Problem Patients Test Physicians
How to Respond to Difficult Patients
By LaWanda Stone Abernathy
LaWanda Stone Abernathy is a writer for
Physicians Practice
 A
physician who successfully deals with difficult patients has a lot
in common with an acrobat who successfully walks high wires. Each
invests time getting familiar with the subject, performs under pressure
and has a strong desire to succeed.
You don’t have to attempt to walk on a high wire barefoot
to know that it’s no walk in the park. Still, dealing with
problem patients in a composed manner requires a level of precision
and patience that makes falling from a high wire into a net seem
like a reasonable risk.
Try reasoning with a dangerously intoxicated homeless person who
uses your office as shelter, taking the opportunity to sleep there
several times a week until medical attention is received. Physicians
need to know how to deal with challenging situations similar to
this, provoked by problem patients, in their daily medical practices.
Setting limits, restating common goals, scheduling regular visits,
and keeping visits short and focused are some strategies recommended
by the Texas Medical Association (TMA) to effectively respond to
demanding patients.
Perhaps you’ve never had such an unnerving experience, but
if you’re like most physicians, you’ve dealt with plenty
of problem patients. About 5 percent to 10 percent of patients in
a typical primary-care practice are considered difficult to deal
with by their doctor, meaning high-volume doctors might see several
such patients every day.
In a survey of 1,100 executives, 85 percent of the time people progress
in their jobs because of their ability to deal with other people,
according to Z. Ziglar’s “Top Performance: How to Develop
Excellence in Yourself and Others.”
Various degrees of difficulty
Certainly, problem patients come in all shapes, sizes and colors.
They may not enter your practice intoxicated, but they may be seductive,
easily angered, complain incessantly, verbally abuse staff, cause
scenes in reception areas and expect everything to go their way.
Difficult patients also appear as demanding, drug seeking, nonpaying,
rescheduling, noncompliant and violent, according to the TMA.
“There is no one-size-fits-all difficult patient,” said
Gary Glober, a gastroenterologist who spent 20 years in private
practice and now conducts relationship-building workshops for health
care professionals. “Difficulty can come in various packages,
and what’s interesting is that what makes a patient appear
difficult is not inherent in that individual. It’s the inability
of the person with whom they are interacting to handle that situation.”
There are many terms used to identify a problem patient, but at
the ground level, the TMA says difficult patients are defined by
the feelings they trigger in the physicians who have to work with
them. Frustration, uncertainty, anger and feelings of being manipulated
or controlled by the patient are typical.
“Physicians are highly oriented toward success — that’s
the culture and their training,” said Gregory Carroll, a psychologist
who directs the Bayer Institute for Health Care Communication, a
research, education and advocacy organization based in West Haven,
Conn. “Part of it is the actual time spent, and part of it
is the perception of time, which is quite subjective. When you ask
doctors how much time they spend on these patients, they would probably
vastly overestimate it. But they clearly spend a disproportionate
amount of time feeling upset and frustrated, and in some ways, feeling
unsuccessful.”
Difficult patients may harbor similar feelings of doubt. Studies
show patients can be difficult because they feel robbed, ignored
or mistreated; have social, personality or financial problems, and
may exhibit a lack of trust, communication or information.
The four-F technique
The best single “solution” to dealing with difficult
patients is to engage in active listening with them, according to
the TMA. Try to understand what they want and need; restate what
you have heard from them, and then — address their concerns,
as clearly as possible.
Randall Bernstein, O.D., has been in practice 29 years and has had
a mix of patients as pleasant as apple pie and as tough as nails.
Dealing with the public in Indianapolis on a daily basis has been
very rewarding for Bernstein, but at times, equally frustrating.
Bernstein follows a technique he calls “the four F’s”
to defuse problem patients: Feel, felt, found and follow-up.
“I’m an optometrist, so I usually receive complaints
like ‘these glasses don’t fit properly; they hurt behind
my ears.’ Many times, people are irate and looking for a fight,”
said Bernstein, who sees approximately 3,000 patients a year. “If
you give them the fight they want, they will raise it to the next
level and escalate this thing. Your challenge is to diffuse the
situation.”
Have you ever tried to argue with a person and hold their hand at
the same time? It doesn’t work. Many problem patients complain
that their physicians don’t listen to them. Bernstein says
the solution is in walking the irate patients to another part of
the office, asking them what’s wrong, letting them vent without
interruption and then following the four-F technique.
Feel: First say, “I understand how you feel”
to validate their complaint. “They just want to be heard,”
said Bernstein.
Felt: Then, tell them other patients have felt
the same way, i.e., they are not alone.
Found: Next, alert them about a proven solution
to the problem. “We have found that by doing A-B-C, we can
take care of this problem. How does that sound to you, Mrs. Jones?”
See if the response was acceptable to the patient.
Follow-up: Lastly, make sure the problem was looked
into and the change was made.
“Statistics show that if you take care of a patient’s
problem within 24 hours, he will remain positive on your practice
and come back,” said Bernstein. If it takes more than a week
to resolve, no matter what, patients will retain negative feelings
about your practice and will not return. “So if there’s
a problem, it’s in your best interest to solve it as quickly
as possible.”
Likewise, physicians will never satisfy about 1 percent of their
patients, no matter what, said Bernstein. “At first, I took
it personally, but there are just some people who are totally unreasonable
who you will never satisfy,” he said. “You just have
to write it off.”
Physicians are accustomed to solving problems, but in some cases,
the problem may be something the physician cannot solve, said Robert
Gillette, a semi-retired family physician in Rootstown, Ohio, and
a professor at the Northeast Ohio Universities College of Medicine.
“You have to recognize early on that you aren’t going
to make everyone happy,” said Gillette. “A lot of physicians
think their job is to please people, and you have to recognize that
you can’t please everyone.”
Improve
Challenging Patient Relations
Difficult patients are a fact of life
in any practice, especially in primary care. They can increase
staff turnover, cost you money and wreak havoc on your job
satisfaction.
Improve relations with your most challenging patients by going
through the steps described by the Bayer Institute of Health
Care Communication in its ADOBE acronym:
- ACKNOWLEDGE the existence
of a troubled patient relationship early, and vow not to
let it eat you up inside. Identify what sort of difficult
patient you’re dealing with (angry, manipulative,
etc.), and determine what it is about this sort of person
that bothers you most.
- DISCOVER the nature of
the patient’s problem by listening closely and repeating
back the most important aspects of what he tells you to
ensure that you and he understand each other.
- Look for OPPORTUNITIES
to demonstrate compassion by doing things such as sitting
down with the patient instead of standing, and verbalizing
empathy.
- Set and enforce BOUNDARIES.
Some patients can go too far. Set boundaries for the protection
of your sanity and your staff.
- EXTEND the network of people
involved in the patient’s care by calling on the patient’s
family members, social workers, specialists and others who
might be appropriate. (Please note, Humana suggests that
you only do this with the patient’s permission; at
Humana, we stress the member’s right to privacy.)
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