It is important to refrain from suggesting that “it's all in your head” and avoid the cycle of vigorous diagnostic testing and referrals.
A strategy for communicating with a new somatizing patient who has “doctor-shopped” might be to address the issue directly at the beginning of the encounter. For example, “I noticed that you have seen several physicians and have had extensive medical tests to try to uncover the cause of your symptoms. I recognize that the symptoms are a real difficulty for you, but I believe that these tests have ruled out any serious medical problems. I have another strategy to suggest that has worked well for patients of mine in similar situations. I would like to make a contract with you to see you every two to four weeks – often enough to see anything truly new going on. If something significant develops that has not already been worked up, we will do more tests. We will meet frequently enough to provide you some assurance that we are not missing anything, and we will avoid uncomfortable and costly tests and procedures unless they are y.”
Grieving patients. Recognizing the effect of grief on some patients' health requires familiarity with the normal stages of grief and the cultural context in which it occurs. Look for vegetative signs of depression and maladaptive behaviors that prevent progression through the normal grieving process, and treat them. Help grieving patients by validating their emotional experience and making sure they understand that grief is a process that takes varying degrees of time for different people. Encourage open communication, avoid inappropriate medication to suppress emotions, and caution against major lifestyle changes too early in the process.
“Frequent fliers.” These patients may stand out due to the sheer bulk of their medical charts. They may be lonely, dependent, or too afraid, or embarrassed to ask the questions they want to be answered were. They may also be patients with a large number of perfectly rational questions, the “worried well,” or simply patients who have been given misinformation that needs clarification.
The first step to a productive interaction is to identify the underlying reasons for the frequent visits. Begin by acknowledging that you notice the pattern of frequent visits. Explain that you have seen other patients schedule frequent visits for different reasons, including concern about undiagnosed symptoms, a need for reassurance, a need for relief from chronic pain, or a need to talk. Ask whether any of these reasons apply or whether the patient has other ideas as to the reasons for the frequent visits. Showing understanding of the patient's reasons often will foster an open discussion of the “reasons behind the reasons.” Contract with the patient for regularly scheduled return visits, and use patient education and support personnel as needed. Well-honed pain-management skills may also come in handy for patients who schedule frequent appointments due to chronic pain.
Physician factors
Physicians' tudes and behaviors, including the following, may also contribute to difficult encounters with patients.
Angry or defensive physicians. Physicians who are burned out, stressed, and generally frustrated over near-term crises or long-term concerns are more likely to react negatively to patients, not just those with characteristics that may contribute to a difficult encounter. Recognizing our trigger issues and knowing what personal baggage we bring into the exam room can be valuable.
Fatigued or harried physicians. Most of us have been overworked, sleep-deprived, or generally busier than we needed to be at one time or another. “Overcommitment” is a closely related phenomenon that is all too common among high-achieving professionals. It is important that we be sensitive to the impact of physician fatigue on medical errors and patient safety and set reasonable limits for ourselves.3 Consider these strategies: Diplomatically bow out of commitments, delegate to others as appropriate, and seek work environments that value setting appropriate limits.
Dogmatic or arrogant physicians. Each of us has things we feel strongly about. Personal beliefs and values and our beliefs and values about medical care can lead us to overemphasize our own beliefs and emotions in ways that disempower patients or prevent them from providing us with adequate information about their care. Our baggage may also prevent us from assessing that information without bias. Identify your trigger issues and avoid situations where your beliefs may inappropriately close off an adequate exchange of information and the shared decision-making critical to a healthy patient-physician relationship.
References
Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159:1069–1075...
2. Adams J, Murray R. The difficult diagnosis: the general approach to the difficult patient. Emerg Med Clin North Am. 1998;16:689–700.
3. Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med. 2002;347:1249–1255.
4. Schilling LM, Scatena L, Steiner JF, et al. The third person in the room: frequency, role, and influence of companions during primary care medical encounters. J Fam Pract. 2002;51:685–690.
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