Presentation on theme: "Addressing Challenging Patient Behaviors in Spinal Cord Injury"— Presentation transcript:
1Addressing Challenging Patient Behaviors in Spinal Cord Injury Maggi A. Budd, Ph.D., MPHVA Boston Healthcare System
2Goals & Objectives Upon completion, participations we be able to: Identify the Multi-faceted issues surrounding “Challenging Patients”Describe characteristics of patients and providers who experience “challenging” patient relationshipsUse basic ethical tenets to help conceptualize appropriate “challenging responses”
3No disclosures or conflicts of interest to report.
4Operating Framework & Definition Team Approach: No Disciplinary TurfBoundariesAssumptions“Challenging” vs. “Difficult”15-20% of patient encounters1,2,3,4Goal: Review the literature, increase our awareness of patient and provider characteristics, and provide a framework for building team solutions
6Why is this so challenging? Oath as providers/Work ExpectationsPatient Experiences/Patient FactorsProvider FactorsClinician’s underlying Beliefs and Attitudes Providers’ personalities, values and emotional “hot buttons” influence their reactions to patients (Novack, 1997)System FactorsInfluences of Labeling on Team PerceptionWork Expectations: Most health care providers in rehab enter the field with the goals of solving medical problems, improving functioning and overall quality of life for our patients.We do not expect to encounter patients who make repeated visits without apparent benefit, patients who do not seem to want to get better, patients who engage in power struggles, and patients who focus on issues seemingly unrelated to their treatment goals. Soon we will review specific patient characteristics that have been reported in the literature as “challenging.”Provider factors: could simply be tiredness due to overwork, unfamiliarity or discomfort with personality disordersSystem factors: health-care system only allocates X amt of time with each provider; clinic may be running late…things out of control of providers; i SCI perhaps it can be lack of continuity of care shifting from acute to subacute to chronic managementCLINICIAN’S UNDERLYING BELIEFS AND ATTITUDES: Read slide. These factors may adversely impact a clinician’s ability to convey empathy effectively, or may lead to under-involvement or over-involvement with some patients.Labeling a patient as “difficult” spreads to all staff/team members and may have a negative influence of the quality of care provided; sometimes impressions are resistant changeWhatever the issue: the results are similar: distraction from effective care, high use of energy, complaints from patients and staff, and ongoing problems for the patients
7Groves (1978) Taking care of the hateful patient N Engl J Med Four Distinct Stereotypes:dependent clingersentitled demandersmanipulative help-rejectersself-destructive deniers
8Characteristics of the difficult patient (Robinson et al. , 2006, p Multiple (unexplained) physical symptomsFrequent attendingSomatization disorderBreaks doctor-patient boundariesWon’t or can’t get better—sick role issuesNon-compliance (including treatment)Believes doctors are GodsHostility and signing outLitigiousManipulativeHas (undiagnosed) personality disorder (borderline/dependent)May have chronic medical disorders or social disabilitiesChronic pain syndromes with or without drug addiction
9Patient Factors (Hahn, 1996, 2001) Difficult patients are “frustrating, time consuming, and manipulative” and up to 50% of physicians “admit to ‘secretly hoping’ the patient will not return” These patients are also “high utilizers of health care and are as dissatisfied with their care as the physicians are upset to provide it”
10Patient Factors (Hahn, 2001 citing Hahn 1994, 1996) Compared to non-difficult patients, three characteristics have been associated:Difficult patients have twice the prevalence of significant psychopathology (67% vs. 35%)Abrasive personality style or frank personality d/o occurred in 90% of difficult patientsMost difficult patients have multiple physical symptoms (often somatoform)
11Risk factors for SCIDisproportionate premorbid history of maladjustment, psychological disorders, and ETOHDepression-Suicide 5-10% vs. slightly above 1% for the general populationAnxiety – 25% of SCI vs. 5% of controlled sampleCognitive deficits (TBI, LD, medication effects)PainSubstance abuse
12Predictors of Difficult Encounters (Jackson & Kroenke, 1999) Four risk factors identified by physicians who perceived encounters as difficult:Depressive or anxiety disorder (29%)Multiple physical symptomsMore severe symptomsPhysician with a “distaste” toward psychosocial side of care (23% vs. 8%)All 4 = 47% of the encounters = “Difficult”
13It is apparent that it is not easy to separate “patient” factors from “other” factorsIs there a profile of a “difficult doctor”???
