The management of the difficult patient.pptx

difficult patient

1. Managing the Difficult Patient Dr Sodipo Oluwajimi (FWACP, FMCFM) Consultant Family Physician LASUTH, Ikeja Delivered at Randle General Hospital on 21 st May 2024

2. Introduction Medical encounters do not always result in a satisfactory outcome to both the patient and the doctor. Some task the patience, the tolerance and the coping skills of the doctor May result in anger, guilt, disappointment, hatred and resentment. Despite not accepting that there is any improvement in their condition,some patients may continue to visit, remain clingy to the Physician and still remain non-adherent to prescriptions/recommendations. The sight of the usually “thick folder” of such a patient, hearing his/her voice or call may make your “heart to sink”

3. Introduction

4. Who is a difficult patient? A patient who evokes negative emotions such as anger, guilt, hatred, resentment, frustration etc. in the doctor A patient who exhibits behavioral or emotional aspects that affects his care ”Patients who are medically challenging, interpersonally difficult, psychiatrically ill, chronically medically ill, or lacking in social support” “ A person who does not assume the patient role expected by the healthcare professional, who may have beliefs and values or other personal characteristics that differ from those of the care-giver, and who causes the caregiver to experience self-doubt"

5. Definition However, it is more appropriate to refer to difficult problems rather than difficult patients. It is the patients who have the problems while doctors have the difficulties.

6. Prevalence About 15% of clinician- patient encounters are viewed as difficult, it could be higher as it is a matter of perception. While it seems to be in the minority , by their nature they can often take up a disproportionate amount of the doctor’s time, energy and emotional reserves. Could be more prevalent in women ( debatable) , older patients and in Nigeria ( those with connections)

7. Factors Associated with Difficult Patient Encounters Aggravating Effect Exhibits fear, hopelessness, hatred ,helplessness and worthlessness Boundary Violations Disrespectful, blaming , complaining , non –adherence to treatment , threatening , demeaning, obsessive, seductive, dependent, litigious, entitled ( government connection/family/friends ) Complicated social issues Circumstance complicated by homelessness, loneliness, death and dying, financial problems, legal problems, religious and spiritual issues cultural issues Difficult Diagnosis History of mental illness , substance abuse , personality disorder, chronic medical condition , pain, disability , obesity, sexually transmitted infections , terminal illness, medically unexplained illness, malingering, thick-folder syndrome

8. Factors Associated with Difficult Patient Encounters

9. Phenotypes of Difficult Patients Phenotype Characteristics The Dependent Clinger They require an unquenchable need for explanation, affection and attention. They may break social or professional barriers to meet this need, such as calling the doctor at home or continually making unplanned presentations at the clinic The doctor can feel threatened by such patients, and if pushed away, dependent clingers can feel rejected, which may exacerbate their behavior. Entitled Demanders They attempt to control the doctor through intimidation and by inducing guilt or fear in the doctor. They project an air of superiority and entitlement, and may demand tests or consultation prioritization, withhold payment and are often litigious. The doctor may understandably feel afraid and exasperated in such situations, but this type of difficult patient is often driven by an underlying insecurity and is attempting to obtain control through an air of authority .

10. Phenotypes of Difficult Patients Phenotype Characteristics Manipulative Help Rejecters They are patients who are on a self-destructive path but refuse to take important medical advice. They crave the relationship with the doctor and solving or improving the medical situation may threaten that relationship. Substance abuse is a common manifestation of how manipulative help rejecters present and manipulate the relationship, to get painkiller prescriptions The self-destructive denier Rather than wanting to cling to the doctor (like the manipulative help rejecter), self-destructive deniers appear to want to damage themselves, their motivation driven by self-loathing. They may induce feelings of indifference or hatred in the doctor because of their destructive behavior and apparent refusal to change their ways

11. Other Types …… The Internet Expert . They may complain of back pain and arrives armed with information from the Internet. After physical examination, you determine a reasonable course of treatment, but the patient counters by demanding an alternative course of costly diagnostics based on research or friend’s experiences. The Silent-as-a-Mouse Patient . The patient is so quiet it is impossible to obtain a health history. Though they seem to have health concerns, fear, embarrassment and even cultural issues are making it difficult to assess the actual condition

12. Differentials of Difficult Patient

13. Consequences of Difficult Patient Encounter Physician and patient dissatisfaction Conflict and Violence Demoralization Physician burn out Higher risk of litigation Higher liability claims Poorer treatment outcomes

14. Management of Difficult Patient First assess the situation, is it a diagnostic dilemma or a difficult problem or a difficult patient encounter Look inwards and assess for bias as a physician Deploy Patient centered clinical tools Don’t be embarrassed to admit challenges and consider support from other colleagues Use of team based approach may help, ie use counsellor , dietician , physiotherapist etc. as appropriate Avoid focusing on only drugs Always remember, that it could be a mater of perception , which can be subjective

15. General Tips

16. Patient Centered Approach to Consultation Use the FIFE technique to assess the illness experience Feelings Ideas Function Expectations Use of tools such as timeline, family circle and ecomap Find common ground regarding the management Use objective vs subjective ways of assessing progress ( e.g questionnaires, physical examination findings , investigation results etc) Use the opportunity for disease prevention and health promotion

17. Other Management

18. Specific Management Phenotype Specific Measure Dependent Clinger They respond well to an empathic approach that needs to be delivered within clearly defined and enforced boundaries. The Entitled Demander The appropriate use of power is clearly required for such patients, but it is important (and often difficult) to stay in control and interact in a respectful and non-confrontational manner. This may include pointing out calmly but clearly when boundaries are being crossed The Manipulative help rejecter It is important to reflect on our own feelings and expectations with such Patient The Self-Destructive Denier An empathic approach is the most useful here, but this may be emotionally draining for the doctor, consider use of counselling /counsellor

19. Specific Management Internet Expert Give overview of challenges of internet ( positive/negatives) Encourage focused research Avoid being dismissive of patient research findings , worsens the situation Structured clinic appointments The Silent-as-a-Mouse Patient . Assess for significant person who can provide information e.g. using family circle /ecomap Consider using writing aids vs speaking e.g. what's app, but remember ethics and medicolegal

20. Summary Difficult Physician-patient encounter is inevitable in practice. It is the responsibility of Physicians to take care of patients irrespective of their circumstances, attitudes and presentations. It makes it necessary therefore, for every doctor to acquire the necessary skills to deal with difficult patients to improve patients satisfaction and to maintain the physicians mental wellbeing as well as to reduce frustration. Practice makes perfect

21. References Eppel A. Approach to the Difficult Patient. McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna . https://empendium.com/mcmtextbook/chapter/B31.II.21.4. Accessed February 21, 2024 Roberts LW, Dyer AR: Caring for “difficult” patients, in Concise Guide to Ethics in Mental Health Care. Arlington, VA, American Psychiatric Publishing, 2004, chap 10, 453-458 Hull SH, Broquet K. How to manage difficult patient encounters. Family Practice Management. June 2007. Available at http//www.aafp.org/fpm Accessed: 24/02/2024 Leonard JH, Jennifer PL, Michael KM, Osman NS. Managing difficult patient. Am Fam Physician. 2005, 72(10) 2063-2068 Justin B, Susan AM, Angela B. Am. Fam Physician 2023, 108(5)494-500