Tuesday 26 September, 2006

How to manage difficult patients

Posted in Emergency Dept., General Practice, May Su, Psychiatry, Wards at 18:13 by May Su

Original article by: May Su :: Printer friendly

There are many reasons why patient interactions can be frustrating or difficult. Most commonly these can be traced to factors relating to the patient, the physician, or the health care system (1).

The management of a “difficult” patient requires time, good communication and firm limit setting.

“Difficult patients” are common and unavoidable. That being the case, “avoidance” should never be the goal of management. More often than not, these patients have real physical and/or psychological health needs. Try to restrain yourself from the all too easy temptation of categorising “difficult” with “undeserving” or tossing them into the “too hard basket”.

Patient factors

  • psychiatric disorders;
  • personality disorders;
  • subclinical behaviour traits.
  • Patients with personality disorders may be excessively dependent, demanding, manipulative, or stubborn, or they may self-destructively refuse treatment.

Physician factors

  • overwork;
  • poor communication skills;
  • low level of experience;
  • discomfort with uncertainty.

Health care system

  • productivity pressures;
  • changes in health care financing;
  • fragmentation of visits and care;
  • and the availability of outside information sources that challenge the physician’s authority.

Addressing these Factors

Patient Factors

  • Try to address any undisclosed psychopathology; are there other issues which the patient is having difficulty expressing. “How have these problems been affecting you?”
  • screen for depression, anxiety, substance abuse, somatoform disorder.

Personality disorders

In screening for personality disorders, it is important to be aware of your own feelings in dealing with patients. A very strong negative emotional reaction to a patient (in an otherwise caring physician) can often be an indication of a diagnosis of personality disorder in a patient.

The most common personality disorders/traits which you will see in practice are usually Cluster B traits, which are the borderline personality or antisocial personality disorder.

Other common personality traits include anxious, dependent and/or obsessive. I will discuss personality disorders in another section.

Physician Factors

  • Seek professional care or support from peers;
  • firm limit setting with difficult patients;
  • consider that increased time may need to be scheduled for those patients known to be “difficult”;
  • be conscious of “countertransference” and try not to project your own emotions into the physician-patient relationship;
  • specific communication techniques and greater patient involvement in the process of care may enhance the relationship.

Communication Techniques for Physicians

(Adapted from Haas, et al. 2005) (1)

Goal: Improve listening and understanding

Activity:

  • Summarize the patient’s chief concerns;
  • interrupt less;
  • offer regular, brief summaries of what you are hearing from the patient;
  • reconcile conflicting views of the diagnosis or the seriousness of the condition.

Suggested phrases:

  • “What I hear from you is that … Did I get that right?”

Goal: Improve partnership with patient

Activity:

  • Discuss the fact that the relationship is less than ideal;
  • offer ways to improve care.

Suggested phrases:

  • “How do you feel about the care you are receiving from me?”
  • “It seems to me that we sometimes don’t work together very well.”

Goal: Improve skills at expressing negative emotions

Activity:

  • Decrease blaming statements;
  • increase “I” messages, e.g., “I feel …” as opposed to “You make me feel …”

Suggested phrases:

  • “It’s difficult for me to listen to you when you use that kind of language.”

Goal: Increase empathy; ensure understanding of patient’s emotional responses to condition and care

Activity:

  • Attempt to name the patient’s emotional state;
  • check for accuracy and express concern.

Suggested phrases:

  • “You seem quite upset. Could you help me understand what you are going through right now?”

Goal: Negotiate the process of care

Activity:

  • Clarify the reason for the patient seeking care;
  • indicate what part the patient must play in caring for his or her health;
  • revise expectations if they are unrealistic.

Suggested phrases:

  • “What’s your understanding of what I am recommending, and how does that fit with your ideas about how to solve your problems?”
  • “I wish I (or a medical miracle) could solve this problem for you, but the power to make the important changes is really yours.”

Health System Factors

Unfortunately under most circumstances we are limited in our ability to change the health system that we are working in, however that’s not to say that we can’t try.

  • Develop good links to mental health and social work professionals;
  • schedule regular follow up visits (e.g. 2-3 week intervals) for suspected high dependency patients, and allow for adequate scheduled time for visits;
  • educate the patients that multiple health care professionals may result in conflicting or confusing approaches;
  • maintain good communication between all service providers involved;
  • set firm limits on when and low long is appropriate for visits, and appropriate behaviour towards yourself and staff.

Reference articles

(1) Haas L., Leiser J., Magill M., Sanyer O. Management of the Difficult Patient. American Family Physician. Vol. 72/No. 10 (November 15, 2005) [download PDF :: 126 Kb :: Link]

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