Managing Difficult Patients - Society of Clinical … Difficult Patients William Robiner, Ph.D....
Transcript of Managing Difficult Patients - Society of Clinical … Difficult Patients William Robiner, Ph.D....
Managing Difficult Patients
William Robiner, Ph.D. HEALTH PSYCHOLOGY
DEPARTMENTS OF MEDICINE AND PEDIATRICS
UNIVERSITY OF MINNESOTA MEDICAL SCHOOL
Raise Your Hand If
You became a health professional
because you wanted to deal with difficult
people
Raise Your Hand If
You have ever encountered a
noncompliant patient
You have ever encountered a difficult
patient
You see anybody else in the room who
might be a difficult patient
Impossible People Exist! You will encounter them!
You can’t avoid them!
You can’t fix them!
You can’t make them like
you!
You can’t beat them!
They may not want your
help!
Friendly Advice: Develop
good boundaries with
them.
What is a difficult patient? Raise your hand if you think it is somebody who
Takes poor care of himself/herself
Doesn’t follow your direction(s)
Communicates poorly
Is mean/belligerent
Has chronic pain or doesn’t get better
Wants prescriptions you question
Narcotics
Is unintelligent/“clueless”
Wastes healthcare resources
Wants to sue you
Definition of the Difficult Patient
… “patients who are medically challenging, interpersonally difficult, psychiatrically ill, chronically medically ill, or lacking in social support.” 1
A patient “whom most physicians would dread to treat.” 2
1Adams J, Murray R: The general approach to the difficult patient. Emerg Med Clin North Am 1998;16:689-700. 2Groves JE: Taking care of the hateful patient. N Engl J Med 1978; 296:883-887.
What is a difficult case?
“When we call a client difficult, what we
really mean is that we, the therapists, are
having difficulty working with him/her.”
(Wessler)
Wessler, R., Hankin, S. & Stern, J. (2001). Succeeding with difficult patients. San Diego, CA: Academic Press.
What is a difficult case?
“Difficult patients are those who make us feel frustrated, uncomfortable, or ineffective” (Duxbury)
Difficult patients present some type of threat: They can reject us or harm us (Duxbury)
Difficult patients are those whose disorders don’t respond to treatment (Pollack et al.)
Duxbury, J. (2000). Difficult Patients. Oxford: Butterworth-Heinemann. Pollack, M.H., Otto, M.W., & Rosenblum, J.F. (Eds.). (1996). Challenges in clinical practice: Pharmacologic and psychosocial strategies. New York: Guilford.
Difficult cases are characterized by:
Multiple treatment failures
High risk of abuse
High risk of violence
High risk of legal action
High risk of suicide
Difficult people are those who lead us to
do things we don’t want to do:
React in ways we are not happy with
Do our jobs ineffectively
Feel guilty, anxious, upset, frustrated,
inferior, defeated, manipulated,
conned, used, exhausted, ‘etc.
Do their share of the work
Labels for Difficult Patients
“Gomers”
“Shpos”
“Frequent flyer”
“Heart sink” patients
“Thick chart” patient
“Slow load” patient
(in EMR)
“Train wreck”
“Hateful”
“Turkey”
“Nudnik”
“Crocks”
In Mental Health
Somatoform Disorders
Impulse Control Disorders
Personality Disorders- “Axis II”
» Borderline
» Antisocial
» Narcissistic
» Histrionic
» Dependent
» Obsessive Compulsive
Difficult Patients in Counseling
Demanding
Angry/Blaming
Unlikable
Treat others (e.g., partner) badly
Defensive
Unappreciative
Others? Bernhardt, B. A., Silver, R., Rushton, C. H., Micco, E., & Geller, G. (2010). What keeps you up at
night? Genetics professionals’ distressing experiences in patient care. Genetics in Medicine, 12, 289-297.
