Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID:28851-24581

Navigating the Difficult Encounter Masil George, MD Associate Professor, UAMS Department of Geriatrics Associate Professor, UAMS Division of Medical Humanities Director, Geriatric Palliative Care Program, UAMS Medical Director, Baptist Hospice 11/14/18

OBJECTIVES To identify a difficult patient- clinician encounter To list patient and clinician characteristics that may lead to a difficult relationship To describe specific strategies to manage difficult encounters

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What is a difficult patient- clinician relationship? Clinical encounter in which patient evokes feelings of dread, frustration or even anger in a clinician Arises when physicians encounter patients with complex, often chronic medical issues (such as chronic pain, and/or mental illness) that are influenced or exacerbated by social factors (such as poverty, abusive relationships, addiction) Occurs in approximately 15% of adult patient encounters (Krebs et al., 2006)

Why is this a problem? The therapies the doctor recommends often entail behavioral changes that the patient is unwilling or unable to make, yet the patient continues to seek the clinician’s advice and treatment The clinician may become frustrated or angry because their advice is not heeded, because the diagnosis or treatment is unclear or ineffective, or because the patient is rude, seemingly ungrateful, or transgresses boundaries in the clinician-patient relationship (e.g. comes to the clinic when she does not have an appointment) The physician could become guarded or distant The patient develops distrust

Mr. Smith’s visit with Dr. G Mr. Smith is a 66y/o M with COPD, DM (poor control), Diabetic neuropathy, CKD and DJD. He complains of worsening cough, flu like symptoms, pleuritic chest pain, and insomnia. Dr. G performs appropriate physical exam, orders labs and imaging, orders medications, and prepares patient hand out with advice on treating COPD exacerbation. As he walks out the door, Mr. Smith mentions that his back pain has been worse, produces an old bottle of script from ER and requests if he could have a refill on this because it “really” helped his pain.

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Dr. G’s response to Mr. Smith Ensure this is not an emergency Empathic response that acknowledges suffering Brief counseling on dangers of opioids Recommendations on non-opioid pain management Schedule follow up visit at my earliest available, or with APN (possibly overbook)

Ms. Remy’s visit with Dr. G Ms. Remy is a 72 y/o with CAD s/p CABG, MCI (mild cognitive impairment), fibromyalgia, OSA, Depression/ anxiety. She has been on Oxycontin 80 mg bid, and hydrocodone 7.5/ 325 for fibromyalgia pain and lorazepam 1 mg tid/ PRN which are being slowly tapered according to CDC guidelines and is currently on Oxycontin 30 mg bid. She is aware that today her dose will be reduced to 20 mg, and lorazepam to 0.5 mg bid/ PRN. She is also on highest dose of Lyrica, Zoloft and Bupropion. Ms. Remy is very emotional during this visit- She is angry that because of some people addicted to opioids, she is forced to reduce dose of medications that are working for her. She asks when she can have marijuana. She is tearful and anxious and wants to know if I reduce her opioids, could I atleast give her back her lorazepam at higher dose.

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Empathy Empathy is a two stage process Clarifying and gaining both a clear understanding and appreciation of another person’s situation or feelings 2) Communicating that understanding back to the patient in a visible and supportive way.

N-U-R-S-E Name or mirror the emotion “You seem very anxious.” Understand the emotion “It can be stressful to learn something new like this that is so important to your health.” Respect the patient “You did a great job with both your glucose testing and insulin injection today.” Support the patient using powerful words “I’ll work with you and help you in managing ……………..(name specific issue).” Explore the emotion further “Tell me what bothers you the most”.

Practice Points 1) Be compassionate and empathic. Keep in mind that most patients whom you find frustrating to deal with have experienced significant adversity in their lives. 2) Acknowledge and address underlying mental health issues early in the relationship. 3) Prioritize the patient’s immediate concerns and elicit the patient’s expectations of the visit and their relationship with you. 4) Set clear expectations, ground rules, and boundaries and stick to them. Have regular visits, which helps convey confidence that the patient can deal with transient flare-ups without an emergency visit. 5) Be aware that strong negative emotions directed at you are often misplaced. The patient may be imposing feelings and attitudes onto you that they have had toward other doctors, friends, family members in the past. This is known as transference. Acknowledge the patient’s feelings and set behavioral expectations.

Practice Points 6) Be aware of your own emotional reactions and attempt to remove yourself so you can objectively reflect on the situation. Involve colleagues. Vent your feelings or debrief confidentially with a trusted colleague so that your negative emotions are kept at bay during patient encounters. 7) Recognize your own biases. For example, patients with addictions genuinely need medical care, but the behaviors associated with addiction are vexing for health care providers. These patients are often both vulnerable and manipulative. Be sure that you are attentive to their vulnerability, rather than focusing exclusively on their manipulative behaviors. 8) Avoid being very directive with these patients. A tentative style tends to work better. Remember that you provide something many of these patients do not have-a steady relationship with someone who genuinely wants to help them. This in itself can improve the patient’s health, even in the absence of medical treatment. 9) Prepare for these visits. Keep in mind your goals of care and make a strategy for the encounter before it occurs.

Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076 Event ID: 28851-24581