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?