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Managing Difficult Patients

Managing Difficult Patients
Author Information (click to view)

Sharon K. Hull, MD, MPH

Director, Executive Coaching Program
Professor of Community and Family Medicine
Division Chief, Family Medicine
Duke University Medical Center

 

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Sharon K. Hull, MD, MPH (click to view)

Sharon K. Hull, MD, MPH

Director, Executive Coaching Program
Professor of Community and Family Medicine
Division Chief, Family Medicine
Duke University Medical Center

 

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Regardless of the setting that a physician practices, there is a high likelihood that they will encounter difficult patients throughout their career. “We can’t blame all of these difficult encounters on patients,” says Sharon K. Hull, MD, MPH. “When we label patients as ‘difficult,’ it often is a sign of complexities in patient care that we don’t fully understand.” Although these encounters are unavoidable, Dr. Hull says being prepared to deal with these situations can make for a better experience for physicians and patients alike.

In a recent article published in Family Practice Management, Dr. Hull and Karen Broquet, MD, described patient, physician, and situational factors that can play a role in difficult patient encounters. “Identifying these factors and responding to them appropriately is critical,” says Dr. Hull.

 

Considering Patient Factors

Difficult patients may include those who are angry, defensive, or frightened about their doctor’s visit. Other patients may be manipulative or high utilizers of care or have vague or exaggerated symptoms. “Each patient case will require different management strategies,” Dr. Hull says. “An important overriding goal should be to avoid getting drawn into a conflict and to modulate responses to situations so that you empathize with patients.”

Dr. Hull also notes that using reflective statements, being aware of your own emotions, and being direct but compassionate are all important strategies to utilize when dealing with difficult patients. Efforts should also be made to encourage open communication.

 

Checking Yourself

Physicians’ own attitudes and behaviors may also contribute to difficult encounters with patients, according to Dr. Hull. These physician factors include being:

  1. Angry or defensive.
  2. Fatigued or harried.
  3. Dogmatic or arrogant.

“Recognizing our own trigger issues and knowing our personal baggage can be valuable,” says Dr. Hull. “After identifying these triggers, we should strive to avoid situations in which our beliefs may inappropriately close off exchanges of information.” She adds that clinicians should be cognizant of the fact that shared decision-making is a critical component of a healthy doctor-patient relationship.

 

Recognizing Other Factors

In some scenarios, difficult encounters have more to do with the circumstances surrounding the encounter than with the people involved. Such situations include:

  • Language and literacy issues.
  • Having multiple people in the exam room.
  • Breaking bad news.

With regard to all of these situations, Dr. Hull recommends allowing extra time for these encounters. When breaking bad news, she recommends that physicians prepare appropriately. “We should know who will be present for the discussion and allow adequate time and privacy,” she says. “We should also assess what the patient already understands or believes and how much more information is wanted. This news should be disclosed directly but we need to allow for adequate response time so patients can express their emotions and process the information.”

After giving bad news, physicians should discuss the implications, offer additional resources, agree on next steps, and summarize the discussion, including arranging for follow-up. “Physicians should prepare for a shift in their relationship with patients after delivering bad news,” says Dr. Hull. “They should also involve other specialists who may be caring for these patients after the bad news is delivered. Doing so can reduce some of the burden that physicians face when delivering this news.”

 

Communicating Carefully

Studies indicate that more adults are coming to medical appointments with friends or family. While having others in the exam room can be helpful for when patients leave the appointment, it can also be problematic if patients do not want others to be in the room. It is important to honor what the patient’s wishes are and ask if they want to have conversations with others in the room when approaching health topics that may be particularly delicate.

“Ultimately, being aware of factors that contribute to difficult clinical encounters and being prepared to address them can help prevent many of these situations,” says Dr. Hull. “We should also be cognizant of the importance of addressing any questions that patients have and reviewing the next course of action. These efforts can help manage potentially difficult patient encounters and improve the overall experience for you and your patients.”

Readings & Resources (click to view)

Hull SK, Broquet K. How to manage difficult patient encounters. Fam Pract Manag. 2007;14:30-34. Available at: http://www.aafp.org/fpm/2007/0600/p30.html.

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