Wednesday, August 3, 2011

8 Ways to Exorcise Difficult Patients

I recently encountered a young patient, college student. He sought consult without a companion.  When I first looked at him, I knew instantly that he was not going to be the usual patient.  He had a serious demeanor and dark circles around the eyes.You know, just like you see in zombie movies.  But that was not all…

During the interview, he revealed that he had a history of chronic, multiple, vague or exaggerated pain, numerous diagnostic tests done, and doctor-hopping (consults with several doctors).  After examining him and telling him that he was essentially normal, he looked at me like I was a talking Martian.  For a while there, I thought he was mesmerized by my good looks.  Then he told me he was quite certain that something was terribly wrong.  With his dark eyes growing bigger than saucers, he said that he was a victim of witchcraft (kulam).

With sudden jerking motions, he bent down and did some weird sideward bending of his spine to demonstrate that he was being possessed.  So from an eerie feeling, I almost fell off my chair and laughed, but tried my best to hide it.  I thought this patient needed a psychiatric consult and not an orthopedic surgeon!  I also knew that this man was the quintessential “difficult” patient.

Like many things in medicine, the difficult patient comes in a myriad of shapes, sizes and forms.  Difficult patients may act ridiculously, complain incessantly without reason, criticize, shout, curse, or may even try to hit us.

It is hard to define what constitutes a difficult patient.  But in general, difficult patients are those who do not heed our advice, confront us with hostilities or maintains his own set of ideas about his or her ill­ness or treatment.  In the US, the reported prevalence of difficult patients is 15%-- not that uncommon.  They are, in fact, an unfortunate occurrence in healthcare.

We don’t always like the patients that we take care of.  That sounds harsh, but I’m just being honest.  But while we don’t always like them, we still have to provide the best possible patient care, and maintain an appropriate level of professionalism and compassion.

So how do we deal with these patients?

I read somewhere how an astute businessman handled a difficult customer who seems to do nothing but complain.  The businessman was a doughnut shop owner.  He saw how the female customer went to the staff and complained why their doughnuts have a hole in the middle.  Now, instead of telling the customer, “Are you nuts?!? All doughnuts have a hole in the middle!”, he stated that their doughnuts have a hole in the middle so that the customer can put her second finger on one side and the thumb on the other.  Doing so, she can hold the doughnut properly and not spill it all over her beautiful dress.  Then he added, “But if you like a doughnut without a hole in the middle, we’ll gladly make one, just for you.”

Whether in business or medicine, we are bound to encounter difficult people.  If you were the doughnut shop owner, how would you answer the customer?  But what about doctors, what can we do to handle difficult patients?  Here are 8 helpful tips:

1.      Identify angry, defensive, frightened or outright ridiculous patients.
Oftentimes, it’s possible to predict who among patients are likely to be difficult.  Patients with chronic diseases who do not seem to get well, those who have been experiencing pain for a long time, the terminally-ill or depressed patients—they all tend to be moody, irrational and easily agitated.  Think women with PMS (pre-menstrual syndrome).  Obviously, patients with diagnosed psychiatric disorders are also prone to disruptive or violent behavior.  For chronically ill patients, the financial burden of their disease may also compound their angry disposition.

2. Slow down, listen, and don’t be arrogant.
It’s important to note that patients aren’t the only responsible party in a difficult doctor-patient encounter.  Before we take the easy way out and blame the patient, realize that we, physicians, play a role in this as well.  Are we tired, frustrated, having a bad day, hungry, or burdened with personal problems?   Once we rule this out, it is then time to ask ourselves, have we done everything we can to understand and address the patient’s needs or expectations?  Many times, a patient’s voice tone, gestures and body postures, reveal more about the patient’s concerns, than his words can.  So sit down, listen and observe – rushing a consultation may be counterproductive.

3. Address the patient’s basic human needs first.

Is the patient feeling cold or warm?  Hungry?  Agitated from the long waiting time?  Need to pee?  When patients are unnecessarily uncomfortable, it adds to their frustration, and this can contribute to poor communication.  So if you sense discomfort or irritability, ask the patient how you can help.  And always check the physical conditions, ex. room temperature, in your clinic or consultation room.  Common courtesy goes a long way.

4.      Show Respect.

Always address the patients as Mr., Ms., or whatever title or nickname he is comfortable with.  Speak in a friendly, non-condescending manner.  Make eye contact, and try to approach patients at eye level.  That means sitting when the patient is sitting and standing when the patient is standing.  A friendly handshake and introducing yourself is also a great way to start a consultation.  

5.      Ask relatives to help.

Family and friends can do more than cram up the consultation room.  If the patient prefers them to be there, they can provide support, create workable solutions, and break the patient’s sense of isolation or fear.

6.      Avoid making assumptions.

I was guilty of this by the way I thought about my kulam patient.  Most patients are not intentionally abusive or disruptive.  They may well be responding to an irritation, cognitive impairment, inability to express themselves or loss of identity.  Physical appearance may also be misleading—you wouldn’t look your best either if you were in chronic pain or haven’t slept in three days.

7.      Avoid tolerating disruptive behavior.

Whereas patience and understanding are essential virtues of a physician as mentioned above, one must also draw the line on unacceptable patient behavior such as foul language or physical violence.  Disruptive behavior must also be controlled if it interrupts treatment or examination.

8.      Let’s not take it personally. 

We can’t really expect our patients to be having a good day during every consultation, act pleasantly at all times or agree with every word we say.  Thus it is said, “Interpersonal mishaps or confrontations are guaranteed when you work with people.”  Even with your best friend, you can have disagreements, right?  You can’t let every difficult patient ruin your day or get in your way to becoming the best doctor that you can be.

In summary, doctors should be able to identify difficult patients and respond appropriately.  Dealing with them can be extremely challenging, but it’s a challenge that we physicians can overcome through practice and experience.  For whatever reason or situation they may have for being difficult, the results are the same: distraction from effective care, waste of energy, dissatisfaction, and continued health problems for the patient. 

In my orthopedic practice, I would rather see fractures, not fractured relationships with patients.

Can you think of other tactics and strategies that can reduce difficult doctor-patient encounters? 

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