Supported in part by Arkansas Blue Cross and Blue Shield

1. Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID:29513-24581

2. Navigating the Difficult Encounter Masil George, MD Associate Professor, UAMS Department of Geriatrics Associate Professor, UAMS Division of Medical Humanities Director, Geriatric Palliative Care Program, UAMS Medical Director, Baptist Hospice 1/23/19

3. OBJECTIVES • To identify a difficult patient- clinician encounter • To list patient and clinician characteristics that may lead to a difficult relationship • To describe specific strategies to manage difficult encounters

4. What is a difficult patient- clinician relationship? • Clinical encounter in which patient evokes feelings of dread, frustration or even anger in a clinician • Arises when physicians encounter patients with complex, often chronic medical issues (such as chronic pain, and/or mental illness) that are influenced or exacerbated by social factors (such as poverty, abusive relationships, addiction) • Occurs in approximately 15% of adult patient encounters (Krebs et al., 2006)

5. Why is this a problem? • The therapies the doctor recommends often entail behavioral changes that the patient is unwilling or unable to make, yet the patient continues to seek the clinician’s advice and treatment • The clinician may become frustrated or angry because their advice is not heeded, because the diagnosis or treatment is unclear or ineffective, or because the patient is rude, seemingly ungrateful, or transgresses boundaries in the clinician-patient relationship (e.g. comes to the clinic when she does not have an appointment) • The physician could become guarded or distant • The patient develops distrust

7. Mr. DM • Mr. DM is a 57 y/o M with CAD s/p CABG, Type I DM (A1C 13), CKD IV, Diabetic neuropathy, Morbid obesity, OSA (non-compliant with CPAP) • Disabled at age 44, living alone on limited income, likes junk food • On Oxycontin 80 mg bid and oxycodone 30 mg every 6 hours/ PRN, lyrica 100 mg bid, Cymbalta 60 mg daily • Frequent ER visits, hospitalizations, on-again/ off again relationship with girlfriend(s)

8. Helpless • Helplessness is a state in which nothing a person opts to do affects what is happening. It is the quitting or the give up response that follows the conviction that whatever a person does doesn’t matter. • Learned helplessness (LH) was initially used to label the failure of certain laboratory animals to escape or avoid shock, despite giving an opportunity, subsequent to earlier exposure to unavoidable shock. • People suffering from LH accept that bad things will take place and they will have little control over them. • Those who are exposed to complex problems for an extended period learn that responses and events are unconnected. Learning attained in this situation weakens imminent learning and leads to inactivity. Consequently, they will be unsuccessful to resolve any concern even if there is a possible solution for the concern. NuvvulaS. Learned helplessness. ContempClin Dent. 2016;7(4):426-427

9. Resistant to Recommendations • Elicit change patient is willing to make • Establish timeline to accomplish changes • Provide written recommendations and follow up at subsequent visit • “I” statements • Express concern about not making progress • Explore the benefit of ongoing patient- provider relationship • Offer to refer to different provider

10. Ms. Davis • Ms. Davis is a 58 y/o WF with HTN, Hypothyroidism, OA & Depression (managed by psychiatrist) • She is pleasant and cheerful, single, estranged from son • She has several stressors- her neighbor, her boss, her sister, her childhood trauma • Discussed her childhood trauma in detail at every visit, used violent language for communication, while keeping a positive demeanor/ affect

11. Difficult to Communicate with • Violent and graphic descriptions of abuse • Exaggeration • Profanity • Descriptions of previous physician encounters • Prepare for my visit, monitor my response, stay objective and helpful, praise when possible, include support staff at end of visit

12. Ms. JR • Ms. JR is a 67 y/o WF with multiple medical problems • Highly educated, “disarmingly charming” • “Text book addict” • Interesting PRMP data • Fired by many clinicians and pain management specialists • Makes small and reasonable requests every time • I gave in once, and regret it!

13. Addiction • Be matter-of-fact with defining unacceptable behavior • Helpful to have a prescriber- patient agreement • Stop prescribing immediately if dangerous behavior (e.g., binging) • Reach out to support system • Provide resources • Follow up

14. Communication Strategies • “What I hear from you is that . . . Did I get that right?” • “How do you feel about the care you are receiving from me? It seems to me that we sometimes don’t work together very well.” • “It’s difficult for me to listen to you when you use that kind of language.” • “You seem quite upset. Could you help me understand what you are going through right now?” • “What’s your understanding of what I am recommending, and how does this fit with your ideas about how to solve your problems?” • “I wish I (or a medical miracle) could solve this problem for you, but the power to make the important changes is really yours.”(Hass et al., 2005, p. 2066)

15. Practice Points 1) Be compassionate and empathic. Keep in mind that most patients whom you find frustrating to deal with have experienced significant adversity in their lives. 2) Acknowledge and address underlying mental health issues early in the relationship. 3) Prioritize the patient’s immediate concerns and elicit the patient’s expectations of the visit and their relationship with you. 4) Set clear expectations, ground rules, and boundaries and stick to them. Have regular visits, which helps convey confidence that the patient can deal with transient flare-ups without an emergency visit. 5) Be aware that strong negative emotions directed at you are often misplaced. The patient may be imposing feelings and attitudes onto you that they have had toward other doctors, friends, family members in the past. This is known as transference. Acknowledge the patient’s feelings and set behavioral expectations.

16. Practice Points 6) Be aware of your own emotional reactions and attempt to remove yourself so you can objectively reflect on the situation. Involve colleagues. Vent your feelings or debrief confidentially with a trusted colleague so that your negative emotions are kept at bay during patient encounters. 7) Recognize your own biases. For example, patients with addictions genuinely need medical care, but the behaviors associated with addiction are vexing for health care providers. These patients are often both vulnerable and manipulative. Be sure that you are attentive to their vulnerability, rather than focusing exclusively on their manipulative behaviors. 8) Avoid being very directive with these patients. A tentative style tends to work better. Remember that you provide something many of these patients do not have-a steady relationship with someone who genuinely wants to help them. This in itself can improve the patient’s health, even in the absence of medical treatment. 9) Prepare for these visits. Keep in mind your goals of care and make a strategy for the encounter before it occurs.

17. Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076 Event ID: 29513-24581