Emotional Effects of Difficult Patients &
Situations on Professionals
Anxiety
Guilt
Sadness
Anger
Shame
Powerlessness/responsible
Uncertainty
Bernhardt, B. A., Silver, R., Rushton, C. H., Micco, E., & Geller, G. (2010). What keeps you up at night? Genetics
professionals’ distressing experiences in patient care. Genetics in Medicine, 12, 289-297
Descriptions of Difficult Patients (Physical)
Multiple symptoms involving multiple body
systems
Poor response to usual treatments
Certain medical conditions
» Chronic pain/fibromyalgia/obesity
Terminal illness
Klein D, Najman J, Kohrman AF, et al: Patient characteristics that elicit negative responses from family physicians. Journal of Family Practice 1982;14:881-888.
Gillette RD. ‘Problem Patients’: A fresh look at an old vexation. Family Practice Management 2000; (July August)7:57-62.
Descriptions of Difficult Patients (Behavioral) Rambling, unfocused
» “Everything hurts”
Raises new problems as visit ends » “Oh, by the way…”
Self-destructive
Medication-seeking
Poor hygiene
Over demanding
Manipulative, hostile, exploitative, rude,
demanding, dissatisfied, controlling, lying,
litigious
Descriptions of Difficult Patients (Behavioral)
“Boundary-Busting” » Seductive (sexually or otherwise) » Dependent, clinging » Call a lot/demand extra time
Resistant to health professionals’
recommendations
» Under appreciative
Poor adherence with treatment » Inconsistent drug use » Miss appointments/come late
High utilization of healthcare
Descriptions of Difficult Patients (Psychological)
Unrealistic expectations of cure
Difficult to communicate with
Vague and shifting complaints
Undue concern
» e.g., about minor symptoms
Excessive preoccupation with physical
disease
Impossible People
Play the “blame game”
Confrontation may be fruitless
» ...and provoke denial and blame
Are not swayed by reason
May need to be treated like children
Provide valuable life lessons
Why Patients Miss Appointments
Emotion
» Fear bad news or uncomfortable procedure
» Scheduling delay implies unimportant
Perceived Disrespect by System/Provider
» Time in waiting room
» Symptom resolution by appointment- no sx
Misunderstanding of Scheduling
» Doing provider a favor
» Perception of schedules as fluid, negotiable
Lacy NL, Paulman A, Reuter MD, Lovejoy B. Why we don’t come: Patient perceptions on no shows. Ann Fam Med
2004; 2: 541-545.
Or…
A good looking, well-trained, capable, helpful, patient, cheerful, professional, ethical, successful, wise, talented humanitarian
What Do They Want?
Somebody who will tell them:
"Don't worry about a thing" - I won't worry!”
'Cause every little thing gonna be all right.”
Scope of the Difficult Patients Problem
Older, more often divorced or widowed,
more acute problems, chronic problems,
chronic & medications1
Of Primary care patient encounters (n = 722):2
» ≈ 30% were troubling to physicians
» Psychosocial problems & lower social class
patients were associated with greater
frequency of difficulty 1Chandry J, Schwenk TL, Roi LD, et al: Medical care and demographic characteristics of difficult patients. Journal
of Family Practice 24:607-610, 1987. 2Havens LL. Taking a history from the difficult patient. Lancet 1978;1:138-40.
Prevalence and Impairment
Of patients in 4 Primary Care settings (n = 627)
15 % were judged to be “difficult”
“Difficult” vs. non-difficult patients had:
More functional impairment
Higher health care utilization
Lower satisfaction with care
Difficult patients did NOT differ from non-difficult patients in:
» Demographic characteristics
» Physical illnesses
Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: Prevalence, psychopathology, and functional Impairment.
Journal of General Internal Medicine 1996;11:1-8.
Underlying Reasons Patients can be “Difficult”
Feelings of fear, guilt, worthlessness, incompetence, shame
Loneliness, social isolation
Fear of abandonment
Life stress
Concern about personal safety: at home, on the street, in clinic/hospital, etc.
Past abuse (e.g., sexual)
Disorganized, chaotic life
Earlier adverse medical experiences
Gillette RD. ‘Problem Patients’: A fresh look at an old vexation. Family Practice Management 2000;7:57-62.
Underlying Reasons
Rational need for medical info/treatment
Involvement with tort law or Worker’s
Compensation system
Mentally Altered/Neurological Disorders
» Strokes
» Traumatic brain injury
» Developmental/organic disorders
Underlying Reasons
Mental Disorders
» Somatoform disorders
» Personality disorders
borderline, dependent, ASPD, OC, etc.
