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Managing challenging patient interactions

How can you get the best clinical outcome from even the most challenging of consultations? Dr Mohamed Bhikhoo, Family Physician, Honorary Lecturer at the Department of Family Medicine (University of the Witwatersrand) and member of the MPS Education Faculty, explains how.

From time-to-time, we all have challenging interactions with patients. This can happen to any doctor, irrespective of their field of practice or level of experience. Patients involved in challenging interactions are often referred to as “difficult”. When analysed carefully, it is actually the interaction or consultation that has become “difficult” or challenging. These experiences can give rise to a whole range of emotional distress for both parties, which can impact significantly on doctor and patient satisfaction.

Doctors have been calling and searching for ways to deal with these distresses. This article examines a range of insights and skills that may assist you to bring about a more favourable outcome for you and your patients.

As doctors, we need to stop and think why the patient may be behaving like this, and consider what the patient has asked or demanded of us that led to us emotively labelling them as challenging. Four broad factors have been identified which can influence challenging interactions.1

Patient factors include:

  • Unrealistic expectations
  • Personality traits
  • Cultural and language differences
  • Misunderstood feelings or dissatisfaction with treatment
  • Inflexibility, seeing no alternatives to their needs.

Clinical factors include:

  • Multiple complaints
  • Chronic pain
  • Substance or drug dependency
  • Mental illnesses, especially personality disorders.

System/environmental factors:

  • Time pressures
  • Limited resources
  • Third party pressures.

Clinician factors:

  • Personality traits
  • Degree of training and skills
  • High patient volumes
  • Burnout
  • Long working hours
  • Focusing on the disease and not on the patient.

Whereas patient, clinical, and system factors are easy to understand, it is a bitter pill to swallow when realising that some of the blame has to be pointed at ourselves. In addition, when system factors are at play, doctors tend to be less empathic towards their patients as they feel that they are unfairly to blame for issues that are outside their control.

The greater the overlap of different factors the greater the difficulty in resolving such challenges. No matter how challenging a patient, it is important to avoid labelling them as such, whether mentally or in writing in the patient’s records. Coded language in a patient’s notes can lead to stereotyping and preconceived ideas regarding their healthcare needs. For example, reading “complaining of backache and wanting sick certificate” = malingering patient; “vomiting again” = alcohol abuse. 

This survival strategy is simply behaviour learnt from seeing similar cases previously, which runs the risk of labelling patients inappropriately and can set up negative behaviour in your approach to the patient, resulting in your patient feeling dissatisfied and neglected. So begins a vicious circle. Furthermore, it can place you at risk of missing serious pathology. For example, the patient with the backache and wanting a sick certificate may in fact have a compressed fracture of the vertebrae. 

Strategies for dealing with challenging interactions 

Firstly, it is important to recognise and diagnose that you are in a difficult interaction. Establish what the difficulty is and where it lies. It is also important to establish the patient’s view, as they may feel that there is no difficulty. Once this is achieved, develop a plan of action to bring about a favourable outcome. The key to dealing with a challenging interaction is good communication. Develop a good rapport with your patient and success will follow.

Often, acknowledging the ‘difficulty’ to the patient is very helpful. “Demanding”, “rigid” and “manipulative” patients, when confronted, will realise their game is up and they need to change their behaviour. Setting boundaries and keeping to them is imperative. When these boundaries are violated it translates into a lack of respect for you, which can result in a strong emotional response. Often, when these boundaries are violated we can feel trapped and the danger is that it can lead to unethical and even illegal behaviour. Examples include prescribing unwarranted narcotic analgesic or writing an inappropriate sick certificate. 

Crossing boundaries happens. Patients may be inappropriately seductive with you and make you feel uncomfortable. In these situations, emphasise that this is a professional relationship and request a chaperone be present in the consultation. If necessary, you may want to terminate the relationship and offer the patient to be seen by another doctor. So it is imperative to set and operate within these boundaries. It is beneficial to explain to the patient that you are operating within these boundaries in their best interest. This often disarms the patient and results in behaviour change.

Establishing the patient’s expectations and keeping the consultation focused to meet those expectations can help to limit the difficulty, as will establishing your own goals of medical care for the consultation. At times, patients can become angry and aggressive. Sometimes, they may resort to violence. Your safety is paramount. Do not get into an argument. Do not try to prove that you are right. Do not exert your authority. Call for help, if it is available. If necessary, slowly move to the door and leave the room, rather than asking the patient to leave. 

Non-compliance is an extremely frustrating issue to deal with. Try and educate the patient about their condition, the need for them to take their treatment responsibly, and the dangers of non-compliance, and make detailed notes. Beyond that the situation is out of your control and it is easier to accept that reality rather than forcing the patient to take the treatment. As with all consultations, it is always good practice to have detailed notes. In the face of a challenging interaction be particularly meticulous with your note keeping, as this is your ultimate line of defence in the event of a complaint or litigation being brought against you. 

With special thanks to Dr Lynelle Govender for additional research.

References

  1. Texas Medical Association, Management of Challenging Patient Encounters (for Medical Students), 2002 www.texmed.org

MPS communication skills workshops

If you would like to learn more about the challenges facing GPs working in healthcare today, MPS offers a Mastering Difficult Interactions with Patients workshop. This workshop looks at why difficult interactions exist and provides techniques to handle them effectively and manage your own internal response.

To register for Mastering Difficult Interactions with Patients and other workshops in this series, please visit: www.medicalprotection.org/southafrica/education

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