Challenging Patients or Challenging Times?

Written by on May 1, 2014 in Practice tips - No comments

Exploring the Changing Nature of Doctor/Patient Encounters

There are certain types of patients few physicians look forward to seeing, most commonly:

  • Patients who demand a laundry list of tests they’ve read about on the Internet
  • Uncooperative patients who won’t follow treatment plans and complain about the outcome
  • Patients who seem aggressive, angry or hostile
  • Patients whose issues are complicated by aging or lifestyle
  • Patients who appear to be drug seeking or exploiting the healthcare system

Studies over the past two decades have consistently shown that clinicians experience up to 15% of patient encounters as “difficult.”1,2 In a 2011 study of 750 walk-in patients at a primary care clinic, 17.8% were perceived as difficult, but the level of physician experience played a key role in how encounters were perceived:

  • Physicians with more than 20 years of experience reported just 2% of their encounters as difficult.
  • Clinicians with less than 10 years of practice described 23% of their encounters with patients as difficult.3

Younger physicians may not have the insight that:

  • A patient who seems challenging or suspicious may actually be frightened.
  • A patient who repeatedly misses appointments for tests may be avoiding facing reality.
  • A patient’s attitudes may have nothing to do with the physician at all.
  • Their own communication skills aren’t as good as they think they are.

Experienced doctors have an advantage, up to a point.  They’ve encountered difficult patients in the past and have developed methods for coping.  The problem is when workloads increase or other stresses come into play, physicians may not employ those skills as successfully–and as a result patients may seem more difficult than they have in the past.

Patient issues are clearly a stressor for many physicians.  In the physician surveys that Physician Wellness Services has done over the past couple of years on stress and burnout, culture and physician engagement, difficult patients—and difficulty with patients—comes up repeatedly.  Yet, most physicians highlight the fulfillment they experience from their patient encounters, validating why they went into medicine in the first place.

However, patients who are demanding, ungrateful, drug seeking or non-compliant, or exhibit other negative behaviors, undermine the satisfaction physicians get from their work. Complicating this, there is no clear roadmap on how to deal with these issues and, given their nature, there is often little the organization can do to help, other than empathize.

IS IT THE PATIENT—OR THE PRACTICE?

In many cases it is not the patient who is difficult, it’s the practice environment that’s difficult.  When physicians are given only a few minutes to determine what is wrong with a patient, they might start feeling more like they are working in a factory than practicing medicine.

Doctors who are satisfied with their working conditions tend to be more satisfied with their patient interactions.  Negativity about working conditions often translates into negativity about the patients themselves.  Mathers et al found that 60% of the variance in the number of difficult patients that general practitioners reported could be accounted for by four variables:

  • Greater perceived workload
  • Lower job satisfaction
  • Lack of training in counseling and/or communication skills
  • Lack of appropriate postgraduate qualifications

Lawsuits can also play a role in negative doctor/patient relationships.  A physician who fears making a mistake may be nervous when dealing with a similar patient or diagnosis.  If patients pick up on that hesitancy, they may begin questioning the doctor’s experience or competency. It can very easily become a vicious circle.

TIPS FOR IMPROVING PHYSICIAN/PATIENT ENCOUNTERS

Here are a few methods physicians should considering using with all patients regardless of their perceived difficulty ratings:

Listen actively:  Take time to listen to what the patient has to say.  (It may seem counterintuitive that taking a little extra time on the front end may end up being a time saver in the long run.)  Rephrase whatever the patient tells you to convey that you heard and understood what was said.

Confirm understanding:  Ask the patient to repeat what you said.  You may be amazed at how much of what you say is unheard or misinterpreted.  Invite your patients to call if they have more questions or concerns about what’s being recommended.

Test impressions:  Is this patient difficult with everyone or just you?  Can a colleague or referring physician give you any insights that may help?

Encourage note taking:  Invite your patient to take notes if they seem to be highly emotional or having trouble grasping what is being discussed.

Welcome support:  Overly anxious patients may appreciate having a family member invited into the exam room.

