The demanding patient
1.1
02-04-2006
Short round of theory
Some of the most stressful patients for a GP are those patients
that start consultations with a strong request in a very
demanding way.
Apparently they use the doctor just as a lifeless tool to get what
they want. They give the impression that they don’t trust you
and you notice that you start to feel angry and defensive. You
feel that the patient disqualifies you and that he reproaches you
without reason. Consultations can end in a sort of (hopefully
verbal) war. The doctor ends the consultation steaming with
anger and ultimately giving in with the patient’s demand
anyhow. How can you change this no win situation?
A typical consultation could be:
Patient: I want you to refer me to the internist, this stomach pain
is unbearable and your tablets don’t work at all.
Doctor: But did you take those tablets? You told me the last
time you had difficulty in taking them.
Patient: That was because they didn’t do anything.
Doctor: We could try some stronger ones.
Patient: I don’t see the point in experimenting on me any longer
and I think some real examination has to be done.
Etcetera, etcetera. By now the doctor feels insulted, belittled and
is ready for nasty action. Any GP will recognize this sort of
consultation.
It is very important to see that, even when the patient has a very
strong demand for something (e.g. a referral to a specialist) it is
not necessarily so that this is actually what he wants.
It is your task as a professional to find out what the patient
really wants and you have to do so without getting into an
argument. You have to prevent that you start to feel angry: it
doesn’t help you, it hinders you in really listening to what the
patient is actually saying, it just takes a lot of energy and most
of the time it is wasted energy: the patient gets what he asked
for anyway.
To contain your anger we can use oriental defence techniques
like judo: we don’t resist, we don’t put on a fight, but on the
contrary we give in immediately.
Patient: I want you to refer me to the internist, this stomach pain
is unbearable and your tablets don’t work at all.
Doctor: Of course that is possible.
The effects of this are enormous: suddenly the patient doesn’t
have to fight anymore, he got what he wanted with the first
stroke. What happens is that the patient relaxes, tension gets out
of the air and the doctor can relax too.
When this happens we can start to appreciate the patients point
of view: he has these longstanding pains, the medication doesn’t
work, his wife is nagging him to ask for a referral, his
colleagues tell him they had a gastroscopy immediately, that he
should ask one himself. He would consider himself a failure
when he didn’t get a gastroscopy as well and he has been
building up courage and aggression to confront the doctor.
Of course this is not the end of the consultation, but a relaxed
beginning is necessary for a successful continuation. After your
initial giving in you have to cash in.
Most of the times you can continue the consultation with
further questioning:
e.g.
Patient: I want you to refer me to the internist, this stomach pain
is unbearable and your tablets don’t work at all.
Doctor: Of course that is possible. (little pause, patient relaxes,
but the doctor as well) But can you tell me what makes you feel
a referral is necessary?
Basically you return to the normal consultation techniques as
discussed in “Structuring the consultation”.
However, to get there you may have to use some additional
interventions called “emotional reflections”.
These are very powerful tools and very effective with angry,
upset or emotional patients. What you do is telling the patient
how you observe and interpret his emotional state.
If you are not used to this it may feel as something illogical, as
something that will make the patient even angrier, but you’ll
find that the opposite is the case. However: not every line or
phrase feels good to everybody. You just have to practice and
try out what feels natural to you.
Emotional reflections are for instance:
“ I have the impression that you feel angry”.
“ I have the impression that you are not satisfied with the
examinations thus far”.
“I have the impression that you feel I didn’t do enough for you”.
“You give me the impression that you are extremely worried”.
You will find that invariably the patient gets less angry and
demanding and becomes open to a more quiet discussion of his
problems. The real worries of the patient can be discussed and
probably you’ll find that you have more understanding of the
patient’s position. But also you may find that the patient doesn’t
really want a referral after all and that you are perfectly able to
help him yourself.
Even if you refer the patient in the end you win: you didn’t get
angry, you didn’t spoil your precious time and energy and you’ll
have improved your relationship with this patient. The next time
you see this patient the consultation will be much more relaxed.
Practice
1. Discuss the theory. Do you recognize it? Can you think of a
patient with whom you had this sort of consultation. Can you
tell about it: what happened? Would you like to play it in a roleplay? Try several techniques. Do you notice a difference?
2. Try to find sentences to use after your initial giving in. Try to
find as much as possible. Which feel natural and useful to you,
which not? Try out as many sentences as you want. Try to get
one or two sentences “in your system” to use in your
consultations. Discuss this afterwards in the group. Try out more
sentences.
3. Try to formulate emotional reflections. Try to find as much as
possible. Which feel useful to you, which not? Try out as many
sentences as you want. Try to get one or two sentences “in your
system” to use in your consultations. Discuss this afterwards in
the group. Try out more sentences.