1 Dealing with Difficult Consultations Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box – Riyadh Tel: – Fax:

2 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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5 Difficult patient is the one with whom the physician has trouble forming an effective working relationship. Definition

6 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

7 Seductive patients. Angry patients. Patients who are shopping from one doctor to another for the same problem. Cont……

Difficult Consultations:  Patient with Hidden Agenda (Patient Reluctant to Talk Freely)  Talkative Patient  Angry Patient  Demanding Patient 8

Patient Reluctant to Talk Freely Causes : Patient Factors : Dr. Factors : Circumstances : Examples : The topic Cultural barrier Social class barrier Dr. authority Time constrains Presence of 3rd party 9

Patient Reluctant to Talk Freely Verbal Communication Giving reason for the question. Comments on the patient attitude Generalization of the problem Asking at the right time Reflection Mirroring Confrontation Non - verbal Com. Showing sympathy & empathy Showing real interest Unhurried manner Touch for reassurance Use of physical examination 10

Talkative Patient communication skills Verbal Communication Summarization Prioritization Behaviors which brake the Interruption Close ended question Non - verbal Comm. Use of touch Sympathy & empathy relationship : 11

Angry Patient Angry Patient Communication Skills Empathy Legitimation Non-judgmental attitude Respect patient autonomy Support Flexibility 12

Even Angry Customers Are Always Right Marsha 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 13

Dealing with Demanding Patient 14

Negotiation Skills (think win-win) Set limit Reinforcement Compromise Be flexible 15

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 16

Difficult patients evokes a feeling of anxiety, pressure, boredom, or frustration Cues for the physician 17

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 18

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. 19

1- Respect for patient autonomy (can be reduced but never absent; people must be allowed to control their health) 2- Informed consent 3- Truth-telling 4- Respect for confidentiality Respect for persons 20

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 21

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……… 22

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……. 23

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Suggestions for Better Practice Management 25

SuggestionActivity Promote continuity of care Educate patients that the involvement of multiple health care professionals may result in conflicting or confusing approaches; help the patient maintain a primary care provider. Schedule appropriately Length of visits should fit patients’ perceived needs and expectations. Modify scheduling systems to allow more time for certain patients at the request of the physician. 26

SuggestionActivity Access community resources Develop on-site or community- based links to mental health and social work professionals Ensure adequate follow-up Schedule regular follow-up visits at two- to three-week intervals, especially if high dependency needs are suspected. Educate the patient in appropriate use of telephone or e- mail contact as an alternative to more frequent visits. 27

SuggestionActivity Set firm limitsDiscuss and enforce your policies regarding abuse of staff, insistence on immediate telephone access, or obstruction of the process of care. Terminating the relationship with the patient is a last resort and should be done with care. 28

Thanks 29