Dealing with Difficult
Consultations
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
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Objectives
• Objectives:
– be able to define difficult patients
– be able to list types of difficult patients
– be able to explain how the problem can effect patientphysician relationships.
– be able to define causes for difficult patients
– be able describe the strategies on how to cope with difficult
patients.
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Definition
Difficult patient
is the one with
whom the
physician has
trouble forming
an effective
working
relationship.
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Types of Difficult Patients
• Somatic fixation
– (patients who express personal distress in the form of somatic
symptoms)
• Dependent Patient
– (Dependent on prescription drugs).
• Demanding Patient
– (frequent visit for minor things; requesting medications, tests,
&referrals ) .
• Manipulative help rejecter)
– (Do not follow doctor instructions)
• Self destructive patients
– (Diabetic patients who induce frequent attacks of keto-acidosis)
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Cont……
• Seductive patients.
• Angry patients.
• Patients who are shopping from one doctor
to another for the same problem.
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Difficult Consultations:
Patient with Hidden Agenda
(Patient Reluctant to Talk Freely)
Talkative Patient
Angry Patient
Demanding Patient
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Patient Reluctant to Talk Freely
Causes :
Examples :
 Patient Factors :
 The topic
 Cultural barrier
 Social class barrier
 Dr. Factors :
 Dr. authority
 Time constrains
 Circumstances :
 Presence of 3rd party
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Patient Reluctant to Talk Freely
Verbal Communication
Non - verbal Com.
 Giving reason for the question.
 Showing sympathy &
empathy
 Comments on the patient attitude
 Showing real interest
 Generalization of the problem
 Unhurried manner
 Asking at the right time
 Reflection
 Touch for reassurance
 Mirroring
 Use of physical
examination
 Confrontation
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Talkative Patient
communication skills
Verbal Communication
• Summarization
• Prioritization
Non - verbal Comm.
• Use of touch
• Sympathy & empathy
Behaviors which brake the
• Interruption
• Close ended question
relationship :
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Angry Patient
Communication Skills
• Empathy
• Legitimation
• Non-judgmental attitude
• Respect patient autonomy
• Support
• Flexibility
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Even Angry Customers Are Always Right
Marsha L. Miley and Thomas J. Weida, MD
7 steps for satisfying 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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Dealing with
Demanding
Patient
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Negotiation Skills
(think win-win)
Set limit
Reinforcement
Compromise
Be flexible
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Dealing with Demanding Patients
 Negotiate agenda & goals : Set limit
Reinforcement
Compromise & Be flexible
 Avoid argumentation,
 Explain your rationale,
 Pay attention to the way you say no, and,
 If all else fails, breathe deeply and start over.
 Exceptionally, for some patient
firm boundaries are the rule
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Cues for the physician
Difficult patients
evokes a
feeling of
anxiety,
pressure,
boredom, or
frustration
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Management
• Acknowledge his/her feeling
• Frequent short visits
• Background
– what is going on, life history, expectation ?
• Affect
– how do you feel about that problem
• Trouble
– what about the situation trouble most ?
• Handling
– how are you handling the problem ?
• Empathy
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Coping Strategy for the Doctor
• Recognize your true feelings. Difficult patients
evoke a feeling of anxiety, pressure, boredom, or
frustration
• Ability to use resources .
• Be alert for countertransferance reaction in your
self.
• Recognize alternative medicine e.g religions,
herbal .
• Involve colleague in your management plan.
• Improve yourself .
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Respect for persons
1- Respect for patient autonomy (can be
reduced but never absent; people must be
allowed to control their health)
2- Informed consent
3- Truth-telling
4- Respect for confidentiality
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Prevention
1. Preventing patient from dropping out from
the care is of primary importance:
a- keep patient waiting time to a minimum
b- a system for follow-up, ensuring that the
patient leaves clinic with a specific time for
future appointment.
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Prevention………
2. Simplify the treatment regimen:
a- eliminate unnecessary medication. avoid
narcotic as pain killer.
b- medication should be prescribed as few times
daily as possible e.g. tricyclic antidepressant.
c- prescribe the least amount of medications that
is needed to achieve the therapeutic goal.
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Prevention…….
3. Try to protect patient from harm in medical field
(e.g.: unnecessary tests, medications or surgeries)
4. Patient should be actively involved in their own care:
a- Studies have shown that negotiating care with patient
results in better compliance.
b- encouraging patient to take greater responsibility for
their care by asking more questions of their physicians
results in improved attendance
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Suggestions for Better Practice
Management
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Suggestion
Activity
Promote continuity
of care
Educate patients that the
involvement of
multiple health care professionals
may result in conflicting or
confusing approaches; help the
patient maintain a primary care
provider.
Schedule
appropriately
Length of visits should fit
patients’ perceived
needs and expectations.
Modify scheduling systems to
allow more time for
certain patients at the request of
the physician.
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Suggestion
Activity
Access community
resources
Develop on-site or communitybased links to mental health and
social work professionals
Ensure adequate
follow-up
Schedule regular follow-up visits
at two- to three-week
intervals, especially if high
dependency
needs are suspected. Educate the
patient in
appropriate use of telephone or email contact
as an alternative to more
frequent visits.
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Suggestion
Activity
Set firm limits
Discuss and enforce your policies
regarding abuse
of staff, insistence on immediate
telephone
access, or obstruction of the
process of care.
Terminating the relationship with
the patient is a
last resort and should be done
with care.
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Thanks
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