Coping with Difficult Patients

PHYSICIANS ♦ ♦ ♦ ♦ FOCUS

Risk Retention Group A Member of The Reciprocal Group®

Volume 11, Number 3 2001 Published by Doctors Insurance Reciprocal (Risk Retention Group)®

Special Edition

Communication: Barriers ... And Bridges Understanding What Makes A Patient Difficult

By Wendy Meyeroff, North-South Medical Communications Strategies

Are some patients really “difficult”… or do they simply present unique challenges to the providers who care for them? Closer examination of the underlying reasons why humans exhibit behaviors that are viewed as difficult may lead to a clearer insight by providers. Greater insight, in turn, promotes more effective responses to such challenging patients.

Challenge #1: The Ill-Mannered Patient Some patients who are viewed as ill-mannered or obnoxious may act that way because they are frightened. Gerontologists and pediatricians face patients daily with a variety of reasons to be fearful, and providers in general can benefit from utilizing their colleagues’ questions for identifying what is truly causing a patient’s “inappropriate” behavior. Is there some communication barrier – hearing problems, language development, etc. – that might be heightening patient tensions? If the patient is advanced in years, might a combination of medications be clouding his/her cognition or judgement?

Could the behavior be an early sign of dementia?

DIR is pleased to publish the following article written by Ms. Wendy Meyeroff, a nationally recognized healthcare communicator. Ms. Meyeroff is a partner at North – South Medical Communications Strategies, a company that services major healthcare clients nationwide.

Ms. Meyeroff is a regular contributor to magazines, newsletters and Web sites for various health professionals.

The purpose of this article is to introduce the topic of "difficult patients," with the intent of more fully outlining effective risk management strategies in future issues of the Physicians Focus.

A major aid for overcoming patient fears is if the provider can develop a strong rapport with the patient’s caregiver, spouse, parent, or adult child. Such an individual can often promote a higher level of patient cooperation, which in turn can facilitate better diagnosis and, ultimately, enhanced compliance with the prescribed course of treatment. The probability of legal disputes may also be reduced, both through the provider being able to deliver better treatment and because the family feels an alliance with the provider.

Challenge #2: “We Are Not Communicating” As the American population becomes more diverse, the number of patients for whom English is a second language increases. Language barriers obviously make proper evaluation and diagnosis difficult. Here, however, utilizing a family member or friends as translators may lead to confidentiality issues, and/or constrained information exchange (the translator may ‘modify’ the patient’s answers out of embarrassment).

PHYSICIANS FOCUS For this reason, many medical practitioners are acquiring proficiency in additional languages in order to better serve their patients. Additionally, medical practices should check on specific federal requirements for providing translation services for such patients.

Challenge #3: The Know-It-All Patient In the current cyberspace ‘information age,’ patients have much wider access to health related information. While it can be disturbing for a physician to have his/her judgement questioned, a patient has the right to ask what the rationale is for prescribing a certain medication, or why a surgical procedure ‘like the one he saw on TV last week’ is not recommended.

Rather than take offense, prudent practitioners will show a willingness to read the cited material and follow that with a discussion about available treatment options with the patient. Conversely, physicians should refrain from being overly anxious to fulfill patient requests for inappropriate or unnecessary procedures.

Challenge #4: “WHO’S Sick?”

It is especially challenging to attempt to treat patients who dismiss the need to follow a specific regimen. Typical is the patient with diabetes who refuses to adhere to the prescribed diet, sneaking ice cream or other “forbidden foods.”

Including both the patient and his/her family members in nutritional counseling (including the risks of poor food choices) may improve compliance in this area.

In other cases, the patient may simply refuse to accept the diagnosis. Showing extremely high levels of denial, the patient may insist that the diagnosis is wrong, since he “hasn’t been sick a day in his life.”

It is important to meticulously document noncompliant behaviors in the medical records of such patients, the associated risks of such noncompliance, and the potential benefits of the advised treatments.

Remember, the content of the discussion, including the patient’s questions and the answers provided, warrant immediate notation in the medical record. Attempting to reconstruct the nature of such important physician-patient discussions at the end of the work day is less effective than making the entry during or at the conclusion of that patient’s visit.

Challenge #5: Physician Burn Out Long days that include difficult patients can cause a physician to wonder, “Why am I doing this?” Experts agree that burn out among medical providers is far more common than is widely recognized.

Strategies to reduce burn out include: • Focus on positive patient encounters that have included respect, humor, appreciation, or professional challenges.

