1. Difficult Patient
Dr. C.K. Wong
24 Oct 2001

2. Groves (1951)
Defined 4 categories of
difficult patient

3. 1. Dependent clinger Express excessive gratitude for doctor’s actions
Seek regular reassurance over minor problems

4. 2. Entitled demander
Frequently complains about imagined shortcomings in service

5. 3. Manipulative help rejector
Presents a series of symptoms doctor is powerless to improve

6. 4. Self destructive denier
Patient refuses to accept his behaviour affecting his disease
Will not modify self-harming habit

7. Difficult relationship
An approach to the
Difficult relationship

8. Acknowledge 1. Engagement
Review Whether you ‘engaged’ properly with the patient at the beginning of consultation

9. Acknowledge
2. Empathy
Make sure the patient knows he or she has been seen, heard and understood

10. Acknowledge 3. Education
Provide patient with enough information to understand what you are advising

11. Acknowledge
4. Enlisted
Motivate patient to accept your advice

12. Rebuild relationship
1. Shave the relationship difficulty by verbalising it
e.g. “ I’m finding it difficult to help you
because…….”

13. Rebuild relationship 2. Build a partnership
e.g. “ How do you feel about that? Can you
think of ways you can help me help
you? Is there something I can do to
help us work together better? ”

14. Boundaries
1. Define you boundaries and seek patient’s acknowledgement and agreement to them
e.g. “ Mrs. Smith, I’ve made a list of the eight things.
You’re asked me to deal with today, but you did
not book a long consultation. I think we can deal
with three today in the time we have, would you
like to say which three you’d like me to deal with
today and which can be deferred to tomorrow? “

15. Boundaries
2. Temporal
How much time you are prepared to give.

16. Compassion
1. Empathy
Acknowledge the patient’s education and make sure he or she knows you see

17. Determine the meaning People do things for a reason
Every patient comes with a pre-set belief about what could be the problem and what might be the solution
Find out what they are thinking

18. Role Play

19. 1. Miss Wong, aged 20, is living with her son
(4 years old). She has no remarkable past
medical history. She works in a karaoke bar. She requests some tests on her liver as her ex-boyfriend died of “liver disease” recently.
How would you conduct this consultation?

20. 2. Mrs. Chan is now aged 49. She divorced
his husband 4 years ago. She recently heard about hormonal replacement therapy in the media and requested this treatment from you. After physical examination and investigation, you found she was fit for HRT. Six months later, Mrs. Chan was admitted into hospital with myocardial infarction. Shortly afterwards her son Paul came to see you. He alleged that the HRT caused her mother’s heart attack.
How would you interview with him.

21. 3. Mr. Wong, aged 45 and a construction site labourer, complained of persistent low back pain for 2 months. He alleged this to a fall at work 3 months ago when he was hit by a pile of stacked timber. He was pursuing compensation for negligence against his employers. He had no abnormal physical signs and X-rays of his lumber spine have been normal. He denied any unhappiness and worries apart from the unbearable pain at work. He has consulted other doctors without relief. He then requested a sick leave certificate for a month as he did not think he can work, and no treatment other than rest could help him.

22. 3. What would you do?
Knowing that you are not going to give him a long sick leave, Mr. Wong bursts into foul languages and wares his arm in front of you while demanding his request again.
What do you do next?

23. X..Y.#..@..%!-Z..@>>>?!!
Angry Patient

24. What is anger
A person’s emotional response to provocation of to a threat to his or her equilibrium
Manifestation of a deeper fear and hidden insecurity

25. Guidelines for handling angry patientDo
Listen
Be calm : keep still and establish eye contact
Ask patient to sit down
Address patient
Be comfortable
Show interest and concern
Use clear and firm language
Be sincere
Allow patient to ventilate feelings
Arrange follow up

26. Guidelines for handling angry patient
Don’t
Touch the patient
Meet anger with anger
Reject the patient
Be over familiar
Talk too much
Be judgmental

27. Questions in the interview
Rapport building
‘ I can appreciate how you feel ‘
‘ it concerns me that you feel so strongly
about this ‘
‘ tell me how I can make it easier for you ‘

28. Questions in the interview
Confrontation
‘ you seem very angry ‘
‘ it’s unlike you to be like this ‘
‘ I get the feeling that you are upset with …’
‘ what is it that is upsetting you? ‘

29. Questions in the interview
Facilitation , Clarification
‘ so you feel that………. ‘
‘ you seem to be telling me…….. ‘
‘ if I understand you correctly……….. ‘
‘ tell me more about this…………. ‘

30. Questions in the interview
Searching
‘ do you have any special concerns about
your health? ‘
‘ do you relate to anyone who has a problem
like yours? ‘

31. Thank You