Transcript Difficult Patient Encounters

Difficult Patient Encounters
Ma. Victoria Pilares-Cruz, MD, DPAFP, FPAFP
Preventive Medicine III
“Difficult” Patients
Has a different sexual orientation than
the provider
 Has higher or lower socioeconomic
status than provider
 Has a mental disorder
 Has a Type A personality
 Has chronic medical problems

“Difficult” Patients
Is demanding
 Is malodorous
 Makes frequent office visits
 Presents barriers to communication
 Takes multiple medications

BATHE Technique





Background- “Tell me what has been happening”
Affect – “How do you feel about that?”
Trouble – “What’s upsetting you most about it?”
Handling – “How are you handling the situation?”
Empathy – “That must have been difficult”
Demanding Patient

Elvira, 38 years old, consulted with low
back pain which started 3 PTC after
lifting bags of groceries. You order a
plain radiograph of the lumbo-sacral
spine and an NSAID. However, she
insists on having an MRI.
How will you respond?
Demanding Patient





Address the patient’s doubts regarding your
ability
Explore the patient’s concern/ doubts
Explain the situation to patient
Encourage patient to seek second opinion
Empathize
– “I realize this symptom is alarming because you
have already gone through a similar experience.”
Angry Patient

You had to attend to a patient with Dengue
Fever necessitating admission. Mr. Tan
although advised of your delay curses at you
for not respecting his time and complains
regarding your unprofessional conduct and
poor medical care.
How do you respond?
Angry Patient


Allow complete angry outburst
Validate the frustration with emphatic comments
– “ I understand that you are upset at having to wait, and I
apologize for the delay.”
– “I can understand why your are upset, I appreciate your
waiting for me.”

Involve the patient in the outcome
– “Do you have any suggestions of how to solve this
problem?”

Provide the opportunity to discuss his concerns
– “How can I help you today?”
Silent/Detached Patient

Identify the cause for the silence
–
–
–
–
–
–
–
Fear of authority figure
Patient on medications causing drowsiness
Depression
Cultural differences/ language barriers
Hearing loss
Shy or passive personality
Previous negative experience with health care
provider
Silent/ Detached Patient

Use open ended questions
– “You seem quiet today. Is there a reason for this?”
– “You seem sad today. Are you depressed?”

Explain the importance of sharing information
in order to help patient
 Encourage a productive office visit
– “ Is there someone close to you who can help to
make decisions with regards to your health care?”
Harassing/ Seductive Patient

During the consultation the patient
makes advances. The patient asks you
out to dinner and attempts to embrace
you.
What would you do?
Harassing/ Seductive Patient

Be pleasant but firm. Maintain a professional
relationship. A romantic relationship will lead
to:
– Loss of Objectivity
– Imbalance of authority

Refer patient to another provider for care.
 This may signal a psychosocial issue in the
patient’s history. Patient might need further
evaluation.
Emotional Patient

Maria, a 27 year old housewife consults
because of chest pain. During the
interview she starts crying because she
feels her husband is no longer attracted
to her because they have not been
intimate for the past few months.
What would you do?
Emotional Patient
Recognize the patient’s emotion
 Explore and address psychosocial
issues raised
 If related to grieving, validate the
emotional experience
 Encourage open communication

Somatizing Patient

Perla, a 34 year old housewife, has
been consulting at the OPD for a few
months now because of easy
fatigability. All laboratory and ancillary
tests were normal.
How would you handle this patient?
Somatizing Patient

These patients present with a chronic
course of multiple vague or exaggerated
symptoms
 Often suffer from co-morbid anxiety,
depression, and personality disorders.
 Have a history of multiple diagnostic tests
 They often have “doctor-shopped”
Somatizing Patient

Address the issue directly at the
beginning of the encounter.
– “I noticed that you have seen several
physicians and have had extensive medical
tests to try to uncover the cause of your
symptoms. I recognize that the symptoms are
a real difficulty for you, but I believe that these
tests have ruled out any serious medical
problems.”
“Frequent Flier”

They may be lonely, dependent or too
afraid or embarrassed to ask the
questions they really want answered
 Patients with a large number of perfectly
rational questions, the “worried well” or
simply patients who have been given
misinformation that needs clarification.
“Frequent Flier”
Begin by acknowledging the pattern
of frequent visits
 To identify the underlying reasons
for the frequent visits.

– concern about undiagnosed symptoms
– a need for reassurance
– a need for relief from chronic pain
– a need to talk.
Unhygienic/Malodorous Patient

Do not show dislike
 Carry on with interview and treat the problem
 Educate patient or caregiver on the
importance of hygiene
 May be a sign of caregiver neglect
 Communication techniques are a learned
skill.
 Unfortunately, many health care providers
discover this after an adverse event
occurs. If this is the case, turn that
negative experience into a positive
teaching tool by asking these questions:
• What can we learn from this?
• How can we prevent a recurrence?
• Is there anything we can do now to alleviate the
situation?