• Delegate elements of the ‘in-take’ patient assessment process (BP’s, etc.) to other clinicians, if possible.

• Try to put a positive spin on difficult behaviors. Understand that patients who appear to be challenging a proposed treatment alternative are, in fact, very interested in their own well being. That often indicates that they will be very committed to getting well.

Summary: In spite of the tightening reimbursement environment in which managed care pressures tend to reduce the opportunity for ‘quality time’ with each patient, the ideas and strategies introduced above may make it a bit easier for providers to understand and cope with their ‘difficult’ patients.

The information contained in this publication has been provided to DIR subscribers for informational purposes only only, and is not intended to be relied upon as legal advice. This publication may contain information that is time sensitive and subject to change. Obtain legal advice from qualified healthcare counsel before acting in any specific situation. This information is not intended to be exhaustive on the subjects addressed. There is no guarantee that any benefit will accrue to those entities which adhere to the above points.

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PHYSICIANS FOCUS

FALL 2001 DIR SEMINARS Remaining Seminar Pr ograms (All seminars are from 5:30—8:00 p.m.)

Programs 10/02/01

Cautery Injuries: Risk Avoidance Techniques, Prince William Hospital, Manassas

10/03/01

Cautery Injuries: Risk Avoidance Techniques, Chesapeake General Hospital, Chesapeake

10/09/01

Current Issues in Healthcare Legislation, Roanoke Memorial Hospital, Roanoke

10/22/01

Strategic Interventions in Coping with Difficult Situations, Riverside Regional Medical Center, Newport News

10/23/01

Strategic Interventions in Coping with Difficult Situations, INOVA Fairfax Hospital, Falls Church

There are four ways for you to register:

On-line Fax Phone Mail

http://www.reciprocalgroup.com/dir/seminars.htm Physician Seminar Registration, 1-804-565-1155 Physician Seminar Registration, 1-800-876-8847 Physician Seminar Registration, DIR, P. O. Box 4880 Glen Allen, VA 23058-4880

Risk Management Services: Communicate with Your Consultant

Telephone Consultations A risk management consultant is available during office hours (8:30 a.m. - 5:00 p.m. Eastern Standard Time) to provide physicians and their staff with real time assistance in answering risk management questions. Our consultants have extensive experience in handling issues that affect your office practice. A consultant can provide valuable assistance in developing an action plan for managing specific risk management concerns or the creation of office-wide risk management policies and procedures.

Your risk management consultant can be contacted by calling one of the following numbers: Richmond, VA Roanoke, VA Jackson, MS Nashville, TN Birmingham, AL

1-800-284-8847 1-800-765-8847 1-800-234-8847 1-800-274-8847 1-800-451-3731

Montgomery, AL Jefferson City, MO Kansas City, MO Atlanta, GA Charlotte, NC

1-800-821-9605 1-800-234-2297 1-800-841-4345 1-877-230-8137 1-888-847-1187

Of fice Site Consultations Office Our approach to managing risk is consultative and educational. Risk management consultations are available at no charge to insured physicians. At the physician’s convenience, a risk management consultant will perform a comprehensive review of the practice’s professional and support staff procedures.

Recommendations for reducing malpractice risks in the office are provided via a written report following the on-site visit. Although the consultation will primarily be conducted with the office manager, physicians are required to participate in the introductory and summation discussions.

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PHYSICIANS FOCUS Are You Listening?

George E. McGee, M.D., Mississippi Physicians Insurance Committee Doctors Insurance Reciprocal (Risk Retention Group)® As Speaker of the House of Delegates, Mississippi State Medical Association, Dr. George E. McGee presented the following “Letter from a Patient” at the 133rd Annual Session held on May 4, 2001, in Biloxi, Mississippi.

The changes witnessed in the practice of medicine over the last century are astounding - almost overwhelming.

Despite the odds that seem to plague us, I am optimistic that one thing will never change ... the day-to-day, one-on-one contact and interaction between patients and physicians.

When physicians meet together in large groups, talk often turns to the same issues over and over. However, I thought it might be refreshing for us to hear a different point of view - a patient’s take - on medicine. Therefore, I asked a friend to share his thoughts and feelings about doctors from a non-physician's perspective.

Dear Doc: Boy did you guys screw up. Really.

Why in God’s name did you pick such a profession to devote yourself?

After all, what other job really demands so much, under impossible conditions, with no guarantee that you’ll achieve your goals each day, let alone for a lifetime?

Pain. Sickness. Death. These are your inescapable constant companions. Misery is your economic pipeline.