» Anxiety disorders
» Mood disorders
» Substance use disorders
Gillette RD. ‘Problem Patients’: A fresh look at an old vexation. Family Practice Management 2000;7:57-62.
28% of Americans have a mental
disorder1
Only ½ of those receive treatment
½ of those treated receive treatment only
through primary care providers
26% of patients in primary care have a
bona fide mental disorder2
25-80% of ambulatory medical patients
have some psychiatric morbidity3
Psychology’s Importance in Healthcare
1U.S. Department of Health and Human Services. (1999). Mental Health: A report of the Surgeon General. Rockville, MD: Author.
2Spitzer, R. L., Williams, J. B., Kroenke, K., Linzer, M., deGruy, F. V., Hahn, S. R. Hahn, Brody, D., & Johnson, J. G. (1994). Utility of a New Procedure for Diagnosing Mental Disorders in Primary Care: The PRIME-MD 1000 Study. JAMA, 272(22):1749-1756.
3 Barsky, A.J. Hidden reasons some patients visit doctors. Annals of Internal Medicine, 94 (1):492-498,
60% of psychiatric care is obtained
from general physicians1
Psychiatrists write < 1 in 4 of all
psychoactive prescriptions2
Non-psychiatric physicians treat >
6.4% of the whole population/year for
mental/substance abuse as part of the
de facto mental health system health1
Most Physicians Provide Mental Health Treatment
1Regier DA, Goldberg D., Tauru CA. The de facto US mental health services system. Archives of General Psychiatry. 1978:35:685-93.
2Moran M. Psychiatrists Write Fewer Than 1 in 4 Psychoactive Prescriptions. Psychiatric News October 16, 2009;44 (20) : 10. 3Regier D.A., Narrow W.E., Rae D.S., Manderscheid R.W., Locke B.Z., Goodwin F.K. The de Facto US Mental and Addictive Disorders Service
System: Epidemiologic Catchment Area Prospective 1-Year Prevalence Rates of Disorders and Services Arch Gen Psychiatry. 1993;50(2):85-
94.
7 of the top 10 health risk factors are
lifestyle or behavior factors1
60% of visits to primary care involve
behavioral health issues2
“100% of medical visits involve a
psychological or behavioral component”3
Psychology and Primary Care
1VandenBos, G. R., DeLeon, P. H., & Belar, C. D. (1991). How many psychological practitioners are needed? It’s too early to know!
Professional Psychology: Research and Practice, 6, 441-448. 2Cummings, N. A., Cummings, J. L., & Johnson, J. N. (Eds.).(1997). Behavioral health in primary care: A guide for clinical integration.
Madison, CT: Psychosocial Press. 3Belar, C. D. (1996). A proposal for an expanded view of health and psychology: The integration of behavior and health. In R. J.
Resnick, and R. H. Rozensky, Ronald H. (Eds.). Health psychology through the life span: Practice and research opportunities.
(pp. 77-81). Washington, DC, US: American Psychological Association.
Mental Disorders & Difficult Patients
Difficult patients (67%) were much more
likely than non-difficult patients (35%) to
have a mental disorder (p < .0001)
Mental disorders account for a
substantial proportion of the excess
functional impairment and
dissatisfaction in difficult patients
Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: Prevalence, psychopathology, and functional
Impairment. Journal of General Internal Medicine 1996;11:1-8.
Depression and Medical Illness
Illness Prevalence of Depression (%)
Cancer 5–50 (most studies: 20–25)
Diabetes 14–22
Fibromyalgia 20–71
Myocardial Infarction 18–25 (40–65 sx)
Alzheimer’s Dementia 15–57
Epilepsy 25–75
Stroke 10–40
Multiple Sclerosis 34–40
Parkinson’s Disease 40
Psychiatric Disorders in Difficult Patients
Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: Prevalence, psychopathology, and functional
Impairment. Journal of General Internal Medicine 1996;11:1-8.
Doctors and Difficult Patients
Evidence suggests that the “problems do
not lie exclusively with the patient” 1
Patients are labeled “difficult” by physicians because of their frustration with the relationship or because of how
the patient sought healthcare2
1Gillette RD. ‘Problem Patients’: A fresh look at an old vexation. Family Practice Management 2000;7:57-62.
