1. Addressing Challenging Patient Behaviors in Spinal Cord Injury
Maggi A. Budd, Ph.D., MPH
VA Boston Healthcare System

2. Goals & 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 relationships
Use basic ethical tenets to help conceptualize appropriate “challenging responses”

3. No disclosures or conflicts of interest to report.

4. Operating Framework & Definition
Team Approach: No Disciplinary Turf
Boundaries
Assumptions
“Challenging” vs. “Difficult”
15-20% of patient encounters1,2,3,4
Goal: Review the literature, increase our awareness of patient and provider characteristics, and provide a framework for building team solutions

5. What “challenges” are of most interest here?

6. Why is this so challenging?
Oath as providers/Work Expectations
Patient Experiences/Patient Factors
Provider Factors
Clinician’s underlying Beliefs and Attitudes Providers’ personalities, values and emotional “hot buttons” influence their reactions to patients (Novack, 1997)
System Factors
Influences of Labeling on Team Perception
Work 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 disorders
System 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 management
CLINICIAN’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 change
Whatever 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

7. Groves (1978) Taking care of the hateful patient N Engl J Med
Four Distinct Stereotypes:
dependent clingers
entitled demanders
manipulative help-rejecters
self-destructive deniers

8. Characteristics of the difficult patient (Robinson et al. , 2006, p
Multiple (unexplained) physical symptoms
Frequent attending
Somatization disorder
Breaks doctor-patient boundaries
Won’t or can’t get better—sick role issues
Non-compliance (including treatment)
Believes doctors are Gods
Hostility and signing out
Litigious
Manipulative
Has (undiagnosed) personality disorder (borderline/dependent)
May have chronic medical disorders or social disabilities
Chronic pain syndromes with or without drug addiction

9. Patient 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”

10. Patient 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 patients
Most difficult patients have multiple physical symptoms (often somatoform)

11. Risk factors for SCI
Disproportionate premorbid history of maladjustment, psychological disorders, and ETOH
Depression-Suicide 5-10% vs. slightly above 1% for the general population
Anxiety – 25% of SCI vs. 5% of controlled sample
Cognitive deficits (TBI, LD, medication effects)
Pain
Substance abuse

12. Predictors of Difficult Encounters (Jackson & Kroenke, 1999)
Four risk factors identified by physicians who perceived encounters as difficult:
Depressive or anxiety disorder (29%)
Multiple physical symptoms
More severe symptoms
Physician with a “distaste” toward psychosocial side of care (23% vs. 8%)
All 4 = 47% of the encounters = “Difficult”

13. It is apparent that it is not easy to separate “patient”
factors from “other” factors
Is there a profile of a “difficult doctor”???

14. An, et al. (2009) Archives of Internal Medicine
422 physicians from 118 clinics, survey data
8-Item Burden of Difficult Encounters Measure
Job Stress
Global Job Satisfaction
Time pressure
Intent to leave practice
Latent Cluster Analysis (High, Medium, Low)
Logistic Regression Analysis to compare

15. An, 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 practices
Physicians 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 relationship
Value/Relevance: Shared responsibility

16. Provider-Patient Interface: Labeling
Labeling can lead to stereotyping; stereotyping can limit your openness and flexibility and may reduce communication
Label of “difficult patient” can actually lead to professional and emotional distance
Labeling assumes the provider is ideal, the provider-patient relationship is ideal, all working in an ideal system

17. Ogunsemi et al. (2008) Ann Gen Psychiatry
144 final year medical students
A single-paragraph case description illustrating a normal person, a social distance scale and questions on expected burden. Half received psychiatric dx/half no dx
Label 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 emotionally
Results 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

18. Progressive View: Dyadic
Provider/Patient interface
Consequence of both Provider and Patient factors; each contributes
Patient-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

19. Tools: Standard Practice
Improve provider-patient communication
Increases 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

20. What to do in real challenges?
Identify the source of the problem
Patient? Provider? Relationships? System?
Psychiatric liaison or Psychology consult to help provide insight and guidance
Clear TEAM treatment plan; setting limits
TEAM is the treatment
CONSISTENCY
Discuss with peers
Try to always respond with respect and frame in ethics

21. Medical Ethics Autonomy: right to refuse or choose
Beneficence: act in the best interest of the pt
Justice: fairness and equality of health resources
Dignity: Pt and provider have the right to dignity
Truthfulness/Informed consent
Non-malfeasance: “first do no harm”

22. Challenges 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.

23. Take 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 SCI
Labeling and “pigeonholing” are not helpful; conceptualize each case individually and contextually
Operating 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 integrity
TEAM approach will optimize mental and physical health for our patients with SCI across all providers and over time…

24. Reminders
Do not take challenging visits personally, recognize that it is normative Dealing with “challenges” signifies mastery rather than weakness

25. Future Directions
Link 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.

26. THANK YOU very much!!