Managing challenging interactions with patients
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4673 (Published 31 July 2013) Cite this as: BMJ 2013;347:f4673
Abstract
Marika Davies suggests strategies for dealing with “difficult” patient interactions
Your clinic is running late, your computer has crashed for the third time today, you missed lunch, and then a patient with multiple complex medical problems comes in with a long list of new symptoms. He demands that you prescribe a new drug that is still being tested in clinical trials and refuses to listen to your explanation as to why you cannot do so. Voices become raised, and the consultation reaches a stalemate. How do you resolve this situation?
Fifteen per cent of clinical interactions with patients are perceived as “difficult” by doctors.12 Doctors can feel pushed to their limit when they encounter a “difficult” patient, but as the above scenario illustrates, several factors contribute to making a patient interaction challenging. Understanding the reasons behind these challenging interactions is a helpful first step in reducing their frequency.
What makes an interaction challenging?
The factors that contribute to a difficult situation can come from many sources, but can be broadly grouped into the following categories: patient, doctor, disease, and system.
The more factors that come into play, the harder it is to manage the patient interaction effectively. Being aware of these factors and taking steps to reduce them could help to prevent difficult interactions from arising. Labelling the “interaction” rather than the “patient” as difficult creates opportunities to influence our perception of that difficulty.
The patient
Patients can be uncooperative, hostile, demanding, disruptive, and unpleasant (although it is important to remember that patients may think that doctors also show some of these same characteristics). They might have unrealistic expectations or be unwilling to take responsibility for their health. All these factors can contribute to making an interaction with such a patient a challenging experience.
The doctor
Interactions can be more difficult if the doctor is hungry, angry, late, or tired (HALT). Personal factors could be a distraction for some doctors, and in other cases the doctor’s personality traits could clash with those of the patient. In addition, it can be easy to stereotype or label certain patients or their behaviours, which might influence the doctor’s perception of the difficulty of the consultation.
The disease
Some conditions can be more challenging to deal with—such as chronic pain, ill defined diagnoses, or those with little prospect of improvement. The difficulty inherent in managing a particular disease can make the interaction with the affected patient feel more challenging than consulting with a patient who has a more straightforward condition.
The system
Limited resources, finances, and support, as well as time pressures and interruptions, all contribute to the difficulties experienced by doctors.
Why challenging interactions are bad for everyone
Difficult interactions with patients can take up a disproportionate amount of a doctor’s time, resources, and emotional energy. They can cause the doctor to feel stress, anxiety, anger, and helplessness, and can even lead to a dislike of the patient and the use of avoidance strategies. This response could compromise the doctor’s ability to give good care and put the doctor at increased risk of making mistakes, which can affect the clinical outcome for the patient.
A difficult interaction will leave both the doctor and the patient feeling frustrated and dissatisfied, and can decrease the trust in the doctor-patient relationship. As a result, the patient may be more likely to ask for an appointment with another doctor in the practice for a second opinion, or turn up at the emergency department in hospital, which ultimately leads to higher use of healthcare resources.
Handling a challenging interaction
A doctor’s reaction to a difficult interaction can make matters worse. You might find yourself making subconscious changes in behaviour, such as body language and degree of listening. Arguing, talking over the patient, or interrupting the patient can lead to a downward spiral in the interaction.
Identifying that you are in the midst of a difficult consultation is the first step towards dealing with the problem. Diagnosis and management of the interactional “difficulty” might be necessary before diagnosis and management of the patient’s “disease.” To do this takes some skill, and some of the techniques suggested below could help.
Being aware of the causes of difficult interactions and using strategies to cope with them should assist both doctors and patients in achieving a satisfactory outcome to a consultation.
Verbalise the difficulty
Verbalising the difficulty with the patient can help define the interactional problem. For example, you might say: “We both have very different views about how your symptoms should be investigated and that’s causing some difficulty between us. Do you agree?”
