1. Keri T. Holmes-Maybank, MD Medical University of South Carolina June 18, 2013

2.  Review the famous Groves article “Taking care of the hateful patient.”  Recognize physician characteristics that lead to a greater perception of a patient as “difficult.”  Recognize patient characteristics and patterns of behavior classified as “difficult.”  Practice the collaboration, appropriate use of power, and empathy approach recommended for managing conflict by Elder.

3.  Illness can alter the patient’s psyche leading to uncharacteristic behavior.  Acknowledge and accept emotional responses to patients.  Physician awareness and acceptance of personal emotions may improve emotional intelligence and physician-patient relationships.  Most important is how the physician behaves toward the patient, not the emotion she is experiencing.  Empathy and collaboration are the keys to effective conflict management.

5.  Dependent Clinger  Entitled Demander  Manipulative Help Rejecter  Self Destructive Denier

6.  Appropriate need for reassurance  Escalates to unreasonable, BOTTOMLESS need for explanation, affection, and attention  Constant reassurance  Increasing dependency  See MD as inexhaustible resource  Warning signs:  Extreme gratitude  MD feels special

7.  MD becomes exhausted, patient feels rejected, ramp up needy behavior with more desperate attempts at contact  Repugnance  Dislike  AVERSION

8.  Empathy  Set limits early without feeling inhuman, without patient feeling deceived or disappointed  Difficult to refer to psychiatrist  Interpret as abandonment/rejection  Reassure you will still see them

9.  Overtly hostile, superior  Intimidation, devaluation, induce guilt  Control by threatening punishments ◦ Withholding payment, demands for more tests/consults, or litigation  Lack of control  Compensation for MD power/knowledge  Ultimately fear abandonment  Entitlement = faith and hope in well-adjusted

10.  Fear  Depression  Wish to counterattack

11.  Do NOT debate or belittle  Acknowledge entitlement to have realistic good care  Very respectfully and non-confrontationally to explain how behavior may compromise health  Cooperative decision-making process  Rechannel energy into following the regimen

12.  Smugly satisfied with failure  Do not want cure, want unending relationship with MD  No regimen will help  Pessimism increases with MD’s efforts and enthusiasm  Manipulation  Want MD close but keep them at significant distance - fear  Relationship will not end if they have symptoms  Deny assistance/advice while spiraling into poor health

13.  Anxiety treatable illness being missed, then irritation, then depression and self-doubt  Guilty  Inadequate  Demoralized  Depression  Unproductive, time-consuming, exhausting

14.  Don’t accuse of manipulation = doctor shopping  Share pessimism – say treatment may not be curative  Consistent, firm limitations – unrealistic expectations or demands  Regular follow-up  Patient’s fear of abandonment put to rest

15.  Simple explanations  Hard to refer to psychiatrist  Make sure they have follow-up with MD  Empathy  Patient education  Encouragement and support

16.  Unconscious self-murderous/injurious behaviors  Spiral of self-destruction while requesting assistance  Glory own destruction  Pleasure in defeating MD attempts to preserve life  Profoundly dependent  Self-hate, project hate through the MD

17.  MD caught between ideal of saving patient and unwanted wish for patient to die  Malice  Objectivity challenged by hatred, or indifference (protects MD emotionally)

18.  MD limited because patient will only allow so much care  All reasonable care for patient  Compassion – terminal illness  Do not abandon  Recognize without shame the feelings the patient provoke in MD  Cannot give perfect care

19.  Physician develops positive or negative feelings toward patient based upon personal experiences in her life  Use it to gain knowledge about where patient is coming from

20.  Patient feels threatened = behavioral regression  Projects these feelings onto MD  Patient feels relieved when these feelings are reflected by MD  Example: Patient feels helpless = complains incessantly = MD feels helpless  If MD recognizes can react supportively

21.  Patient autonomy  Patients more educated  Boundaries are being crossed by email and info about physicians on internet  Defensive medicine

22.  Productivity pressures  Changes in health care financing  Fragmentation of visits  Interrupted visits  Outside information sources challenge the physicians authority  Less trust in their physicians  Feel rushed or ignored may repeat themselves or prolong visit  18% of encounters classified as “difficult”