Each customer is selfish and demands immediate gratification.

We never want to see you. Begrudgingly, we only call when we must. But you better be happy and cheerful that we did.

Where else do you find a field of professionals who day-in-day-out do extraordi-nary things, deliver miracle after miracle, all in answer to the fickle faithless pleas and prayers of their supplicants, only to immediately be vilified for cost of service, and then forgotten?

Physician. Surgeon. Doctor. These are the accepted social references for your work.

But health and healing are misnomers. Deceitful descriptions for what you really are expected to do.

Scapegoat. Enabler. Janitor. Magician. These are the real functions we want.

Take the blame and carry the burden, that is our irreverence for the gift of life. We take better care of our cars than our bodies, and we’re more apt to listen to a mechanic than you.

Let us keep being bad and just give us what we need when the consequences of our actions flare up and inconvenience our access to pleasure.

“No speeches Doc, just give me something to make it go away. Now. Clean up my mess.”

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PHYSICIANS FOCUS And when the task at hand is impossible, you’re still not off the hook. We want you to beat the odds.

Worse, you want to beat them too, even in the face of a sure defeat.

Masochists. All of you.

Sure, when we need you, you’re the best. You’re our everything.

We are always too happy to drag you into our game; an unspoken Muenchausen syndrome in each of us expects you to validate our public demand for pity. Secretly, we are never happy when you don’t tell us our whining is justified. That it isn’t as bad as we make it out to be. And we’re just as upset when you tell us it is.

We put you in the unsought position of an earthly deity, ascribing you all the powers of God, and then chastise you for our invented perception that you think you are superior to us.

We can’t spend a single second to do most of the things we should do to help ourselves.

But should you make us wait a minute for your help, forcing us to pass those excruciating minutes anticipating the salvation you better have in pocket with a year old article in some pop culture magazine that was in your office and that bores us to death; although, we’ll still steal it and take it home to finish later. Why - how dare you?

You’re dealing with the sick and dying. I’m sick and pretending I’m dying. All the same, why don’t you have the time to have more than “Highlights” in the waiting room? Really, is there no decency?

You serve a clientele that begs you to help only when in trouble, ignore most of the advice you offer to fix the situation, and then complain about what we had to pay for the services.

It is we who cloak you in these royal clothes. It is we who wish you to be supreme and almighty. Just don’t drive a car that suggests you’re starting to believe this perception yourself.

All too often, when you fail to overcome our decades of abusing ourselves, not to mention a rock solid indifference to what you know and repeatedly share with us, we rush to extract damages from you for not righting our own years of neglect and carelessness.

“Fail me once you Country Club Crony and I’ll use the lawyer at the table next to you in the pro-shop café to sue you straight to the almshouse. Do as I ask and you’re not getting so much as a thank you.” Hell, we won’t even come back in two weeks to let you see for yourself that we’re doing better.

But don’t stop caring.

Ever.

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PHYSICIANS FOCUS So what do you say for yourself Doc? Feeling duped? How about this to irritate the wound?

You chose this job. Spent years in study. Deal daily with all I just mentioned. And now, you don’t even have the authority and control to perform most of what your learning has taught you.

You’ve memorized Gray’s. You’re still reading the PDR. You gave up your twenties to prepare for this job, and then gave up your thirties paying for what you learned in your twenties. And now someone just entering his or her own second decade is deciding how you’ll do what you do and when and where you’ll do it with not much more than a calculator.

Makes you want to give it up and just go drive a bus.

Or, worse, jump in front of one.

All in all though, I haven’t told you anything you didn’t already know, have I? And you’re still at it.

Well, Doc, you really haven’t screwed up. Because I don’t think you really chose this job.

You were called to it. And it isn’t just one job. You are every person. You are every job.

In no other profession, in no other role or job anyone of us does, in the communities of this world, is your function more connected to humanity.

Distant towns, far from urbanity, can do without pastors and politicians, lawyers, realtors, marketers and even farmers, for each of us can minister, litigate, elect leaders and find homes and food to some degree of our own inherent human nature.

But none of us can do without your skills.

Your skills are special in that they are all fragments, an amalgamation, forged of all these roles. It is the most important of jobs.

You’ve heard, “It’s not the heat, it’s the humidity” and think, “It’s not the cliché, it’s the idiot saying it.”

Except this time.

“We are nothing without our health.”

Cliches are cliches because they are so true — they are never reworded.

My God, Doc, I’ve just told you you’re a cliché.

Ready for that bus yet?

