Dreading that patient encounter? Help is here

Difficult patients are a part of every physician’s clinical practice. Clinicians find as many as 15% of patient encounters to be difficult, according to one report. Unfortunately, difficult patient encounters can lead to complaints against physicians and even malpractice claims in some situations.

“Risky or difficult patients can include those who are noncompliant, exhibit bad behavior toward our staff and physicians, or are drug-seeking,” says Robin Edmonson, provider and patient relations manager at Austin Regional Clinic (ARC), a large multi-specialty practice in Austin, Texas, where she helps manage any risks associated with patient care.

If you find yourself anxious, angry or dreading a patient encounter, the strategies below may help you mitigate the stress, inefficiencies and risks that these scenarios may cause.

A risk management plan

At ARC, difficult patient encounters are few and far between, according to Gerald Fincken, DO, associate chief of the family medicine department who served as a risk management subject expert on a medical malpractice study.

“Some patients are unhappy, of course,” Dr. Fincken says. “That is mostly due to unmet expectations.”

The ARC staff works hard to ensure a positive environment from the time the patient walks in the door by delivering an accommodating front desk, a relaxing waiting area and short wait times.

“We all try and understand and learn how to manage a patient who is upset by actively listening and empathizing,” Dr. Fincken says. “If they’re really upset, we have a plan to get them to talk to someone else who is well-trained in helping to diffuse a situation.”

Most often, that person is Edmonson, who beyond monitoring the practice’s malpractice suits and any complaints to the Texas Medical Board, is also responsible for handling tough patient encounters. “I deal with patient complaints that can’t be handled at a clinic level,” Edmonson says. “People are ill and health care is expensive, so we don’t see people at their best all the time, and sometimes that will erupt into a verbal altercation.”

Actively sympathizing with a patient’s frustration and trying to be an empathetic listener are invaluable steps to take, Edmonson says. A useful phrase she often uses is “Would you be willing to …?”

“It shows that we’re a team trying to fix something,” she says.

Edmonson also makes sure to follow up with each patient that she’s interacted with, regardless of how the interaction went, to update them on their issue or complaint. “Once a situation has diffused, I find it can be helpful to inject some humor,” she says. “That can help us relate on a human level and not make it just about facts and business.”

This free one-hour webinar on working with difficult patients offers strategies to calm upset patients. Sponsored by AOA Insurance and Gallagher, the webinar recommends incorporating phrases from the Universal Upset Person Protocol into the conversation. These include:

• “You look really upset.”
• “I’m so sorry this is happening to you.”
• “What would you like me to do to help you?”
• “Here’s what I’d like us to do.”
• “Thank you for sharing your feelings; it’s important that I understand you today.”

Setting boundaries

Setting boundaries for difficult patients is very important in maintaining control of the situation, says Steven Scheinthal, DO, a geriatric psychiatrist and chair of the psychiatry department at Rowan University School of Osteopathic Medicine. This might mean telling a patient who is continuously losing her scripts that you will not re-fill them next time. Or it could be refusing to see a patient who is abusive toward your staff.

“A lot of these behaviors, regardless of age, really speak to personality and personality disorders,” says Dr. Scheinthal. “The best way to manage personality is through consistent behavior. If you’re always giving in to this behavior and your partner is being rigid, what will happen is the patient will only want to see you. So everyone in the practice, from the front desk down, needs to react the same way.”

ARC has implemented a chain of communication in dealing with difficult patient encounters. It’s a protocol that is continually being evaluated, says Dr. Fincken. “If something gets really out of hand, we have an overhead page that would announce a code and our employees would know how to proceed with safety measures,” he says.

Aging boomers

As more and more baby boomers age, physicians will likely see their elderly patient population grow. Caring for older adults may require unique communication skills and approaches.

Personalities can become exaggerated in the elderly patient, says Dr. Scheinthal, who is often called on to assess difficult patients in assisted living facilities.

“As we all age, our personalities become more firm; they harden,” Dr. Scheinthal says. “If you’re a warm and caring person today, it would be very unlikely at 80 that you’re not going to be warm and caring. If you’re challenging and cantankerous, you’re going to be more so as you age.”

The first step in assessing a difficult older patient is in determining whether they are cognitively intact, Dr. Scheinthal says. The next step is in understanding what can and can’t be changed about the behavior.

Dr. Scheinthal offers a hypothetical example of an older patient who is suddenly found to be urinating in the potted plants of his assisted living facility. “If you talk with the family and find out he was a construction worker who often urinated outdoors, that might make sense,” he says. “This is considered old, learned behavior. No matter how bad we think that behavior is, we’re not going to change it. It’s the caregivers who need to be educated to understand where the patient’s coming from and not be alarmed.”

Acting out

It’s also good to remind yourself that a bad incident with a patient is not necessarily a harbinger of what’s to come, he says.

“The one thing that I honestly recognize with all of my patients, regardless of age, is that everyone can have a bad day,” Dr. Scheinthal says. “I’m amazed at how bad behavior in kids gets labeled a temper tantrum, but in older people, it gets medicalized. Adults, geriatric patients, everyone throws tantrums, not just 5-year-olds.”

Related reading:

Handle with care: How to deal with 4 types of difficult patients

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