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WHOISTHEDIFFICULT PATIENT?

One who impedes the clinician's ability to establisha therapeutic relationship

A person who does not assume the patient role

expected by the healthcare professional, who mayhave beliefs and values or other personalcharacteristics that differ from those of thecharacteristics that differ from those of thecare-giver, and who causes the

caregiver to experience self-doubt"

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THEHOWTOOF DOCTOR-PATIENTCOMMUNICATION

All communication problems are relationshipproblems.

When communication is difficult, the physicianshould reflect on his/her possible contributions tothe difficulties.

Talking about fears, worries, & the impact of theillness on the patients life is always therapeutic.

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WHOISTHEDIFFICULT PATIENT?

Typical Difficult Patients:

Angry patients

Patients in pain

Anxiouspatients

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UNDERSTANDINGAN ANGRY PATIENT

Mostly due to:

Unmet expectations

Having a disease (suffering the

consequences) Long waiting time

(Perceived) unfair treatment

Inefficient / unfriendly /

unresponsive staff

Wrong diagnosis / treatment

Missed diagnosis

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THE SKILLS

All the ones you learned previously AND

1. Interpersonal space

2. Reflection (statement of an observation of a

feeling or verbal response)3. Facilitation (any comment or behaviour that

encourages elaboration)

4. Personal support

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WHATYOUSHOULDDO

Reflect You look a little upset.

Pause and be attentive

(facilitate)

Tell me about whats upsetting

you.

Acknowledge the difficulty Having to wait for 2 hours is

really a long time. Please accept

my apologies.

Find out the specifics Tell me more about what the

receptionist said to you.

Express empathy Its very frustrating to wait for so

long.

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Guess the meaningbehind the anger

Was it frustrating because you felt

it was a waste of your time?

Take an action on

patients behalf

Ill find out what caused the delay.

Maybe it is something that can beavoided the next time.

Link the patient withresources

Would you like to register a

complaint?

Transition to purpose ofvisit

Well, now that you finally got to

see me, what can I do for youtoday?

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UNDERSTANDINGA PATIENTIN PAIN

Mostly due to:

Immediate pain symptoms

Reduced mobility

Increased dependence Worry about condition

Expects immediate relief

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WHATYOUSHOULDDO

Observation

Verbalizes specific

expressions

Showing some form of

concern

Observe with youreyes, ears, nose,hands

I can see that you

are in pain

It must be difficult for

you to ..

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WHATYOUSHOULDDO (CONT.)

Explaining the need forcooperation

The information is important for

us to understand your condition.

Encouraging &reinforcing positivechange

How are you feeling now?Can we continue?

Establishing &

maintaining control ofthe situation

I understand the:

pain you are going throughthe difficulties you have facedbut

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IDEALDOCTOR-PATIENT RELATIONSHIP

What is Partnership?

Partnership implies a team approach , in whichpatient & doctor work together toward the samegoal.

The use of the pronouns We&Usexpressespartnership.

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EXAMPLE

Lets work togetherin looking at this problem

Lets figure out a way (together) to help you with

this problem

Perhaps we canwork together to make you feelbetter

Together we canwork out some solutions that mayhelp after wehave talked some more about yourproblems

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UNDERSTANDINGAN ANXIOUS PATIENT

Mostly due to:

Medical conditions

Worry about self or family members

Missed / lost opportunities Misunderstanding / myths / hearsay

Stigma

Family history

Fear

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EXPLORATION

The primary communicative intervention forpatients with anxiety is to explore concerns & fears.

"When you think about your illness, what are youmost afraid of?"

Yes, we hear about cancer everydayCan you tell

me what makes you think it could be cancer?

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SOME TIPS

Listen. Anxious patients are usually eager to telltheir stories. Make eye contact. Give them enoughtime.

Ask open-ended questions. Express genuineconcern for their suffering and offer hope that theywill feel better. Make it clear that you take theircomplaints seriously.

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SOME TIPS(CONT.)

Summarize what you believe you have heard andinvite your patient to clarify your perceptions.

Ask them whether there are any other importantthings they want you they want you to know, andwhether they to know, and whetherthey believe you have a goodunderstanding of their case.

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HOWTO COMMUNICATE EMPATHY

Verbal (other than I understand)

I really feel bad for you.

That must be very difficult for you to cope with.

You seem (sad / angry / stressed) today. This cant be an easy time for you.

Well work together to get through this.

Please call me anytime.(If you say this, be sure

that you can make yourself available).

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HOWTO COMMUNICATE EMPATHY

Non-Verbal

Using a sad or sympathetic tone of voice

Expressing concern through your facial expression

Touching a patients hand / pat on the shoulder

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TAKEHOMEMESSAGE

All of your knowledge about dealing with difficultpatients will be of no value unless you master aclinical approach that allows for a caring attitude, athoughtful evaluation, and an accurate diagnosis

and appropriate treatment.