Dealing w ith Difficult Consultations

1. Dealing with Difficult Consultations Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

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.

3. Not all difficult encounters can be blamed on the patient side of the interaction

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

6. Types of Difficult Patients • Somatic fixation • (patients who express personal distress in the form of somatic symptoms) • Dependent Patient • (Dependent on prescription drugs). • Demanding Patient • (frequent visit for minor things; requesting medications, tests, &referrals ) . • Manipulative help rejecter) • (Donotfollowdoctorinstructions) • Self destructive patients • (Diabetic patients who induce frequent attacks of keto-acidosis)

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

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

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

10. 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 Patient Reluctant to Talk Freely

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

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

13. Even Angry Customers Are Always RightMarsha L. Miley and Thomas J. Weida, MD 7 steps for satisfying angry patients: • Handle problems privately • Listen to patients' complaints • Disarm anger with kindness • Delegate up when necessary • Follow through on promises • Involve the patient in prevention • Be grateful

14. Dealing with Demanding Patient

15. Negotiation Skills (think win-win) Set limit ReinforcementCompromise Be flexible

16. 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

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

18. 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

19. 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 .

20. Respect for persons 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

21. Prevention • 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.

22. Prevention……… • 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.

23. Prevention……. • Try to protect patient from harm in medical field(e.g.: unnecessary tests, medications or surgeries) • 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

25. Suggestions for Better Practice Management

29. Thanks