Sterling Ransone, MD, a family medicine physician in rural Deltaville, Virginia, used to dread the legal pad filled with a list of concerns that his patient would bring to every appointment.
"At first when I saw that legal pad, my brain would explode, especially when we'd get to the bottom of the list and she'd turn the page," he said.
Ransone came up with a solution: He now says, "Let's see that list," at the beginning of the appointment. Scanning the list with his patient at the outset of the visit enables him to group and address related complaints quickly while working with his patient to identify the two primary concerns they will focus on during the encounter. "I write those on a white board to keep her focused," he says. "She feels listened to, we address what's most important, and we schedule another appointment if she has things we didn't get to."
Whether they're angry or anxious, chatty or evasive, there are times when "dealing with patients is an emotional, volatile roller coaster," says Terry Schraeder, MD, author of Physician Communication: Connecting with Patients, Peers, and the Public (Oxford 2019). When that's the case, finding the right words can be essential not only to the patient, but to the doctor and his or her staff.
Almost every physician has challenging encounters with some patients. Doctors often become frustrated, but most have developed strategies for talking with difficult patients during these times.
Here are some situations you may encounter, and suggestions for how to handle them.
1. Patients who won't talk about what's wrong.
Gary LeRoy, MD, a family medicine physician at a federally qualified health center in Dayton, Ohio, knows some patients have a hard time talking about what's really bothering them. "There's kind of this social dance that takes place," he says. "They'll talk about everything else that is going on, but they'll wait until the end when I've got my hand on the doorknob to mention the crushing chest pain they've been experiencing that's causing them to sweat."
When LeRoy senses a patient is being evasive, he'll look them in the eye and ask if anything else is going on. Sometimes, when that doesn't work, he'll get up and put his hand on the doorknob. "They'll say, 'Wait, you're leaving?' And then they'll tell me what's really bothering them."
2. If there's more going on than meets the eye.
As a pediatrician, Susan Kressly, MD, deals with her fair share of crying babies, surly teens, and demanding parents, so when she recently walked into the exam room and the child under her desk shouted, "Shut up, you're getting on my nerves! You're giving me a headache!" Kressly realized that the child was likely repeating words she herself had heard many times.
Kressly knew the visit wasn't going to be about medications or vaccinations: It was going to be about conversation.
Kressly, who practices in Warrington, Pennsylvania, enlisted a nurse to play with the child in the next room while she spoke with the mother. The conversation enabled the mother to open up about her own stress and how it affected the way she spoke with her child, and gave Kressly an opportunity to suggest resources and strategies that could help. "Sometimes I think we have more impact in those conversations than we do in writing a prescription."
3. Why is your patient crying?
You walk into the exam room to find your next patient in a puddle of tears, meaning the routine physical or follow-up you had anticipated will be anything but.
Kressly recently opened the door to what was supposed to be a well-visit for a teen patient, only to find the patient and her mother crying. "You have to put your humanity first in that situation," she says. "I pushed my computer aside, and said 'OK, can I give anyone a hug?' They both stood up, and we all shared a group hug. I knew at that moment that my entire agenda for a well- visit was about to go out the window and that whatever I was about to do was way more important."
It turned out the mother had been diagnosed with cancer and had just shared the news with her child. Kressly spent the visit talking with them about the diagnosis and helping them process the news. "You have to be able to shift with the wind and deal with what is sitting in front of you," she says. "Sometimes we try to shoehorn people into our agenda and that doesn't work."
4. Patients who are angry before you even walk into the room.
It's easier to interact more effectively with a rude or angry patient when you're not caught off guard, says Ada Stewart, MD, a family medicine physician in Columbia, South Carolina. Expecting and understanding a patient's anger, Stewart says, helps you keep from getting defensive, enables you to apologize if necessary, and helps you defuse the situation.
"If I say, 'I hear from the front desk that you're having some issues, is there anything I can do to help?' I'm offering my help and putting myself on their side. Ninety-nine percent of the time it works and they calm down."
Get a heads up from staff about angry patients. Often, walking into a room and being verbally attacked is not only unpleasant, but it triggers a defensive reaction or your own anger. Speak with your staff, and let them know what you're trying to accomplish by getting some advance warning.
