DEALING WITH DIFFICULT PATIENTS: PART IIADVANCED COMMUNICATION TECHNIQUESA recent study in the Journal of General Internal Medicine found that physicians characterize almost 18% of patients as difficult. “Difficult patient” involves patients who are hard to deal with on a personal level as well as those whose health doesn’t improve. Difficult patients were 2.4 times more likely to have worse symptoms two weeks after a visit and to report that their expectations weren’t met. Younger physicians, those with less than 10 years of experience, reported that almost one in four patient visits was difficult, while older physicians ranked the number at just 2%, While physicians define patients as difficult because of their medical interactions, staff finds that patients are difficult in other ways. The purpose of this article is to describe who difficult patients are, why they are difficult, and offer techniques for dealing effectively with such patients. WHO ARE “DIFFICULT PATIENTS”AND WHY ARE THEY DIFFICULT? These are difficult times. People have lost jobs, income, homes, health insurance, dignity, and, in some cases, hope. Everyone reacts to stress differently. Those who might be able to “roll with the punches” during less stressful times may have sustained too many punches making them irritable, cranky, argumentative, and even hostile. Many fear financial ruin and inability to care for themselves and their families. Admittedly, some folks are just that way, for reasons only known to them, and they can make life miserable for all those around them. Some patients are difficult because they have expectations beyond what is reasonable. They want everything to be fine and expect perfect outcomes. The fear of serious consequences makes them point the finger at the health care provider when things do not go as they would hope. Enter the patients to your office. We never know what is going on with them when they come in to see us. All we know is that something is not right with their health and they are seeking our care. The physician’s office has generally been a place of care and comfort. Like children who act up with their parents because they know it is safe to do so, some patients may feel the same about you and your care. They believe it is appropriate to act up in your presence because it is a safe place, filled with people who care about them. Whatever the reasons, these are some of your patients today. Dealing with difficult people can be in itself difficult and draining. Therefore, it is important for all of us to learn how to deal as effectively as we can with a wide variety of people and their behaviors. The following are some communication steps to take which should generally reduce emotion, let patients know you are on their side, and help resolve the difficulty.
TYPICAL SCENARIOS Patient is angry for having to wait for a long time in your waiting/reception area. Do: Acknowledge that you personally know that no one likes to wait and that you are truly sorry. Say, “We are so sorry to have made you wait today. It is very uncomfortable for us as well. Please know that we appreciate your patience and will get you in and treated as soon as possible. Is there something we can do to make you more comfortable?” Offer alternatives: rescheduling with a priority or calling ahead next time. Don’t: Minimize by saying, “You should know that you always have to wait here.” Or roll your eyes and shun the patient. Noncompliant patient. This individual is a huge risk for you because a patient who does not follow your suggestions can become sicker – and then blame you! Do: Say, “It is very disconcerting and scary for us when you won’t get that mammogram/see the specialist/quit smoking/take your medications. We worry about your health. Please explain what you are thinking so we can better understand. There must be some root causes we need to discuss. If we do not, we might not be able to continue to see you. It is way too difficult for us to watch you disregard your health in this way. This is a partnership in this practice and we need you to do your part as well. So, let’s get that test scheduled today, ok?” Don’t: Continue to see patients who are woefully neglectful about their own health. See the article on how to discharge patients from your practice. Do: Document all your conversations with the patient including actual words the patient used to explain noncompliance. Patient identifies unrealistic expectations. These patients might say such things as, “Everything will be ok, won’t it?” “I’ll be able to play tennis again, won’t I?” “That won’t leave a scar, will it?” ”This cancer won’t kill me, will it?” These are very difficult situations and it is important that everyone in the practice is honest with the patient and the family while offering support and hopefulness, even in the most dire of situations. Patient conditions can often be serious and have life-changing consequences. As health care providers, we want patients to be optimistic and we do not want them to suffer emotionally from fear. However, some patients are not realistic and will hold you accountable for less than perfect outcomes. Research is clear that people can adjust to “bad news” although it can take some time. Honesty is the best policy, tempered with hopefulness and support. Do: Say, “This is a serious condition. I wish the news were better. We can give you information on your condition, if you want to learn more about it. We are here for you. Everyone in this practice is available to answer your questions. We are very hopeful here. We always look on the bright side and hope you do also. However, we must be realistic. This procedure is serious, you will probably have scarring, recovery might be long and discouraging, and the outcome is unsure. But we believe in you and will do all we can to help you through this. What questions do you have now? How can we help you?” Patient has untoward or less than desirable outcome. Outcomes are never guaranteed, which is why we go through the informed consent process with patients. It is, however, still disappointing, heart-breaking, and even frightening for patients whose results are not as they hoped. Handling this situation is a two-step process. First, we should prepare the patient for certain foreseeable and unforeseeable results. While remaining hopeful, we must share with patients some of these facts. Hopefully, all goes well, but we know that is not always the case. However, when the outcome is less than desirable, we need to (a) help patients understand what happened; (b) help them to deal emotionally with the disappointment and/or loss; and then (c) help them look to the future. Do: Say, “We wish this could have turned out better for you. I know you remember we discussed this possibility beforehand, but that doesn’t make the situation any better at the moment. We are here for you. Our entire staff will help you get the physical therapy/grief counseling/specialist care to make sure you are getting all the assistance you can. Right now, what is bothering you the most and how can we help you?” Do: Make sure all staff are trained in how to deal with disappointed and grieving patients. Each person in the practice should face the patient directly, acknowledge the difficulty, give a warm smile and hug, if appropriate, and be there physically and emotionally for the patient. Don’t: Shun the patient or make the patient feel like it is their fault. It is better to deal with these situations right away than to wait to deal with them within the legal process. There is no guarantee that patients will not seek legal remedies if they think they have been wronged or that malpractice has occurred. Your caring and responsive attitude will help the patient start to move forward – and the (documented) assistance your office provides will help to mitigate any appearance of patient disregard after an untoward event. Patient becomes threatening or abusive. There are people who, when faced with frightening or frustrating situations, can become abusive and even violent. Your entire office needs to be prepared to handle this immediately. Conduct an office meeting to discuss who will do what in the event of such an outburst or threat. You might include the building security people as well. Determine what is a threat then the action steps each of you will take in order to secure the safety of yourselves and your other patients. No one should be a hero. If reasonable efforts to defuse such an individual are unsuccessful, all of you might need to exit the premises. Someone should call 911 and/or the building security people. Make sure everyone knows where the exits are and basic escape strategies. Better to be safe than sorry. In the March 2011 issue of Consumer Reports, from a survey of physicians and patients, it reports that, “For patients, the more they reported being treated respectfully and listened to, the more satisfied they were with their physician.” In other words, for a majority of patients, giving them simple, caring, honest communication will help defuse the tensest situations. The purpose of this article has been to give medical professionals some additional tools for dealing with difficult patients. Please let us know of other situations and how we can help you develop effective and caring and communication strategies. I can be reached at Idora.silver@ind-insurance.com or (775) 829-0606 and would appreciate hearing of your other patient challenges. IND offers three risk management programs per year, two in Las Vegas and one in Reno. In addition, tailored programs are also held for nurses, administrators, and medical office staff. Information regarding these programs can be found here: http://www.ind-insurance.com/risk-management. Please contact Idora Silver, IND Director of Risk Management, at (775) 829-0606 if you have any specific risk management questions or would like to consult with her on customizing a program specific to your needs. |
