maggi a. budd, ph.d., mph va boston healthcare system
TRANSCRIPT
Addressing Challenging Patient Behaviors in
Spinal Cord InjuryMaggi A. Budd, Ph.D., MPH
VA Boston Healthcare System
Upon completion, participations we be able to:
1. Identify the Multi-faceted issues surrounding “Challenging Patients”
2. Describe characteristics of patients and providers who experience “challenging” patient relationships
3. Use basic ethical tenets to help conceptualize appropriate “challenging responses”
Goals & Objectives
No disclosures or conflicts of interest to report.
Team Approach: No Disciplinary Turf Boundaries Assumptions
“Challenging” vs. “Difficult”◦ 15-20% of patient encounters1,2,3,4
Goal: Review the literature, increase our awareness of patient and provider characteristics, and provide a framework for building team solutions
Operating Framework & Definition
What “challenges” are of most interest here?
Oath as providers/Work Expectations Patient Experiences/Patient Factors Provider Factors
◦ Clinician’s underlying Beliefs and Attitudes Providers’ personalities, values and emotional “hot buttons” influence their reactions to patients (Novack, 1997)
System Factors
Influences of Labeling on Team Perception
Why is this so challenging?
Four Distinct Stereotypes:
dependent clingers entitled demanders manipulative help-rejecters self-destructive deniers
Groves (1978) Taking care of the hateful patientN Engl J Med
Multiple (unexplained) physical symptoms Frequent attending Somatization disorder Breaks doctor-patient boundaries Won’t or can’t get better—sick role issues Non-compliance (including treatment) Believes doctors are Gods Hostility and signing out Litigious Manipulative Has (undiagnosed) personality disorder
(borderline/dependent) May have chronic medical disorders or social disabilities Chronic pain syndromes with or without drug addiction
Characteristics of the difficult patient (Robinson et al., 2006, p. 278)
Difficult patients are “frustrating, time consuming, and manipulative” and up to 50% of physicians “admit to ‘secretly hoping’ the patient will not return”
These patients are also “high utilizers of health care and are as dissatisfied with their care as the physicians are upset to provide it”
Patient Factors (Hahn, 1996, 2001)
Compared to non-difficult patients, three characteristics have been associated:
1. Difficult patients have twice the prevalence of significant psychopathology (67% vs. 35%)
2. Abrasive personality style or frank personality d/o occurred in 90% of difficult patients
3. Most difficult patients have multiple physical symptoms (often somatoform)
Patient Factors (Hahn, 2001 citing Hahn 1994, 1996)
Disproportionate premorbid history of maladjustment, psychological disorders, and ETOH
Depression-Suicide 5-10% vs. slightly above 1% for the general population
Anxiety – 25% of SCI vs. 5% of controlled sample
Cognitive deficits (TBI, LD, medication effects) Pain Substance abuse
Risk factors for SCI
Four risk factors identified by physicians who perceived encounters as difficult:
1. Depressive or anxiety disorder (29%)2. Multiple physical symptoms3. More severe symptoms4. Physician with a “distaste” toward
psychosocial side of care (23% vs. 8%)
All 4 = 47% of the encounters = “Difficult”
Predictors of Difficult Encounters(Jackson & Kroenke, 1999)
It is apparent that it is not easy to separate “patient” factors from “other” factors
Is there a profile of a “difficult doctor”???
422 physicians from 118 clinics, survey data 8-Item Burden of Difficult Encounters
Measure Job Stress Global Job Satisfaction Time pressure Intent to leave practice Latent Cluster Analysis (High, Medium, Low) Logistic Regression Analysis to compare
An, et al. (2009)Archives of Internal Medicine
A “dose response” was found across all tested end points, including stress, job satisfaction, time pressure, intent to leave one’s practice, and perception of suboptimal care practices
Physicians who perceived a higher volume of difficult encounters were more burned out and dissatisfied with their jobs (also supported in previous studies)
More women; younger in the field **Limitations: no cause-effect relationship Value/Relevance: Shared responsibility
An, et al. (2009)
Labeling can lead to stereotyping; stereotyping can limit your openness and flexibility and may reduce communication
Label of “difficult patient” can actually lead to professional and emotional distance
Labeling assumes the provider is ideal, the provider-patient relationship is ideal, all working in an ideal system
Provider-Patient Interface: Labeling
144 final year medical students A single-paragraph case description illustrating a
normal person, a social distance scale and questions on expected burden. Half received psychiatric dx/half no dx
Label on case: would not rent their houses, unwilling to select as a neighbor, not allow sister to marry, felt they would exhaust them physically and emotionally
Results strengthen the view that stigma attached to mental illness is not limited to the general public; medical students can also be part of the stigmatizing world
Ogunsemi et al. (2008)Ann Gen Psychiatry
Provider/Patient interface Consequence of both Provider and Patient
factors; each contributes Patient-centered care appreciates the
asymmetry of the relationship, wherein the provider holds more responsibility for empathy and “focus of treatment”
Bundled approach: organizational, contextual, and provider factors
Progressive View: Dyadic
Improve provider-patient communication◦ Increases patient satisfaction &◦ Improves health outcomes (Kravitz, 2001)◦ Decreases complaints and lawsuits (Virshup et al., 1999;
Levinson et al., 1997)◦ Improves adherence 19% (Zolnierek & Dimatteo, 2009)
Ask patients about their understanding of the illness/problem and expectations of care (correct misconceptions and unrealistic expectations; exposes barriers/benefits/risks; builds rapport)
Include psychology
Tools: Standard Practice
Identify the source of the problem◦ Patient? Provider? Relationships? System?
Psychiatric liaison or Psychology consult to help provide insight and guidance◦ Clear TEAM treatment plan; setting limits
TEAM is the treatment CONSISTENCY Discuss with peers Try to always respond with respect and frame
in ethics
What to do in real challenges?
1. Autonomy: right to refuse or choose2. Beneficence: act in the best interest of the
pt3. Justice: fairness and equality of health
resources 4. Dignity: Pt and provider have the right to
dignity5. Truthfulness/Informed consent6. Non-malfeasance: “first do no harm”
Medical Ethics
Psychological (depression; anxiety; noncompliance)Physical (chronic pain; sleep; nutrition; fatigue;
substance abuse; sexual problems; agitation)Cognitive (delirium/dementia; attention; initiation;
memory; processing speed; unawareness)MISC (excessive demands; anger; apathy/silence;
verbal outbursts; decreased participation)
Budd, M.A. (in press). Rehabilitation Psychology. In M Gonzalez-Fernandez & JD Friedman, eds, Physical Medicine and Rehabilitation Pocket Companion. Demos Medical: New York.
Challenges to effective rehabilitation
1.It is not uncommon for providers to view patients as “challenging” particularly when working within a specialized field inherent with abundant stressors such as SCI
2.Labeling and “pigeonholing” are not helpful; conceptualize each case individually and contextually
3.Operating from an Ethical Framework is a fundamental place to start for all interventions; always is in the best interest of our patients as well as our professional integrity
4. TEAM approach will optimize mental and physical health for our patients with SCI across all providers and over time…
Take Home (& to The Team) Messages
Do not take challenging visits personally, recognize that it is normative
Dealing with “challenges” signifies mastery rather than weakness
Reminders
Link perceived “challenges” to specific encounters and measure the patient and provider’s perspectives in tandem, and include longitudinal assessment to evaluate the effect of challenging encounters on patient and provider satisfaction, adherence, functional improvement, quality of life and health care costs.
Future Directions
