How can we better manage difficult patient encounters?

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Applied Evidence

How can we better manage difficult patient encounters?

J Fam Pract. 2013 August;62(8):414-418, 421

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References

1. Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: preva- lence, psychopathology, and functional impairment. J Gen Intern Med. 1996;11:1-8.

2. An PG, Rabatin JS, Manwell LB, et al. Burden of difficult encoun- ters in primary care: data From the minimizing error, maximizing outcomes study. Arch Intern Med. 2009;169:410-414.

3. Hinchey SA, Jackson JL. A cohort study assessing difficult patient encoun- ters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med. 2011;26:588-594.

4. Haas LJ, Leiser JP, Magill MK, et al. Management of the difficult patient. Am Fam Physician. 2005;72:2063-2068.

5. Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159:1069- 1075.

6. Ashworth CD, Williamson P, Montano D. A scale to measure physi- cian beliefs about psychosocial aspects of patient care. Soc Sci Med. 1984;19:1235-1238.

7. Leigh H, Stewart D, Mallios R. Mental health and psychiatry training in primary care residency programs. Gen Hosp Psychiatry. 2006;28:189-194.

8. Katon W, Unützer J. Collaborative care models for depression: time to move from evidence to practice. Arch Intern Med. 2006;166:2304-2306.

9. Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298:883- 887.

10. Fortin AH, Dwamena FC, Frankel RM, et al. Smith’s Patient-Centered Interviewing: An Evidence-Based Method. 3rd ed. New York, NY: McGraw-Hill; 2012.

11. Stuart MR, Lieberman JA. The Fifteen Minute Hour: Therapeutic Talk in Primary Care. 4th ed. Milton Keynes, UK: Radcliffe Publishing; 2008.

12. Smith GR Jr, Rost K, Kashner TM. A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry. 1995;52:238-243.

13. Baker LH, O’Connell D, Platt FW. “What else?” Setting the agenda for the clinical interview. Ann Intern Med. 2005;143:766 -770.

14. Smith RC, Lyles JS, Mettler J, et al. The effectiveness of intensive training for residents in interviewing. A randomized, controlled study. Ann Intern Med. 1998;128:118-126.

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Core principles for handling frustrating cases

A useful approach to the difficult patient encounter, detailed in the TABLE that we created, is based on 3 key principles:

The doctor-patient relationship should be the target for change.
The patient’s emotional experience should be an explicit focus of the clinical interaction.
The patient’s perspective should guide the clinical encounter.

In our experience, when the interaction between patient and doctor shifts from searching for specific pathologies to building a collaborative relationship, previously recalcitrant symptoms often improve.

Use these communication techniques
There are 2 main ways to elicit a conversation about personal issues, including emotions, with patients. One is to directly ask patients to describe the distress they are experiencing and elicit the emotions connected to this distress. The other is to invite a discussion about emotional issues indirectly, by asking patients how the symptoms affect their lives and what they think is causing the problem or by selectively sharing an emotional experience of your own.

Once a patient has shared emotions, you will need to show support and empathy in order to build an alliance. There is more than one way to do this, and methods can be used alone or in combination, depending on the particular situation. (You’ll find examples in the TABLE.)

Name the affect. The simple act of naming the patient’s affect or emotional expression (eg, “You sound sad”) is surprisingly helpful, as it lets patients know they have been “heard.”

Validate. You can also validate patients like Mr. E, Mr. A, and Ms. S by stating that their emotional reactions are legitimate, praising them for how well they have coped with difficult symptoms, and acknowledging the seriousness and complexity of their situations.

Align. Once a patient expresses his or her interests and goals, aligning yourself with them (eg, “I want to do everything in my power to help you reduce your pain...”) will elicit hope and improve patient satisfaction.

And 2 mnemonic devices—detailed in the box ^10,11—can help you improve the way you communicate with patients.

Communication can also be nonverbal, such as thoughtful nodding or a timely therapeutic silence. The former is characterized by slow, steady, and purposeful movement accompanied by eye contact; in the latter case, you simply resist the urge to immediately respond after a patient has revealed something emotionally laden, and wait a few seconds to take in what has been said.

2 mnemonics to boost your patient communication skills

NURS is a reminder to:

Name the patient’s emotion (“you say that these constant headaches really get on your nerves.”)
Understand (“i can see why you feel this way.”)
Respect (“you’ve been through a lot and that takes a lot of courage.”)
Support (“i want to help you get better.”)¹⁰

BATHE can help you learn more about the patient’s situation:

Background (“What has been going on in your life?”)
Affect (“how do you feel about that?”)
Trouble (“What troubles you the most about this situation?”)
Handling (“how are you handling this?”)
Empathy (“That must be difficult.”)¹¹

How to provide therapeutic structure

Family physicians can further manage patient behaviors that they find bothersome by implementing changes in the way they organize and conduct patient visits. Studies of patients with complex somatic symptoms offer additional hints for the management of frustrating cases. The following strategies can lead to positive outcomes, including a decrease in disability and health care costs.¹²

Schedule regular brief visits. Mr. E, Mr. A, and Ms. S should have frequent and regular, but brief, appointments (eg, 15 minutes every 2 weeks for 2 months). Proactively schedule return visits, rather than waiting for the patient to call for an appointment PRN.¹¹ Sharing this kind of plan gives such patients a concrete time line and clear evidence of support. Avoid the temptation to schedule difficult cases for the last time slot of the day, as going over the allotted time can insidiously give some patients the expectation of progressively longer visits.

Set the agenda. To prevent “doorknob questions” like Ms. S’s new symptoms, reported just as you’re about to leave the exam room, the agenda must be set at the outset of the visit. This can be done by asking, “What did you want to discuss today?”, “Is there anything else you want to address today?”, or “What else did you need taken care of?”¹³ Explicitly inquiring about patient expectations at the start of the visit lets patients like Ms. S know that they are being taken seriously. If the agenda still balloons, you can simply state, “You deserve more than 15 minutes for all these issues. Let’s pick the top 2 for today and tackle others at our next visit in 2 weeks.” To further save time, you can ask the patient to bring a symptom diary or written agenda to the appointment. We’ve found that many anxious patients benefit from this exercise.