Resist resentment:  You may resent having your authority questioned or a patient judging your knowledge or credibility, but you can choose not to let it get under your skin.  Those irritating questions may be related to a patient’s fear and desire to maintain control over something that is feeling uncontrollable.  Avoid arguments at all costs.

Detach emotionally:  You can’t solve every problem or cure every disease—and the fact that patients seem to expect that from you doesn’t make it reasonable.

Document thoroughly:  Documentation is always important, but particularly so after a challenging encounte

WHEN CHALLENGING PATIENTS START CHALLENGING YOU

A generalized and growing dislike of patients should be a red flag.  The satisfaction of helping people is what attracted many physicians to medicine, so if all the joy has gone out of your practice, that’s not good for you or your patients.

Additional red flags may include:

  • Poor patient satisfaction surveys
  • Finding yourself disliking your work
  • Being irritated with patients
  • Increased non-compliance from patients
  • Having difficulty setting boundaries or limits on your own time or unreasonable requests
  • Feeling like you’re working harder to help patients than they themselves are working
  • Being overly afraid of making a mistake

Before you find yourself taking early retirement or embarking on a second career, consider taking steps to improve the way you interact with patients.  An experienced physician peer coach can help you sort through the difficulties you’re encountering today and help you figure out what, if any, changes are needed in your workload, work attitudes or communication skills.  Speaking with trusted colleagues can also be helpful in providing feedback on your approach and suggestions on how to deal with problematic patients.

DIFFICULT ENCOUNTERS OF A DIFFERENT KIND:  CASE STUDIES

Scenario:  A patient was referred by his physician to a neurologist’s office and presented with an iPad full of research, insisting the referring doctor had recommended the wrong test, and demanding an explanation of the rationale for and the cost of the exam he was about to undergo.

While it was tempting to ignore the patient’s concerns and try to hurry him through the procedure, there were many risks involved with this course of action. There was concern that the patient might leave without having the procedure done—or have the procedure done and complain about it to the referring physician, or give the referring physician and the neurologist poor online ratings, or spread negative comments about them to friends, family and in the community.

Recommendation:  The neurologist took a few extra minutes to listen to the patient’s concerns.  During the course of this discussion a valid indication for the exam that the patient was about to have came to light.  The neurologist then reassured the patient about the appropriateness of the test and the need for that particular study to be done.  He was also able to decipher what the patient’s additional concerns were—for instance, what was involved with the procedure, when the results could be expected and what the cost of the procedure would be.  By answering a few simple questions, it placed the patient in a different, more pleasant frame of mind.

Scenario:  A gynecologist with degrees from impressive universities and many years of experience couldn’t understand why the patients referred to her at a practice she’d recently joined didn’t seem to have the same trust in her diagnoses as patients at previous practices.  The physician began to worry that she was losing her edge or had joined the wrong practice.  Her self-doubt seemed to beget patient doubt and she found herself wondering if she should even take time to finish unpacking her boxes.

Recommendation:  When exploring the differences between her old and new practice—down to variables such as location and décor—she came to realize she hadn’t taken time to hang her diplomas on the wall.  She took a recommendation to hang them above and behind her desk.  Once they were up, she noticed patients who came in to her office for consultations initially looking over her head.  Immediately after that she could see significant shifts in patients’ attitudes.  She hadn’t realized the role her framed credentials had played in building trust.

1 Steinmetz D and Tabenkin H. The ‘difficult patient’ as perceived by family physicians. Family Practice 2001; 18: 495-500.
2 Mathers N, Jones N, Hannay D. Heartsink patients: a study of their general practitioners. Br J Gen Pract. 1995; 45:293-296.
3 Sherri A. Hinchey, MD MPH and Jeffrey L. Jackson, MD MPH, A Cohort Study Assessing Difficult Patient Encounters in a Walk-In Primary Care Clinic, Predictors and Outcomes, J Gen Internal Medicine 2011; June 26 (6) 588-594

By Liz Ferron, MSW, LICSW
Vice President of Clinical Services
Physician Wellness Services

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