How to deal with Difficult Patient

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How to deal with Difficult Patient

• Non Sowanna. Family Medicine of CFOM Department
  Naresuan Hospital

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Definition

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• The prevalence is estimate to be 15 percent of
  patients
• The presence of depressive or anxiety disorder,
  somatic symptoms and greater symptom severity

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Four Principles of Family Medicine in Canada,CFPC

• Doctor-Patient Relationship
• 2. Skillful Clinician
• 3. Community-Based Practice
• 4. Resource Person to a Defined Population

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• An expert to explore
  the complex interaction of
  physical, psychological and social problem

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Nobody goes to a doctor with just a symptom.
They go with ideas about the symptom, with
concerns about the symptom and with expectations
relate to the symptom
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Angry, defensive, frightened or resistant patient
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Nobody likes a confrontation with an anger person
Do we have the right to return the anger?
Do the choice dealing with anger patient
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Sign of anger

• Clenched fists
• Furrowed brows
• Wringing from hands
• Restricted breathing patterns
• Warning from office staff

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Type of responses

• Factual responses
• The aggressive/hostile response
• The judgmental response
• The reassuring response( the pacifier )
• The empathic response
• Silence

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Management

• Try to uncover the source of anger
• Emotions related to the medical issues
• Reflective response

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Reflection

• The act of listening
• Show you have heard and have interpreted what the
  patient said

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Fearful about a diagnosis or Treatment

• Assess the patients fear
• Talk about context

If you sense a potential for harm to you or your
staff
Ask for assistance
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Manipulative patients

• Play on the guilt of others
• Threatening rage
• Legal action
• Suicide

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Management

• Aware of your own emotions
• Attempt to understand the patients expectations
• Realistic and reasonable
• Say no

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Somatizing patients

• The patients present with a chronic course of
  multiple vague or exaggerated symptoms
• Suffer from comorbid anxiety, depression and
  personality disorder
• Doctor shopped

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Warning signs of Illness

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Warning signs of Illness

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• The patient is as frightened as you are.
• The patient think it is more serious than you do.
• Illness is frightening, but understanding what is
  going on help. This applies both to the patient
  and to you.
• Taking a history is a method of controlling what
  the patient says

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Management

• Describing diagnosis with compassion and
  emphasizing
• Regularly scheduled visits
• Reframe idea that its all in you hand
• Avoid the vicious cycle

Diagnosis testing and refer
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Grieving patient

• Normal stage of grief
• Look for sign of depression and maladaptive
  behaviors
• Vary degree of time for different people

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Management

• Encourage open communication
• Avoid inappropriate medication
• Caution against major lifestyle change

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Frequent visit patients

• Patient with rational questions
• Misinformed patients
• Patients who are ashamed or embarrassed
• Patients with mental disorder
• Drug seekers
• Lonely, dependent patients
• The worried well
• Patients who dont want to get well

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Management

• Clear picture of the patients situation
• People assimilate information at different rates
  and that some may not
• Etiology-base approach
• Regular schedule
• Empathic response
• Acceptance and validation of the patients
  feelings
• Ask patients idea if you are unsure about
  diagnosis
• Take and document a careful history

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Frequency visit patients require more than black
and white science or professional advice
The first step in treating them should be trying
to identify the underlying reasons for their
frequent visits
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Personal Iceberg Metaphor
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Behavior Coping (stances)
Feelings Feelings about feelings
Perceptions Expectations
Yearnings Self I am, life energy
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Components of difficult
Patient Characteristics
Physician Characteristics
Situational issues
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Physician factor

• Anger or defensive physicians
• Fatigued or harried patients
• Dogmatic or arrogant patients

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Situational factor

• Language and literacy issues
• Multiple people in the exam room
• Breaking bad news
• Environmental issues

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How to Break Bad News
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A Six-Step Protocol

• Step 1. Getting the physical context right
• Step 2. Finding out how much the patient knows
• Step 3. Finding out how much the patient wants to
  know

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A Six-Step Protocol

• Step 4. Sharing the information
• Step 5. Responding to the patients feeling
• Step 6. Planning and follow through

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Step 1. Getting start

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• Where?
• Who should be there?
• Starting off

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Step 2. Finding out how much the patient knows

• Patients Idea
• How serious he/she thinks it is
• How much it will affect the future
• Gap between patients comprehension and medical
  reality
• Style of patients statement
• Emotional content

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Step 3. Finding out how much the patient wants to
know
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Step 4. Sharing the information

• Start from the patients starting point
• Give information in small chunks
• Avoid medspeak
• Check reception frequently
• Repeat important points
• Listen to the patients concern
• Listen for the buried question

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Step 5. Response to Patients Reaction

• Humor
• Denial
• Anger
• Crying
• Fear
• Guilt
• Bargaining

• Shock
• Anxiety
• Hope
• Fulfilling an ambition

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Step 6. Planning and Follow Through

• Demonstrate an understanding of patients problem
• Distinguish fixable from non-fixable
• Make a plan and explain it
• Identify other source of support
• Making a contract

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Communication with care

• Basic communication skills
• Active listening
• Respond

Do you have any questions about what we discuss
today?
Attending to your own physical and mental
process as you see patients
Aware of your own emotional baggage in the room
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No physician can avoid the difficult clinical
encounter but having the tools to deal with
these situations when they arise can make for
batter experience for both you and your patient
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• Are there any questions youd like to ask me now?