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Difficult Difficult ConsultationsConsultations

Prepared byPrepared byDr. Mohammad AL-ShahraniDr. Mohammad AL-Shahrani

Under Supervision ofUnder Supervision of Dr. Ahmad ShakerDr. Ahmad Shaker

IntroductionCausesExamplesDealing with difficult patients and

managing a difficult consultation appropriately.

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CONTENTS

To know the causes of difficult consultations in general.

To be aware about different types of difficult patients.

How to deal by an appropriate way with such difficult patients.

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Groves (1978) developed four stereotypes of difficult patients, whom he labeled dependent clingers, manipulative help-rejecters, entitled demanders and self-destructive deniers.

These patients consistently trigger negative feelings in physicians, who cannot satisfy their endless demands and

complaints .

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Around ( 10 – 20 % ) of daily consultations are Around ( 10 – 20 % ) of daily consultations are considered to be difficult. These difficulties are either considered to be difficult. These difficulties are either due to : due to :

1. Difficult patient .

2. Difficult doctor .

3. Difficult communication between the doctor and the patient.

4. Difficult environment.

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Psychotic patient, suicidal patient etc. Psychotic patient, suicidal patient etc. Depressive patient.Depressive patient. Talkative patient.Talkative patient. Withdrawn and isolated patient.Withdrawn and isolated patient. Bereaved patient.Bereaved patient. Angry patient.Angry patient. VIP patient.VIP patient. Demanding patient.Demanding patient. Manipulative patient.Manipulative patient. Hypochondrial “the worried well” patient.Hypochondrial “the worried well” patient. Reluctant patient.Reluctant patient. Somatizing patient.Somatizing patient.

Difficult Patients

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Doctor in a hurry. Authoritarian doctor. Passive (submissive) doctor. Angry doctor. Alien doctor (from different

culture). Doctor who have social or

psychological problems.

Difficult Doctor

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Language difficulties. Social class differences.

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Crowded clinic. Poor organization.

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Dealing with

Demanding Patient

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The first step in addressing unnecessary demands is to ascertain the patient's needs.

Allow the patient to fully tell the story, with minimal interruptions.

Ask the patient for details: “I understand you are here because you want an MRI of your knee; I'd like to understand how you reached that decision.”

Consider agreeing with the patient.

Dealing with Demanding Patients

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Negotiate agenda and goals : Set limits. Reinforcement and help. Compromise and be flexible.

Avoid argumentation. Explain your rationale. Pay attention to the way you say no. Under pressure, breathe deeply and start

over. For some patients

“firm boundaries are the rule”

Dealing with Demanding PatientsCommunication Skills

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summarize the points aloud for the patient. This allows the patient to correct or amplify. It also gives the patient the experience of being heard and understood.

An attempt to reflect the emotion behind the request is important. e.g “It sounds

incredibly frustrating to be laid up with knee

pain for so long, but…”

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Empathy Non-judgmental attitude Respect Support Flexibility

Dealing with Angry Patients

Communication Skills

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7 steps to deal with angry patients:

1. Handle problems privately

2. Listen to patients' complaints

3. Disarm anger with kindness

4. Delegate up when necessary

5. Follow through on promises

6. Involve the patient in prevention

7. Be grateful

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Examples : The topic Cultural barrier Social class barrier Dr. authority Time constrains Presence of 3rd party

Causes :Patient Factors :

Dr. Factors :

Circumstances :

Dealing with Patients reluctant to talk freely

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Verbal Give reasons for your

questions. Comments on the patient

attitude. “if you talk more, I’ll be able to help you.”

Generalization of the problem. Asking at the right time. Give choices.

Non - verbal Showing empathy. Showing real interest. Unhurried manner. Touch for

reassurance.

Patient reluctant to talk freely

Communication Skills

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many patients have a script of what they want to say to the doctor.

Letting them speak uninterrupted initially allows you to gather key details form the history and lets the patient disclose their agenda.

it is important that the doctor takes control and directs the consultation.

Dealing with Talkative patients

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Talkative patients need to be politely but firmly steered back to the key points.

One tactic is to acknowledge any digressions and then focus the patient back to the question asked.

Another tactic is to regularly summaries problems and concerns to allow you to impose focus to the consultation.

If you need to interrupt then use non verbal as well as verbal signs such as raising your hand to indicate that you want to speak.

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Verbal Communication Summarization Prioritization Interruption Close ended question

Non - verbal Comm. Hand movement. Sympathy & empathy.

Talkative PatientsCommunication Skills

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Recognize your true feelings. Difficult patients evoke a feeling of anxiety, pressure, boredom, or frustration.

Be alert for counter-transferance reaction.

Use resources. Involve colleagues in your

management plan. “you are not alone.”

Improve yourself .

Coping Strategies for the Doctor

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Whatever the difficulty, the physician Whatever the difficulty, the physician maintains rapport, respect, and relationship maintains rapport, respect, and relationship with these difficult patients by listening for with these difficult patients by listening for their concerns.their concerns.

By giving the impression of being unhurried By giving the impression of being unhurried and having time to listen, the physician and having time to listen, the physician maintains relationship and conveys to the maintains relationship and conveys to the patient that the physician-patient patient that the physician-patient relationship will continue undamaged by the relationship will continue undamaged by the difficulty of the present moment. In this difficulty of the present moment. In this way, the relationship becomes a part of the way, the relationship becomes a part of the healing process.healing process.

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