14An, et al. (2009) Archives of Internal Medicine 422 physicians from 118 clinics, survey data8-Item Burden of Difficult Encounters MeasureJob StressGlobal Job SatisfactionTime pressureIntent to leave practiceLatent Cluster Analysis (High, Medium, Low)Logistic Regression Analysis to compare
15An, et al. (2009)A “dose response” was found across all tested end points, including stress, job satisfaction, time pressure, intent to leave one’s practice, and perception of suboptimal care practicesPhysicians who perceived a higher volume of difficult encounters were more burned out and dissatisfied with their jobs (also supported in previous studies)More women; younger in the field**Limitations: no cause-effect relationshipValue/Relevance: Shared responsibility
16Provider-Patient Interface: Labeling Labeling can lead to stereotyping; stereotyping can limit your openness and flexibility and may reduce communicationLabel of “difficult patient” can actually lead to professional and emotional distanceLabeling assumes the provider is ideal, the provider-patient relationship is ideal, all working in an ideal system
17Ogunsemi et al. (2008) Ann Gen Psychiatry 144 final year medical studentsA single-paragraph case description illustrating a normal person, a social distance scale and questions on expected burden. Half received psychiatric dx/half no dxLabel on case: would not rent their houses, unwilling to select as a neighbor, not allow sister to marry, felt they would exhaust them physically and emotionallyResults strengthen the view that stigma attached to mental illness is not limited to the general public; medical students can also be part of the stigmatizing world
18Progressive View: Dyadic Provider/Patient interfaceConsequence of both Provider and Patient factors; each contributesPatient-centered care appreciates the asymmetry of the relationship, wherein the provider holds more responsibility for empathy and “focus of treatment”Bundled approach: organizational, contextual, and provider factors
19Tools: Standard Practice Improve provider-patient communicationIncreases patient satisfaction &Improves health outcomes (Kravitz, 2001)Decreases complaints and lawsuits (Virshup et al., 1999; Levinson et al., 1997)Improves adherence 19% (Zolnierek & Dimatteo, 2009)Ask patients about their understanding of the illness/problem and expectations of care (correct misconceptions and unrealistic expectations; exposes barriers/benefits/risks; builds rapport)Include psychology
20What to do in real challenges? Identify the source of the problemPatient? Provider? Relationships? System?Psychiatric liaison or Psychology consult to help provide insight and guidanceClear TEAM treatment plan; setting limitsTEAM is the treatmentCONSISTENCYDiscuss with peersTry to always respond with respect and frame in ethics
21Medical Ethics Autonomy: right to refuse or choose Beneficence: act in the best interest of the ptJustice: fairness and equality of health resourcesDignity: Pt and provider have the right to dignityTruthfulness/Informed consentNon-malfeasance: “first do no harm”
22Challenges to effective rehabilitation Psychological (depression; anxiety; noncompliance)Physical (chronic pain; sleep; nutrition; fatigue; substance abuse; sexual problems; agitation)Cognitive (delirium/dementia; attention; initiation; memory; processing speed; unawareness)MISC (excessive demands; anger; apathy/silence; verbal outbursts; decreased participation)Budd, M.A. (in press). Rehabilitation Psychology. In M Gonzalez-Fernandez & JD Friedman, eds, Physical Medicine and Rehabilitation Pocket Companion. Demos Medical: New York.
23Take Home (& to The Team) Messages It is not uncommon for providers to view patients as “challenging” particularly when working within a specialized field inherent with abundant stressors such as SCILabeling and “pigeonholing” are not helpful; conceptualize each case individually and contextuallyOperating from an Ethical Framework is a fundamental place to start for all interventions; always is in the best interest of our patients as well as our professional integrityTEAM approach will optimize mental and physical health for our patients with SCI across all providers and over time…
24RemindersDo not take challenging visits personally, recognize that it is normative Dealing with “challenges” signifies mastery rather than weakness
25Future DirectionsLink perceived “challenges” to specific encounters and measure the patient and provider’s perspectives in tandem, and include longitudinal assessment to evaluate the effect of challenging encounters on patient and provider satisfaction, adherence, functional improvement, quality of life and health care costs.