Transcript Power and Politics - Gaining Stature Within Your Healthcare System.

That Son of a Bitch – Dealing
With The Difficult Patient.
Derek C. McCalmont M.D., FACEP, MS Management
Service Chief
Henry Ford West Bloomfield Hospital ED
March 7, 2012
Goals for the next 30 min.
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Identify some common difficult patients
Identify some common difficult doctors.
Understand where both are coming from.
Develop strategies to make these
interactions easier on both sides.
• Earn 30 min. of CME credit!
Why Do We Bother?
http://www.youtube.com/watch?v=TmwqWB
Jahto&feature=email
Why should I care?
• One out of 6 visits are considered
“difficult”
• Physician burnout (and lower
work satisfaction) 12x more likely
• Difficult patients have lower
satisfaction with their care
The Bottom Line
• Difficult patients represent a
relationship problem, not a clinical one.
• It is the clinician’s responsibility more
than the patient’s to address and
resolve the relationship problem.
• Physician’s have more access to and
control over our own reactions than we
have over the patient’s.
It’s Not A Contest!
Who Are These Patients
Demographically?
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Older
More often separated or divorced
Women>men
More Acute and Chronic Problems
More medications
More x-rays and tests
More visits
Lower satisfaction with their care
Who Are These Patients
Diagnostically?
• More likely to have mental disordermultisomatoform disorder, panic disorder,
dysthymia, generalized anxiety, major
depression, alcohol abuse or dependence.
• Personality disorders- Borderline, OCD,
Dependent, Self-defeating, narcissistic,
paranoid etc.
• Chronic Pain
What About The Easy Patients?
• Objective signs and symptoms of a
treatable disease.
• Make no emotional demands on the
clinician
• Cooperates in the treatment process
• Displays gratitude for the help received
A Common Definition?
• One who impedes the clinician’s ability to
establish a therapeutic relationship.
• One who’s behaviors are perceived to
challenge provider’s competence and/or
control.
• One who- by a variety of behaviors related
to profound dependency stimulates
negative feelings in most doctors.
Who Are These Doctors?
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At some level- all of us.
Younger (less experienced)
Female
Overworked
Lower job satisfaction
Medical rather than a biopsychosocial approach
(most of us).
• Lack of communication skills training (most of
us)
• Lack of self-awareness (most of us)
Clinician Awareness
• Negative emotional reactions not fully
recognized
• Negative reactions are the primary
controllable determinant in these
interactions
• Increased physician
awareness=decreased perception of
difficult patients=increased physician
satisfaction
We Have All Been There
• Being self-aware and patient
centered and incorporating
knowledge about the patient’s
personality are baseline
requirements for working with
all difficult patients.
Do’s
• Allow more time for these patient
encounters
• Continue to listen
• Continue to educate
• Encourage the patient to gain control
• Maintain hope
• Frame referrals to Psych in terms of the
stress produced by mysterious or
intractable symptoms.
Dont’s
• Brush them off
• Tell them nothing is wrong
• Use “stress” or “anxiety” as a diagnosis
without considering what can be done
about it.
• Be angry
• Be punitive
• Propagate despair.
Patient 1
• 37 y.o. female
• CC- Chest Pain
• HPI- Pressure-like sub-sternal pain
radiating to the left arm for two days
unrelieved by NTG
• PMH- Unremarkable
• PSH- Smokes 5-10 cigarettes daily.
Denies alcohol or drug abuse.
Dependent Clingers
• Escalate from appropriate request for
reassurance to excessive demands for
attention, medications etc.
• Naïve about their effect on physicians.
• Run the gamut from healthy to life
threatening.
• Self perception of bottomless need and
physician/healthcare as inexhaustible.
Strategy
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Identify as early as possible
Specify limits of physician knowledge/time
Provide specific follow-up appointments
Remind patient to utilize office visits for
recurring problems.
Patient 2
• 56 y.o. male
• CC- Abdominal Pain
• HPI- Patient with epigastric pain of 2 hours
duration with nausea.
• PMH- Hypertension, GERD
Entitled Demanders
• Like Clingers- profound neediness
• Use intimidation, devaluation, guiltinduction to obtain attention/testing/meds
• Less naïve about their effect on physicians
• Threatening (litigation/complaints)
• Exude a repulsive sense of innate
deservedness
Strategy
• Recognize Hostility is born of fear of
abandonment
• Entitlement is their religion- don’t
blaspheme it.
• Support but re-channel the entitlement.
“You deserve the very best care we can
give you but you need to help”.
• Avoid logical/illogical arguments
Patient 3
• 32 y.o. male
• CC Low back Pain
• HPI- Left LLB Pain radiating down left leg
for 5 days.
• PMH- Chronic back pain with
radiculopathy
• Current Meds- Vicodin (out)
• Allergies- NSAIDS, Ultram
Manipulative Help-Rejecters
• “Crocks”
• Feel that no regimen will help
• Frequent flyers happy to report that yet
another treatment has failed
• Pessimism increases in proportion to
physician’s efforts
Strategy
• Suspect depression
• “Share” the pessimism. Agree that
treatment may not be entirely curative.
• Provide simple reasoning. Avoid
complicated explanations.
• If needed schedule psych follow-up but
also PCP follow-up AFTER psych vist to
avoid abandonment issues
Patient 4
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65 y.o. male
CC- Constipation
HPI- No BM for 3 days
PMH- Metastatic bone CA.
Current Meds- none
PSH- Lives alone. Family lives nearby but
not involved in care.
Dr. Cox Responds
http://www.youtube.com/watch?v=RK8dMRL
VWvg&feature=email
Self-Destructive Deniers
• Unconsciously self-murderous behaviors
• Profoundly dependent but have given up
hope of ever having their needs met
• Non-compliant with medical regimen and
take pleasure in defeating family and
physician attempts to save their lives.
• Prize their independence and deny
infirmity
Strategy
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Limited Options
Acknowledge your own frustration
Best you can while you can
Psych consult- usually refused.
Final Thoughts
• Difficult patients and their frustrated
physicians fail each other. We flop
together. We lose hope. And there is no
more useless doctor than one who has
lost all hope.
• Difficult patients are an opportunity to
further define ourselves as clinicians. To
be compassionate, not hostile in the most
trying of circumstances.