Articles and Case Studies

Difficult Patients

31 May 2006

Deborah Jackson

by Ms Deborah Jackson

Sitting in conversation with a senior woman

There are many reasons why patients are difficult, bearing in mind the breadth of the perception of a difficult patient. For example, some patients do not understand the medicine and that it cannot always fulfil their expectations.

Some patients provoke dislike or negative feelings because of personality characteristics and others invoke a loss of effective neutrality with the clinician. This can make it difficult to reach a shared understanding of the problems or for the patient and clinician to agree in the way forward in relation to their management.

Clinicians are aware patient complaints are often made by patients who are under the erroneous assumption that their health concerns have not been appropriately or adequately addressed. This complaint can take the form of a formal letter of complaint or a display of rude, aggressive or even violent behaviour.  In a practical sense, how can these difficult situations be better managed and how do we effectively deal with these patients when difficult situations  arise? Some tips are outlined below.

It is essential that a protocol or policy be put in place in order to provide some clear guidelines for all staff to implement when dealing with these types of patients.

It is advisable that every doctor’s surgery have a simple and discreet alarm system, including nursing and reception areas, for use in the event of aggressive or violent behavior. This will ensure that all staff members are aware that there is an emergency situation and can assist or, alternatively, contact Police.  It is also prudent immediately after a disturbance that all staff involved communicate with one another in order to talk out their immediate reactions. In order to deal effectively with difficult patients depending on the degree of their behaviour, it is advisable to discuss these patients at practice meetings with all members of staff, with emphasis on the “level” or “degree” of their difficult behaviour.  Not only does this provide a debriefing for all the staff members concerned, it also provides a forum to enable your procedure to be reviewed and modified if necessary when dealing with challenging patients.

In the event you decide that the therapeutic relationship has broken down to the extent where you can no longer treat the patient, it is advisable to inform the patient. Depending on the patient, you can inform them in person or by letter that they need to find another clinician. It is preferable that this communication be in writing and the letter be sent by Registered Post to ensure that the patient receives your letter. Your legal duty then requires you to write a health summary and to arrange for photocopies of the patient’s clinical records to be forwarded to the next clinician. If the patient has a serious condition you must ensure that the importance of being followed up by another clinician is emphasised in your correspondence. It is important that the patients treatment not be compromised during the handover period.
 

Some tips for coping with difficult patients:

  1. Understand that patients are usually only difficult when they are anxious, worried, frightened or they do not understand the information they have been given.
  2. Treat patients with warmth, understanding, consideration and empathy.
  3. Listen to patients in an active and interested manner.  Ask open-ended questions in order to determine what is making the situation difficult.
  4. Consider your body language. Studies indicate few people are physically aggressive without any non-verbal warning signs.
  5. Be aware of your own feelings, values and behaviour making sure they do not cloud your response to the patient.
  6. If it becomes evident that the patient is upset, give them time to talk, take care regarding the venue where this discussion takes place. Depending on the nature or degree of the patient’s distress it may be advisable not to take the patient into a room. It may be advisable to communicate with the patient in an open area with another member of staff close by. You must ensure the patient’s privacy if you speak to the patient in an open area.
  7. Clinician and practice staff should be cognisant of their own responses, avoid any aggressive body language or signals and avoid any temptation to verbally or non-verbally provoke a situation which may increase the tension.
  8. Remember, highly anxious and inarticulate people are most likely to express themselves in an angry and/or possibly violent manner.
  9. At no time when dealing with difficult patients should you touch the patient.
  10. Acknowledge and recognise that some people are anxious and may regress and become childlike, reacting in an angry manner.  Staff must refrain from becoming angry themselves and not treating the patient as a child.
  11. Validate the patient’s feelings and acknowledge that they are angry and upset and that you will endeavour to do your best to fix the problem.
  12. If need be, contact another member of staff to observe and be close by whenever you are dealing with difficult patients.
  13. As a last resort, you can consider no longer treating the patient. You are legally and ethically bound only to treat a person in an emergency situation.

References

  1. Breaking up is never easy, Tim Stokes, Mary Dixon-Woods and Robert K McKinley, Family Practice, Vol. 20, No. 6 2003;
  2. Confrontation and Politeness Strategies in Physician and Patient Interactions, SOC, SCI, MED. 1981: Vol. 27 (3);
  3. The Difficult Patient as Perceived  by Family Physicians, Dov Steinmetz  and Hava Tabenkin, Family Practice  2001;
  4. Dealing with Difficult Patients What Goes  Wrong, Estfan Cembrowicz, The Practititioner, April 1989,  Vol. 233;
  5. Royal Australian College of General Practitioners, Difficult Patients Guidelines.
This article originally appeared in Defence Update - Winter 2006
Communication with Patients, Practice Management, Anaesthesia, Dermatology, Emergency Medicine, General Practice, Intensive Care Medicine, Obstetrics and Gynaecology, Ophthalmology, Pathology, Practice Manager Or Owner, Psychiatry, Radiology, Sports Medicine, Surgery, Physician, Geriatric Medicine, Cardiology, Plastic And Reconstructive Surgery, Radiation Oncology, Paediatrics, Independent Medical Assessor - IME
 

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