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Dealing Dealing wwith Difficult ith Difficult ConsultationsConsultations

Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM

PO Box 27121 – Riyadh 11417Tel: 4912326 – 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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Difficult patient is the one with whom the

physician has trouble forming an effective working

relationship.

Definition

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• Somatic fixationSomatic fixation– (patients who express personal distress in the form of somatic

symptoms)• Dependent PatientDependent Patient

– (Dependent on prescription drugs). • Demanding PatientDemanding Patient

– (frequent visit for minor things; requesting medications, tests, &referrals ) .

• Manipulative help rejecterManipulative help rejecter)– (Do not follow doctor instructions)

• Self destructive patientsSelf destructive patients – (Diabetic patients who induce frequent attacks of keto-acidosis)

Types of Difficult Patients

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• Seductive patients.• Angry patients.• Patients who are shopping from one doctor

to another for the same problem.

Cont……

Difficult Consultations:Difficult Consultations:

Patient with Hidden AgendaPatient with Hidden Agenda (Patient Reluctant to Talk Freely)

Talkative PatientTalkative Patient

Angry PatientAngry Patient

Demanding PatientDemanding Patient

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Patient Reluctant to Talk Patient Reluctant to Talk FreelyFreely

Causes :Causes :Patient Factors :

Dr. Factors :

Circumstances :

Examples :Examples :The topicCultural barrierSocial class barrierDr. authorityTime constrainsPresence of 3rd party

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Patient Reluctant to Talk FreelyPatient Reluctant to Talk Freely Verbal CommunicationVerbal CommunicationGiving reason for the question.Comments on the patient attitudeGeneralization of the problemAsking at the right timeReflectionMirroringConfrontation

Non - verbal Com.Non - verbal Com. Showing sympathy &

empathyShowing real interestUnhurried mannerTouch for reassuranceUse of physical

examination

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Talkative PatientTalkative Patient communication skills 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 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:1. Handle problems privately 2. Listen to patients' complaints 3. Disarm anger with kindness 4. Delegate up when necessary 5. Follow through on promises 6. Involve the patient in prevention 7. Be grateful

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Dealing Dealing with with

DemandinDemanding Patientg Patient

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Negotiation SkillsNegotiation 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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Difficult patients evokes a feeling

of anxiety, pressure,

boredom, or frustration

Cues for the physician

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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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1- Respect for patient autonomy (can be reduced but never absent; people must be allowed to control their health)

2- Informed consent3- Truth-telling4- Respect for confidentiality

Respect for persons

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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.

Prevention

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2. 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.

Prevention………

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3. Try to protect patient from harm in medical field(e.g.: unnecessary tests, medications or surgeries)

4. Patient should be actively involved in their own care:a- 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

Prevention…….

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Suggestions for Better Practice Management

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Suggestion Activity

Promote continuityof care

Educate patients that the involvement ofmultiple health care professionals may result in conflicting or confusing approaches; help the patient maintain a primary care provider.

Scheduleappropriately

Length of visits should fit patients’ perceivedneeds and expectations.Modify scheduling systems to allow more time forcertain patients at the request of the physician.

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Suggestion Activity

Access communityresources

Develop on-site or community-based links to mental health andsocial work professionals

Ensure adequatefollow-up

Schedule regular follow-up visits at two- to three-weekintervals, especially if high dependencyneeds are suspected. Educate the patient inappropriate use of telephone or e-mail contactas an alternative to more frequent visits.

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Suggestion Activity

Set firm limits Discuss and enforce your policies regarding abuseof staff, insistence on immediate telephoneaccess, or obstruction of the process of care.Terminating the relationship with the patient is alast resort and should be done with care.

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Thanks

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