This approach names the “elephant in the room” and avoids casting blame. It also externalises the problem from both the patient and the doctor and creates a sense of shared ownership. Verbalising the difficulty can help to build trust and opens the way to considering working together towards a solution.
Consider alternative explanations for the patient’s behaviour
A person who is angry and abusive might, in fact, be highly anxious—for example, about a terminally ill partner. Explore possible alternative explanations through respectful questioning. This approach—known as “reframing”—will make the patient feel more supported and will increase the possibility of finding a way to work more effectively together.
Support the patient
Support the patient by listening carefully and showing empathy. People are more likely to listen if they feel that they have been listened to.
Set boundaries where appropriate
The boundaries you might choose to set could relate to the interaction, such as the patient turning up late for appointments, or clinical issues, such as prescribing drugs with no evidence base. Boundaries should be applied consistently and by all members of the team.
Find some common ground
Doctors and patients might have differing ideas on issues such as diagnosis, investigations, and management options. Difficulties can arise when there seems to be no common ground, which is often the result of unrealistic expectations. Patients might be viewed as “demanding” or “manipulative”’ when they push for a diagnosis or treatment that the doctor is not comfortable providing. As soon as there is some overlap and common ground, the difficulty rapidly diminishes.
Focus on finding solutions rather than areas of disagreement
A solution focused process demonstrates that you are working as a team with the patient. Encouraging the patient to come up with options and working together to agree a solution that is acceptable to both parties can relieve the doctor of being the sole solution maker.
Top tips
Stay calm and professional
Try to see the consultation from the patient’s perspective
Work together with the patient to find a solution and act in their best interests
Have a “debrief” with colleagues after a difficult consultation
Consider a training session in mastering challenging interactions
Case studies*
General practice
Mrs W had asthma, hypertension, and a history of deep vein thrombosis, for which she was on regular drug treatment. She was poorly compliant with the nurse led review clinics and the monitoring of her conditions. However, she would regularly demand emergency appointments to see a general practitioner at which she would inevitably request new prescriptions, claiming to have lost or run out of her inhalers and pills. She would be rude to reception staff and refuse to leave the consulting room until she got what she wanted.
Dr H found himself dreading Mrs W’s name appearing on his clinic list. He realised that he was rushing to end the consultations with her to avoid confrontation, and was prescribing drugs for her when it may not have been in her best interests to do so.
Dr H raised the issue at a practice meeting and discussed ways of dealing with the problem with his colleagues, whom he found supportive. It was agreed that boundaries needed to be set for Mrs W around the use of emergency appointments and behaviour towards staff, and her repeat prescriptions would be monitored. These decisions were shared with all members of staff so that they could be applied consistently.
The boundaries were explained to Mrs W in a way that helped her understand that they were being set in her best interests. Although Mrs W did not turn into the perfect patient overnight, having the boundaries in place made Dr H feel better able to deal with the consultations and hence to manage Mrs W’s health needs.
Hospital
Dr A was on duty one evening in the emergency room. A 70 year old male patient, Mr C, had been brought in by ambulance after a fall in the street, and was waiting in a cubicle to be seen. Dr A could hear shouting and swearing from behind the curtain, and understood that the patient had upset one of the student nurses.
Dr A went in to see Mr C and raised her voice above his shouting to admonish him for being rude to her colleague. She then tried to take a history, but the patient would not cooperate and simply kept repeating that he wanted to go home. Dr A felt frustrated and irritated by the situation. She was also tired and hungry, having been on her feet all day without a break. She recognised this and asked for assistance from her senior colleague, Dr B.
Dr B reviewed Mr C and managed to establish that he was extremely worried about his wife, for whom he was the sole carer. While he was in hospital, his wife was at home alone and unable to take her medication or care for herself. By taking steps to resolve this problem, the patient was then much calmer and willing to cooperate with the necessary investigations and treatment.
*The case studies in this article are composite.
Footnotes
Competing interests: This article is based on a talk given by Mark Dinwoodie, head of member education at the Medical Protection Society (MPS), at the MPS General Practice Conference 2013.