2Chandry J, Schwenk TL, Roi LD, et al: Medical care and demographic characteristics of difficult patients. Journal of Family Practice 24:607-610, 1987.
It Takes 2 to Tango
A difficult patient for one
doctor is not necessarily
difficult for another1
Doctors with poorer
attitudes about
psychosocial problems
perceive more of their
medical encounters as
difficult2
1Mathers NJ, Jones N, Hannay D. Heartsink patients: A study of their general practitioners. British Journal of General
Practice 1995;45: 293-296. 2Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: Clinical predictors and outcomes.
Archives of Internal Medicine 1999;159:1069-1075, 1999.
Dealing with Difficult Patients
The patient “whose problems will not go
away...is an uncomfortable reminder of the
doctor’s inadequacy and impotence…”1
Providers’ internal reactions can include:
» Anger, depression, frustration,
resignation, repugnance, disgust
1Corney RH, Strathdee G, Higgs R, et al: Managing the difficult patient: Practical suggestions from a study day. Journal of the Royal College of General Practice, 1988;38:349-352.
2Simon JR, Dwyer J, Goldfrank LR. Ethical issues in emergency medicine: The difficult patient. Emergency Medicine Clinics of North America 1999; 17: 353-370.
Surveys of hospital staff members…blame
badly behaved doctors for low morale,
stress and high turnover.
http://www.nytimes.com/2008/12/02/health/02rage.html?pagewanted=2&_r=1&sq=abusive%20doctor&st=nyt&scp=2
Arrogant, Abusive and Disruptive — and a Doctor
Provider Contributions to Difficult Patient Interactions
Provider Personality and Beliefs
» Judgmental, perfectionism, stubborn
» Depression, self-esteem
» Anxiety, approval-seeking
» Need for control, defensiveness
Other Stressors
Work Style
Time
"If our fast-food society becomes also a
fast-care society, the process may
ultimately squeeze out the essential
ingredients of a workable patient-doctor
relationship, leaving both frustrated
doctors and frustrated patients."
Don Lipsitt, M.D., 1997
Editor, General Hosp Psych
Cultural Contributions to Difficult Patient Interactions The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures.
Anne Fadiman. New York, NY: Farrar, Straus, and Giroux, 1997. “The history of the Hmong yields…lessons ... Among the
most obvious … are that the Hmong do not like to take orders; that they do not like to lose;… they would rather flee, fight, or die than surrender;… they are not intimidated by being outnumbered; … they are rarely persuaded that the customs of other cultures, even those more powerful than their own, are superior, and… they are capable of getting very angry.” (p. 17)
What Do Difficult Patients Want?
“Difficult patients and difficult families
want to be heard and understood…If you
reach out and help them understand that
you want to make them happy,
comfortable, and help them get well, you
will diffuse most conflicts before they
even start.”
http://blog.mynursinguniforms.com/index.php/dealing-with-difficult-patients-and-difficult-families-while-nursing/
Relationship Building Techniques
PEARLS Partnership Let’s work together
Empathy That sounds hard...
Apology I'm sorry for...
Respect I appreciate your...
Legitimization Anyone would be.. ...
Support I'll stick with you …
http://nyumacy.med.nyu.edu/
When Using Confrontation
Choose power struggles carefully
» Enter only those that are worth having
» Enter mainly those that you can win
» Avoid Win-Lose situations
» Avoid Lose-Lose situations
» Take a long view
Seek to “win” wars, not battles
Be diplomatic
Have only a few priority goals
Coping with Difficult Patients- Communication
Avoid being judgmental
Be patient, tolerant
Get good history to understand patient
Use direct communication
Humor
Selective personal disclosure
Coping with Difficult Patients- Additional Strategies
Set limits for time and content
Referral for tests, labs, specialists,
alternative health, mental health
Develop treatment plan/contract
» Set limited objectives
» Schedule for addressing needs
Involve others- family/friends (with consent)
Steer focus away from emotional issues
when necessary
Benefits of Regularly Scheduled Appointments
Make patients feel cared for and understood
Address small concerns before they overwhelm patient
May gradually lead patient to more mature thought patterns
Reduce or eliminate unnecessary telephone calls, tests, admissions, ER visits
Gillette RD. ‘Problem Patients’: A fresh look at an old vexation. Family Practice Management 2000;7:57-62.