23.  Greater perceived workload/overwork  Lower job satisfaction  Lack of training in communication/poor communication skills  Inexperience  Discomfort with uncertainty  Poor attitude

24.  Professional identity ◦ I am unable to make better *** ◦ Conflicts with my professional standards  Personal qualities ◦ Feel taken advantage of ◦ Difficulty making relationship with patient  Time management ◦ Takes too much time  Comfort with patient autonomy ◦ Patient sets the agenda  Confidence in skills ◦ Too hard to solve  Trust in patient ◦ Lose trust in patient

25.  Increased dissatisfaction with services  Become more demanding  Repeated visits without medical benefit  Seemingly endless complaints  Unmet expectations  Insatiable dependency  Report worsening symptoms

26.  Do not seem to want to get well  Power struggles  Focus on issues seemingly unrelated to medical care  Worried every symptom represents a serious illness  Reported greater symptom severity  Chronic pain (+/- narcotics)

27.  Psychiatric ◦ Axis II ◦ Depression ◦ Somatization (alcohol, borderline) ◦ Mood d/o (insist on physical cause) ◦ Anxiety (multi complaints, think cardiac, not enough being done)  Lower social class  Female  Thick clinical records  Older  More medical problems  Greater use of health care services  Poor functional status

28.  Cluster A (odd or eccentric, fears social relations) ◦ Paranoid ◦ Schizoid ◦ Schizotypal  Cluster B (dramatic, emotional erratic disorders) ◦ Antisocial ◦ Borderline ◦ Histrionic ◦ Narcissistic  Cluster C (anxious or fearful disorder) ◦ Avoidant ◦ Dependent ◦ Obsessive-compulsive  Appendix B ◦ Depressive ◦ Passive-aggressive (negativistic)

29. DissatisfactionDifficult patients Not- difficult Physician's technical competence9%1%P<.001 Bedside manner7%0.7%P<.001 Time spent with clinician13%3%P=.002 Explanation of what was done12%3%P<.001 Higher number of visits42P=.004 Jackson, JL, Kroenke K. Difficult Patient Encounters in the Ambulatory Clinic: Clinical Predictors and Outcomes Arch Intern Med. 1999;159(10):1069-1075.

30.  Helpless  Inadequacy  Frustration  Anger  Guilt  Dislike

31.  Leads to: ◦ Unconscious punishment of the patient ◦ Self-punishment by the doctor ◦ Inappropriate confrontation ◦ Desperate attempt to avoid patient ◦ Errors in diagnosis or treatment ◦ Decreased quality of care ◦ Work burdensome ◦ Burnout

32.  Disproportionate emotional energy can be spent dealing with negative feelings  Strong negative emotional reaction is important clinical data about patient’s psychology (personality d/o)  Sensitivity to MD feelings ◦ Improved physician well being ◦ Less destructive patient behavior ◦ Lower risk of litigation

33.  Collaboration  Appropriate use of MD power  Empathy

34.  Priority setting ◦ Prioritize patient concerns  Diagnostic skills ◦ Thorough history, physical, and testing  Decision making ◦ Explain ◦ Be consistent and objective ◦ Be honest and fair ◦ Facilitate patient decision making  Team approach ◦ Use referrals (mental health, pain, etc.) ◦ Enlist/see family ◦ Provide quality care  Coaching ◦ Set small, achievable goals ◦ Short term symptom relief

35.  Encourage patient to start taking responsibility  Think of their care as a team effort  Adjust expectations of what can be accomplished  Patient education  Collaboration has most impact on clinical interaction

36.  Set clinical management rules ◦ Schedule patient frequently, longer visits ◦ Clinic time management ◦ Good documentation  Set boundaries and limits ◦ Set general limits ◦ Make explicit rules when necessary ◦ Limit number of patient concerns ◦ Limit time at each visit

37.  Understand patients psyche  Focus on patient emotions  Compassionate and firm  Patient centered  Reinforce positives  Keep professional distance

38.  Protects MD from developing negative responses to difficult and challenging behavior  Allows insight into patient issues and why patient has resorted to negative response patterns ◦ Illness can alter patients – uncharacteristic, childlike  Creates an environment conducive to more suitable health care delivery, a healthier lifestyle, better work satisfaction