I’ll try to say it better.

Pastor. Politician. Lawyer. Realtor. Marketer. Farmer. Even Janitor. You are all these things. You haven’t picked just one. You picked them all.

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PHYSICIANS FOCUS You have no choice. You must do this. You must do every job. Every time.

You must be our clergy when we face and fear the unknown.

Stay politically on the cusp of protecting us all. Even from ourselves. You must lead us to better lives. Even when we’ve squandered the ones we have.

You must be our negotiators when we bargain for a better tomorrow than the one we feel today. Trade our behavior for cures. you must pay the mortgage.

You must build shelter for the sick and dying, and

You must grow new cures for the curses of this civilization we have carved from the collective wilderness, all in the name of progress; with no regard to the system such progress upsets.

You must promote ways to take better care of all that we have, even beyond our own bodies. And it will always be a hard sell.

You must clean up what you can when we make a mess of our health. Either individually, or as a community guilty of such careless actions.

That’s a lot more than the “do no harm” of your ceremonial oath now isn’t it Doc? So I’ll leave you with a different creed.

If you’re like me, or the man reading this to you right now, and were raised on a farm, you might recognize it. It’s the 4-H’s of rural America’s agriculture clubs.

Pledge your heads to greater thinking, your hearts to greater loyalty, your health to better living, and your hands to larger service.

Not just for your clubs, but for your communities, your country and your world.

That ought to do it. Keep that credo and we’ll keep the old game going.

I’ll tell you I cannot promise that vilification and the begrudging of what you gather as possessions will cease. Or that you will never again be blamed not overcoming our own self-neglect. I cannot promise that we’ll at last start listening to you. That we’ll heed your words and grant you the recognition you so richly deserve.

But you’ll rest each night knowing you are still doing good. That you are not doing harm. That you have kept your promise no matter if we keep ours.

And you’ll also know that if you work to keep each and every one of us as far as possible from the gates of heaven until it truly is our time, when that day at last comes for yourself, those in line will be asked to step aside so that you might pass right through.

Keep your promise Doc, even when the rest of us can’t. God always keeps his, and even He is grateful for what you do.

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Risk Retention Group A Member of The Reciprocal Group速

P.O. Box 4880 Glen Allen, VA 23058-4880 Physicians Focus welcomes comments and questions, 1-800-876-8847 EDITOR Helen Woodfall, Vice President Risk Management Services Graphic Designer Connie Frazier

ANNOUNCING ... THE RETURN OF

Susan Keane Baker ACHE Baker,, MHA, F FACHE In 1996 and 1997, Susan Keane Baker "wowed" DIR audiences with her unique approach to exceptional patient care. Speaking to capacity crowds in Alexandria, Leesburg and Richmond, Virginia, Ms. Baker received outstanding reviews such as:

"Excellent, useful, wonderful; something I can really use! Thank you."

"Best speaker ever!"

"Ms. Baker was most outstanding. Lively, entertaining, knowledgeable."

It's now four years later and we are pleased to bring Susan back to speak to Reciprocal insureds. Her seminar entitled, Strategic Interventions in Coping with Difficult Situations, deals with patient anger and salvaging the clinician-patient relationship.

Susan will appear on

Check out Susan's Web site, www.susanbaker.com

Monday, October 22 -

Riverside Regional Medical Center, Newport News, Virginia

Tuesday, October 23 -

INOVA Fairfax Hospital, Falls Church, Virginia

If your schedule doesn't allow your attendance at one of these fall programs, Susan will be returning in the spring of 2002. Look for more details coming soon!

The following excerpt is taken from Ms. Baker's article entitled, Your Patient Or Your Guest?

Do you consider your patients your guests? Think about the process you follow when you invite guests to your home: First, you invite them - you let them know that you like their company and spending time with them.

Second, you prepare for their arrival. You clean up until your children ask, "Who's coming over?" You try to make your guests feel comfortable when they arrive. "May I get you anything? May I take your coat?"

Third, you give them directions and a time to arrive. You might expect them to be fashionably late, but you'll be there, ready to greet them at the appointed hour.

You introduce them to others in your home. You might give them a tour - even of the obvious. "This is the dining room." You don't speak in a foreign language, such as Portuguese or medicolese.

You don't leave them sitting in the living room alone for forty minutes without telling them what's happening. If asked for something, you would never say, "You're not our only guest, you know." You try to find common interests to talk about. When the visit is over, you thank them for coming.

Are you treating patients the way you treat friends? It's the acid test for determining the level of service quality you are providing.