5. There's silence in the exam room.
Communication isn't just about words, Schraeder says. "We are all so nervous about conversational pauses sometimes we feel like we have to fill up the silence with chatter," she says. Sharing silence "slows down the pace of the room, allows us to observe the patient, and allows the patient to say something spontaneous if they want."
Still, it's wise to be attuned to whether the patient may have an issue to speak about that they're too uncomfortable to bring up, or if something is bothering them. It's worth it to 'check in' and ask if there's something on their mind.
6. A patient is upset and overwhelmed and can't continue the visit.
It can be challenging to lend a sympathetic ear when the clock is ticking. Stewart says taking a break can salvage your schedule and give the patient a chance to collect themselves.
Stewart recently comforted a patient who was feeling overwhelmed with a hug, tissues, and 15 minutes of attentive listening. "But it gets to a point, where you have to think about the patients who are waiting for you, so I said, 'I'm going to step out and let you have a minute to yourself. Maybe get a drink of water or splash some water on your face, and then I'll come back and we'll talk.' "
Often, it's useful to take a break and then come back. Stewart used the break to see two other patients. When she returned, the woman had calmed down, and Stewart was able to point her to resources she might find helpful, including the clinic's on-staff counselor.
7. An anxious patient calls constantly about medical worries.
It's very helpful to be creative in dealing with a patient's anxieties. Sometimes, the best way to help a challenging patient is to "color outside the lines," Kressly says. She described a mother who would call every Friday afternoon insisting her child needed to be seen immediately.
After repeatedly finding nothing wrong with the child, Kressly asked her staff to schedule the woman to come in during the last slot of the day so they could talk.
"It turns out she's anxious and her family makes her feel like she doesn't know what she's doing as a parent," Kressly says. "The weekends when there's no school make her nervous." Now that she understands the situation, Kressly has a care coordinator touch base with the woman every Friday morning to make sure she feels supported going into the weekend.
8. A very talkative patient throws off your day's schedule.
With some patients, it's helpful to use strategic scheduling to alleviate the time pressure. It may not involve words, but strategic scheduling can definitely enhance communication, particularly when you've got a chatty patient.
Ransone and his staff huddle every day and often tweak the next day's schedule to better accommodate patients who need a little extra time.
"One of the most difficult patients I've ever had was bipolar with fibromyalgia," he says. "My office manager knew to put her at the end of the day," because she had trouble focusing when she was manic, he says. Allowing that extra time not only gives the patient time to talk, it enables the doctor to listen more attentively. "Medicine is a challenge and a puzzle. If you can alleviate some of the time pressure, it helps."
9. A patient doesn't tell family members what the medical treatment should be.
In this type of situation, you can often turn a family member into an ally. When LeRoy senses a patient is not being forthcoming about his or her medication compliance, he will often ask the patient to bring a family member to the next visit.
"One of the wonderful things about ongoing relationships and charting is you can say, 'Remember our conversation about taking your medicine?' And the family member will get this stunned look in their eye and say, 'Wait, mom, you never told me about whatever it is.' At that point, I've got a potential ally. I wish I had a buck for every time that happened."
10. Demanding patients want a treatment that you don't feel is best.
Whether they want antibiotics for a child's earache or opioids for their back pain, some patients will bully, beg, flatter, lie, or try in some other way to manipulate a doctor. In those cases, doctors often say, "no" by relying on their own personal scripts. You need to trust your best clinical judgment.
"I have a standard phrase I used in those situations," says Alan Schwartzstein, MD, a family medicine physician in Oregon, Wisconsin, who recently refused to sign off on ankle surgery for a patient with uncontrolled diabetes, heart disease, and high blood pressure. Schwartzstein understood the man's frustration and explained why surgery would be dangerous for him, but he wasn't willing to argue the point. "I told him, 'I'm sorry, I'm just not comfortable doing this.' I have to do what I think is best for the patient."
Shelly Reese is a freelance writer based out of Cincinnati, Ohio.
Medscape Medical News © 2019
Cite this: 10 Smart Ways to Deal With Challenging Patients - Medscape - Nov 11, 2019.