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Difficult doctor-patient relationships

By Sara Jenkins,2014-04-22 20:24
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Difficult doctor-patient relationships

Difficult doctor-patient relationships

    Paul Nisselle,MBBS, FRACGP is Chief Executive, Medical Indemnity Protection Society.

    Abstract

    Background Although difficult consultations constitute about 15% of general practice work,

    patients considered 'difficult' by one doctor, may not be thought Ôdifficult' by another. Rather than

    labelling and therefore dismissing patients, it is more helpful to consider that the relationships may

    be difficult rather than the patient.

    Objective To change the perspective from labelling a patient as difficult to considering the

    difficulties in the relationship between doctor and patient. This empowers the doctor to use

    communication skills to develop appropriate strategies for change.

    Discussion This article describes a method for managing difficult doctor-patient relationships that

    involves acknowledging the problem, settling boundaries, using additional communication skills

    and, when necessary, bringing in external resources to assist both doctor and patient.

    You might agree intellectually that while it's OK to judge a behaviour, it's not OK to judge a patient,

    but do you follow that dictum in practice? For example, we condemn nicotine, alcohol and drug

    addiction but do we really support smokers, alcoholics and drug addicts in their attempts to stop

    their addictions? Or are they just too difficult?

    Labelling, and thus dismissing, difficult patients, is easy but not helpful. Instead, it is more helpful

    to think of difficult relationships. [1-3] Some of the patients that I couldn't stand, were found easy

    to deal with by my partner (and vice versa). Some of the patients found me to be a difficult doctor,

    some found my partner difficult. The differences were in the relationships. The differences and the

    difficulties are as much in us as they are in our patients.

    There are now a number of different programs offered to both general practice trainees and

    established general practitioners to assist in the more effective management of difficult

    relationships. One such program was developed by the Bayer Institute for Health Care

Communication in the US, a not for profit foundation established in 1987 by, but independent of,

    Bayer Pharmaceuticals. [4] To use the Bayer Institute's language, its Difficult Clinician Patient

    Relationships Workshop addresses techniques to assist in those 15% of consultations that are in

    the 'challenge' zone. Its other workshop, the Clinician Patient Communication Workshop, which is

    now offered throughout Australia by a number of RACGP medical educators, teaches techniques to

    enhance both patient and doctor satisfaction from the other 85% of encounters in the 'comfort'

    zone. In becoming the first Australian trained to conduct the 'Difficult Clinician Patient

    Relationships' workshop I discovered that managing difficult relationships is as easy as A, B, C, D

    and E!

    An approach to the difficult relationship

    Acknowledge Some consultations get badly out of control and both you [5] and the patient become more and

    more frustrated. As entrenched positions are fortified, the battle becomes more important than the

    outcome. Saving face becomes a higher priority than problem resolution. Stepping back to both

    acknowledge and verbalise the emerging difficulty gives both doctor and patient a chance to

    restart the relationship. [6] A technique advocated in the Bayer course is to recognise when to say

    to ourselves 'Don't just do something, stand there!' We tend to plough on instinctively, getting

    deeper and deeper into trouble, when it would be far better to pause and reflect. 'Something's

    wrong'. 'What's going on?' Your own emotions can be used as diagnostic tools. 'I'm getting angry.

    Why?'

    If in that situation:

    ? Review whether you 'engaged' properly with the patient at the beginning of the

    consultation. Did you begin aggressively, carrying into the new consultation anger and

    frustration lingering from the last patient (or the argument you just had with a staff

    member/your spouse/your partner...)?

    ? Then mentally run through the rest of the four 'Es' of effective communication to see if

    they have been fully used. After checking engagement, think whether you have

    demonstrated empathy (by making sure the patient knows he or she has been seen, heard

    and understood)? Has the patient received sufficient education, that is,been provided with

    ? Next, make a conscious choice whether you really want to try to work with that particular enough information to understand what you are advising? Have you enlisted the patient patient. If your honest and rational (ie. not based on anger) decision is that you do not motivated them to accept your advice? want to be further involved in that patient's care, then carefully prepare him or her for

    referral or, rather, transferral. Ensure though that you make it clear that such referral is in

    the patient's best interests. In the US doctors have been accused of a new form of

    negligence abandonment!

    If you decide to continue, then you will need to rebuild the relationship before you can proceed to

    manage the medical problem.

    The first step is to share the relationship difficulty, by verbalising it. 'I'm finding it difficult to help

    you because...' Then build a partnership to solve the difficulty. 'How do you feel about that? Can

    you think of ways you can help me help you? Is there something I can do to help us work together

    better?'

    Boundaries

    It's honest, as much as a matter of practical importance, to define your boundaries and seek the

    patient's acknowledgement and agreement to them. [7] Some will be rigid a firm precondition

    for accepting that person as a patient. Some will be negotiable. [8]

    ? 'While I will do everything medically I can to help addicts, I never prescribe drugs of

    addiction to support an addiction.'

    ? 'Mrs Smith, I've made a list of the eight things you've asked me to deal with today, but you

    did not book a long consultation. I think we can deal with three of these today in the time

    we have. Would you like to say which three you'd like me to deal with today and which can

    be deferred to tomorrow?'

    The latter approach is subtle, it sets a time boundary but leaves the patient empowered by leaving

    her the choice of what gets dealt with today.

    Boundaries are commonly temporal (how much time you are prepared to give) and physical (agree

    to a request for a home visit or ask the patient to come to the surgery; accept or avoid a kiss) but

more subtly, they may define a role limit. 'I know you've come to get me to give you a workers'

    compensation certificate, but I don't think I can do that. I'm very happy though to provide a

    detailed medical report to whomever you nominate so you can make a claim for compensation.'