39.  Point person - may get conflicting info from consultants  Tactful assessment of patient’s distress/emotion  LISTEN  Interrupt less  Regular, brief summaries of patient’s concerns  Reconcile conflicting views of diagnosis/illness

40.  Acknowledge problem  Both parties may contribute to difficulty  Use communication skills  You can discuss that have poor relationship:  “How do you feel about the care you are receiving from me?”  “It seems to me we sometimes don’t work together very well.”  Use “I” statements ◦ “I feel it’s difficult for me to listen to you when you use that kind of language.”

41.  1. ***Does my patient prioritize health?*** ◦ Not if patient works with MD to prevent and treat disease. ◦ Unpleasantness alone is not grounds.  2. Is confrontation of my patient ethically permissible? ◦ If patients self-corrosive decisions come with expectations of accommodation. ◦ If MD bearing majority of burden in failing treatment. ◦ If health deteriorating from patient action or inaction.  3. What if confronting my patient is emotionally gratifying? ◦ Recognize countertransference v. projective identification. ◦ Assess motives and emotions in real time and discuss with a peer.

42.  Butler CC, Evans M. The “heartsink” patient revisited. Br J Gen Pract. 1999;49:230- 233. Butler CC, Evans M. The “heartsink” patient revisited. Br J Gen Pract. 1999;49:230- 233.  Elder N, Ricer R, Tobias B. How respected family physicians manage difficult. J Am Board Fam Med 2006;19:533– 541. Elder N, Ricer R, Tobias B. How respected family physicians manage difficult. J Am Board Fam Med 2006;19:533– 541.  Feldman MD, Berkowitz SA. Role of behavioral medicine in primary care. Curr Opin Psychiatry. 2012;25:121-127. Feldman MD, Berkowitz SA. Role of behavioral medicine in primary care. Curr Opin Psychiatry. 2012;25:121-127  Kontos N, et al. Fighting the good fight: Responsibility and rationale in the confrontation of patients. Mayo Clin Proc. 2012;87(1):63-66. Kontos N, et al. Fighting the good fight: Responsibility and rationale in the confrontation of patients. Mayo Clin Proc. 2012;87(1):63-66.  Fried TR, Bradley EH, O’Leary J. Prognosis communication in serious illness: Perceptions of older patients, caregivers, and clinicians. J Am Geriatr Soc. 2003;51:1398-1403. Fried TR, Bradley EH, O’Leary J. Prognosis communication in serious illness: Perceptions of older patients, caregivers, and clinicians. J Am Geriatr Soc. 2003;51:1398-1403.  Groves JE. Taking care of the hateful patient. N Eng J Med 1978;298:883-887. Groves JE. Taking care of the hateful patient. N Eng J Med 1978;298:883-887.  Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. American Family Physician. 2005;72(10) Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. American Family Physician. 2005;72(10)  Jackson, JL, Kroenke K. Difficult Patient Encounters in the Ambulatory Clinic: Clinical Predictors and Outcomes Arch Intern Med. 1999;159(10):1069-1075. Jackson, JL, Kroenke K. Difficult Patient Encounters in the Ambulatory Clinic: Clinical Predictors and Outcomes Arch Intern Med. 1999;159(10):1069-1075  Mathers N, Jones N, Hannay D. Heartsink patients: A study of their general practitioners. Br J Gen Pract. 1995;45:293-296. Mathers N, Jones N, Hannay D. Heartsink patients: A study of their general practitioners. Br J Gen Pract. 1995;45:293-296  O’Dowd TC. Five years of heartsink patients in general practice. BMJ 1988;297:528-530. O’Dowd TC. Five years of heartsink patients in general practice. BMJ 1988;297:528-530.  Strous RD, Ulman AM, Kotler M. The hateful patient revisited: Relevance for 21st century medicine. European Journal of Internal Medicine. 2006 (17)6;387-393. Strous RD, Ulman AM, Kotler M. The hateful patient revisited: Relevance for 21st century medicine. European Journal of Internal Medicine. 2006 (17)6;387-393.