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Challenging interactions with patients

09 August 2019

Sometimes interactions with patients can be challenging. Learn more about the techniques you can use to manage these

Many doctors face a challenging consultation with a patient on a weekly basis.

Unrealistic expectations and alcohol/drug misuse by patients can be common causes of this, with many doctors reporting experiencing verbal abuse, aggressive demands for treatment or drugs and violent or aggressive behaviour.

These challenging encounters can cause stress and anxiety, and even an increase in workload from dealing with the repercussions; there may also be delays in appointments to deal with.

Dealing with challenging patients will impact on a doctor's stress level and morale, which in turn can negatively affect patient care. Several factors contribute to making a patient interaction challenging, so understanding the reasons behind these interactions can reduce their frequency.

The different factors generally fall into four different domains; System, Disease, Clinician and Patient.

We may be able to take difficulties arising in one or even two of these domains within our stride. But the more domains that come into play, the more difficult it is to manage the interaction effectively – partly because we may have fewer positive factors we can draw on to provide a counterbalance.

One of the first key steps in dealing with difficult interactions is realising that “difficult” is a statement about our discomfort rather than the patient.

If you ask several different healthcare professionals from the same setting who their “difficult patients” are, while there will be some overlap, there will also be considerable differences both in terms of individual patients, but also the conditions they present with.

It is therefore more helpful to talk about difficult or challenging interactions rather than difficult patients. This is because it helps us consider a broader range of factors that contribute to the difficulty: in particular what we can do to help reduce the perception of that difficulty.

When a difficult interaction does arise we firstly need to internally recognise and acknowledge that difficulty and then make a diagnosis of it.

Our automatic thought processes tend to lead to reflex judgments, such as “the patient is a nuisance”; however, these do not help us or the patient. The real diagnosis may be more like: “we have different understandings about how to manage this situation” or “my patient’s anxiety about her diagnosis is probably contributing to her impatience”.

Defining the problem, naming it and externalising it from the patient and the doctor can help enormously in enabling us to ‘manage it’ effectively.

Medical Protection has developed the A.I.D.© model, which is a reminder of the important steps required to help find an effective solution – to move the interaction beyond debating points of difference to a mutually agreeable outcome.

The elements of the model are:

-  Acknowledge the patient’s position
-  Inform them of your position
-  Discuss a way forward.

Acknowledging the patient’s position requires skills such as empathy, actively listening and understanding the patient, and reframing: choosing to consider alternative explanations for the person’s behaviour.

It is critical that the patient feels that the clinician fully appreciates their position. This must be done well, even if the clinician does not agree with the patient or feels uncomfortable. 

When informing the patient of your position you should acknowledge the difficulty in the interaction, and explain the relevant personal and professional boundaries. When placing boundaries, it is most important to ensure that the motivation for imposing the boundary by the clinician is in the patient’s best interest.

The final step is discussing a way forward. You should encourage the patient to suggest possible solutions before supplementing them with your own. Discuss the pros and cons of all the options and agree a solution that is acceptable to both the patient and the clinician. The patient should then be empowered to go forward with that solution.

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