    Boundaries can even be behavioural. 'Mr Smith, please calm down. I'm going to step outside for a

    moment. If, on my return you persist with your aggressive behaviour and foul language, I will have

    to ask you to leave.'

    Sometimes, it's the patient who seeks to impose the boundary.

    Compassion

    Compassion starts with empathy (acknowledging the patient's emotion and making sure he or she

    knows you see, hear and understand them) to which is added practical, helpful action. [9] At its

    simplest it may just be passing a box of tissues when you notice the patient's eyes fill with tears (as

    opposed to not acknowledging the patient's distress because you don't know how to, or don't

    want to, manage that distress). The next level might be to give practical help in making

    appointments, finding contacts and resources. Sympathy is passive; compassion is active. In short,

    compassion is 'feeling plus doing'. [10] Determine the meaning

    People do things for a reason. For example, the teenage girl perceives a positive, immediate

    benefit from smoking (peer acceptance) and perceives the negative, health risks as remote, both

    in frequency and age.

    Every patient comes to you with a pre-set belief about what could be the problem and what might

    be the solution. [11] Your skill is not just to come up with your solution to the patient's problems but to find out what they are thinking. [12] Sometimes their expectations appear irrational. That

    usually means there's a piece of the jigsaw you haven't found. A flat refusal to contemplate a

    caesarian section may flow from 'I'm redheaded. Red heads always bleed a lot. My redheaded

    great aunt had a caesarian and nearly died from haemorrhage.' The science may be wrong, but the

    logic is impeccable. Unless you look behind the apparent unwarranted fear or unrealistic expectation to understand its meaning to the patient, the relationship will remain stuck. It's sometimes helpful not to ask: 'Why did you come to see me today?' which is directly

    interrogative but rather: 'How did you come to see me today?'

    Some concrete thinkers as well as some jokesters will say 'by car' but most patients will understand the question to mean: 'How did you come to decide you wanted to see me today?' which invites information as to the patient's thinking. The 'Why' question will be answered: 'Because I need a Pap smear.' The 'How' might be answered: 'My best friend has just had a breast cancer diagnosed and my Aunt Maude got her cancer of the uterus at my age.' The meaning of the request for a Pap smear is revealed.

    Extend the system

    There will be many occasions when you will want to scream 'Help!' Relationship problems are as much a reason for seeking help as are technical problems. Help can be obtained by referral or transferral but can also be obtained by co assistance. In my own practice we often (ie. two or three times a year) swapped heart-sink patients. One of us would 'wear' the patient for a while and then usually when that partner was on holiday, the other would take on the patient and then keep seeing the patient for a time after the vacationing partner returned.

    If you see a 'battered wife', the external help you might seek will include resources (accommodation, financial assistance), legal advice (what legal obligations are you under to report?), support/advocacy (support groups, legal aid) and more expert medical help. The one caveat is to ensure that the patient does not think you're trying to get rid of him or her. Conversely, if you are indeed referring to another doctor or agency for complete management, make sure the patient understands why.

    Summary

These techniques for assisting in the management of difficult doctorpatient relationships satisfy

    the Gestalt test any experienced general practitioner will have an instant sense that they sound

    right. But have they been proven effective? Over 20 000 doctors have attended one or other of the

    Bayer Institute's courses in the United States. Assessment forms collected at the end of each

    workshop and follow up 5 weeks afterwards indicate the attendees perceived clear benefits were

    obtained from attendance. But that does not prove that the workshops produced behavioural

    change in the attendees or improved outcomes for both doctor and patient. With the assistance of

    Bayer Australia, an Australia wide program of workshops is proposed for the year 2000, with pre

    and post workshop attendance clinical audits, conducted in accord with RACGP protocols.

    Insight into the problem is the necessary first step to solving it. Making the paradigm shift away

    from thinking of difficult patients to thinking of difficult relationships is the first step to managing

    such relationships better.

    References

    1. Lipsett D R. The difficult doctor-patient encounter. In: Branch W T ed. The office practice

    of medicine. Philadelphia: W B Saunders 1987; 1348-1356.

    2. Hahn S R, Thompson K S, Wills T A, et al. The difficult doctor-patient relationship:

    somatisation, personality and psychopathology. J Clin Epidemiol 1994; 47:647-657.

    3. Klein D, Najman J, Kohrman A F, Monro C. Patient characteristics that elicit negative

    responses from family physicians. J Fam Pract 1982; 14:881-888.

    4. www.bayerinstitute.com - lists all the Bayer Institute workshops.

    5. Zinn W M. Doctors have feelings too. JAMA 1988; 259:3296-3298.

    6. Novack D H, Suchman A L, Clark W, et al. Calibrating the physician: personal awareness

    and effective patient care. JAMA 1997; 278:502-509.

    7. Quill T E, Brody H. Physician recommendations and patient autonomy: finding a balance

    between physician power and patient choice. Ann Intern Med 1996; 125:763-769.

    8. Lazare A. The interview as a clinical negotiation. In: Lipkin, Putnam, Lazare eds. The

    medical interview: clinical care, education and research. New York. Springer-Verlag 1995;

    50-64.

    9. Willis T A, Hahn S R. Challenges to altruism in medical settings. In: Montada L, Bierhoff H

    W, eds. Altruism in social systems. Germany: Hogrefe and Huber 1991; 204-223.

    10. Suchman A L, Markakis K, Beckman H B, Frankel R A. A model of emphatic communication

    in the medical interview. JAMA 1997; 277:678-682.

    11. Barsky III A J. Hidden reasons some patients visit doctors. Ann Intern Med 1981;

    94:492-498.

    12. Del Banco T L. Enriching the doctor-patient relationship by inviting the patient's

    perspective. Ann Intern Med 1992; 116:4514-418.

    AFP - Journal of the RACGP - 29(1) January 2000

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