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Dealing With That Patient
OK, that's an unfair advantage. And certainly, Sauvager has had her share of presedation scuffles. Still, positively interacting with patients, along with getting them to honor your practice policies, challenges all who work in the medical field. What can you do to foster a mutually beneficial relationship with those you serve? Let's look at each of the major types of difficult patients for answers. The Bill Shirker To be sure, some people really do struggle to produce a $25 copay, and insurance companies are piling more and more out-of-pocket expenses onto the consumer. "There's no more $10 copays," says registered nurse Denise Kleber, who is the team leader for the Heart Center's gastroenterologist. But with overhead costs absorbing half of your gross receipts and reimbursements shrinking like the polar ice caps, you need to be on top of collecting every dime you're due from reluctant patients. Luckily, there are some specific strategies to help you ramp up your collections at the time of service:
The Appointment Jilter Frustrating? Yes. Can you improve your stats? Depends. "You really have to look at each case individually," says Kleber. When you have a patient who is chronically late or in absentia, start by probing for details. Can these individuals drive themselves? Are they handicapped in any way? "We'll be a lot more tolerant in those cases," she says. Johnston concurs, adding, "If patients are institutionalized, it's never their fault." She also takes into account the fact that 60 percent of their patient population is on Medicare, which seems directly related to appointment time befuddlement. "They're either 15 minutes late or a half-hour early." Regardless of where the fault lies, you still have a right to decide whether you want to continue a relationship with a patient who's habitually AWOL. If a patient contracts a case of terminal tardiness you may choose to discharge him, but make sure you've noted — literally — a pattern you can prove. "Grievously late" is fairly subjective; decide what's right for your practice. If you use open access scheduling, you'll have a varying ability on any given day to retrofit Johnnie-come-latelies into the daily docket. Those with traditional scheduling will have less wiggle room. For Heart Center, says Kleber, "If it's someone who no-shows three times, the doctors here will consider discharging that patient." She says this is in deference to the rest of the patient panel, some of whom wait four weeks for an appointment. Also, decide when "late" becomes an official "no-show." After 15 minutes? Twenty? Again, disseminate the policy to your patients. Note that if you have a multispecialty practice, needs might differ across specialties. Heart Center Medical Group's endocrinology had problems with "a plethora of patients who were noncompliant. Now if they're late, they have to reschedule. If they miss two appointments [the staff endocrinologist] has them see another physician," says Johnston. The practice took a hard line here because diabetes treatment needs consistent compliance for success. Nuclear testing also has rigid rules, she says: "Three no-shows, and they have to go to the hospital instead. We have the dose of cardiolite ready and it could be wasted. It's very expensive." The Charm School Dropout Or, the belligerence might stem from past history — a former problem that was misdiagnosed, a physician with a curt bedside manner, a snippy nurse, you name it. Such experiences, especially if never resolved, can leave a patient with hair-trigger anxiety and a snappy, demanding tone. Does this mean the individual is just nasty? No, not necessarily. Likely, a patient's wicked ways are fear-based. For whatever reason, this patient's trust in you, your practice, and/or the entire medical system has been damaged. Without trust, protection instincts kick in — sometimes to a rather rude effect. Although it can be tempting to respond in kind to a provocative comment, step back instead, remind yourself the rudeness is not personal and concentrate on resolving the problem. The instant gratification of shootin' from the hip may not be worth the decline in your patient base. As Johnston points out, "one disgruntled patient will tell 50 others." First and foremost, listen to your angry patient, says Johnston. Really listen. "A lot of times it just takes listening to the patients to calm them down. Not all of them; some are just mean. But mostly, they're scared," says Johnston. Ask a few clarifying questions along the way if necessary, and sympathize with the patient's perspective: Yes, insurance companies can indeed be hard to deal with, Mr. Crabbington. Oh, I know, Mrs. Tensionstein, waiting for more than a week for test results can be nervewracking. Next, enlist the patient in mutually solving the problem, while
retaining control. Simply asking, "What are your thoughts
on solving this?" puts some responsibility on the patient
who's off on a rant about waiting 25 minutes over her appointment
time; she may have some truly good ideas. Some patients seem ready to unload an arsenal of sarcasm just
before interacting with your staff. They're irked about
fill-in-the-blank, and somebody's gonna pay. Front-line
office staff and nurses often get the brunt of this. Teach them
that matter-of-fact deflection will go a long way to keeping the
peace. Licensed vocational nurse Bertha Romano provided 57 years
of care in this way; she claims to have loved every minute of it.
Retired just two years, Romano, 83, says she "never had
a lot of problems with patients. They would start something, and
I would change the subject. I would start kidding and teasing,
and they would come around." Romano says she consistently maintained her composure by imagining herself in her patient's place. "Some people don't do that, and they get mad and say things. They always have to eat their words." Important note here: You do not have to become the world's punching bag to provide good care. Draw a very clear line in the sand with your patients; they will honor it. Sauvager says, "I've had patients be rude and cuss me out. I tell them, 'You talk to me like that again, and you can find someone else to help you.' I've never had anyone say, 'Good, go get me someone else.'" Johnston also takes issue with the increasing societal demand for instant gratification: She recalls one infamous, hypersensitive patient with irritable bowel syndrome who barreled into the practice, sobbing, demanding an on-the-spot appointment. When Johnston said the nurse practitioner had a tiny open spot, the patient's husband punctuated his response — "She's not seeing a nurse practitioner. We want to see the doctor now" — by jabbing his finger at Johnston's face. "Some of our patients — the next generation — want it now. Unfortunately, health care doesn't operate that way," says Johnston. "We offer the emergency room, in that case." From Johnston's observations, the biggest demands come from patients who are not critically ill. "I'll second that," says Kleber. "You'll have a patient with a hemoglobin of seven, and it's like pulling teeth getting him in. He'll say, 'Gee, I really don't feel that bad.' The chronic ones want no pain." Finally, follow through — probably the most critical action you can take to appease patient peevishness, says Kleber. "If you can calm your patients and get them to see that you want to help them, you must follow up within 24 hours or you lose all credibility." Johnston says that Heart Center Medical Group takes follow-up very seriously, even if it sometimes means making a call after business hours. "I think [patients] deserve that. We're caregivers. We nurture. That's the best advertising a practice could have."
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Joyce
Sauvager has it easy when it comes to dealing with patients. "If
I have a difficult patient, I just put him under. No more difficulty,"
says the veteran nurse anesthetist. "People
can be nasty. They get violent with me, I step away. But then the
drugs go in, the patient goes out. End of trouble."
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