Coping with Difficult Patients- Stress-Management
Prepare for the encounter
» Breathe deeply/catch breath
» Check labs/chart in advance
» Spread out difficult encounters
Accept the situation
» “It’s life; this is part of my job”
Approach situation gingerly
» Choose words carefully
» Find things to appreciate
Neutralizing Impossible People
Maintain/protect your self-esteem
Avoid letting your anger take hold
Sidestep accusations/complaints
Don’t appear defensive
Don’t absorb their “impossibleness”
Use silence, humor
Use appropriate touch (e.g., handshake,
pat on back)
Responding to the Difficult Patient
Roberts L.W., Dyer A.R. Caring for "difficult" patients, in Concise Guide to Ethics In Mental Health Care. Arlington, VA, American
Psychiatric Publishing, 2004, chap 10
Steps in Managing Difficult Patients
Step 1: Understand yourself
Step 2: Understand your patient
Step 3: Think, don’t react
Step 4: Form an alliance
Step 5: Treat whatever is treatable
Step 6: Avoid the traps
Step 7: Get help
Step 8: Handle your emotions
Roberts L.W., Dyer A.R. Caring for "difficult" patients, in Concise Guide to Ethics In Mental Health Care. Arlington, VA,
American Psychiatric Publishing, 2004, chap 10
Step 1 in Managing Difficult Patients
Understand yourself
Be aware of your own biases and responses
Understand why certain types of patients
upset you
Realize you’re not a “bad” doctor if you have
negative feelings about some patients
Recognize that everyone has trouble
managing some patients
Roberts L.W., Dyer A.R. Caring for "difficult" patients, in Concise Guide to Ethics In Mental Health Care. Arlington, VA,
American Psychiatric Publishing, 2004, chap 10
Step 2 in Managing Difficult Patients
Understand your patient
Every difficult behavior is a form of
communication
Every difficult patient is trying to express
real fears and needs
Roberts L.W., Dyer A.R. Caring for "difficult" patients, in Concise Guide to Ethics In Mental Health Care. Arlington, VA,
American Psychiatric Publishing, 2004, chap 10
Step 3 in Managing Difficult Patients
Think, don’t react
Remember your duty to help and not harm
Focus on medical and psychiatric issues you
can treat
Strive to be empathic, consistent, and stable
Roberts L.W., Dyer A.R. Caring for "difficult" patients, in Concise Guide to Ethics In Mental Health Care. Arlington, VA,
American Psychiatric Publishing, 2004, chap 10
Step 4 in Managing Difficult Patients
Form an alliance
Find something you can agree upon
Educate the patient about your limits and
responsibilities
Reinforce positive behavior; don’t reward
negative behavior
Roberts L.W., Dyer A.R. Caring for "difficult" patients, in Concise Guide to Ethics In Mental Health Care. Arlington, VA,
American Psychiatric Publishing, 2004, chap 10
Step 5 in Managing Difficult Patients
Treat what is treatable
Screen for medical conditions
Screen for Axis I and Axis II psychiatric
disorders
Use therapy and medication to treat
problems
Roberts L.W., Dyer A.R. Caring for "difficult" patients, in Concise Guide to Ethics In Mental Health Care. Arlington, VA,
American Psychiatric Publishing, 2004, chap 10
Step 6 in Managing Difficult Patients
Avoid the traps of
Wanting to save the patient and be idealized
Wanting to reject the patient and not be hurt
Wanting to punish the patient
Doing anything to help the patient so he/she
won’t hurt himself/herself
Roberts L.W., Dyer A.R. Caring for "difficult" patients, in Concise Guide to Ethics In Mental Health Care. Arlington, VA,
American Psychiatric Publishing, 2004, chap 10
Step 7 in Managing Difficult Patients
Get help
Seek consultation
Foster team consensus
Encourage patient to participate in support
groups
Roberts L.W., Dyer A.R. Caring for "difficult" patients, in Concise Guide to Ethics In Mental Health Care. Arlington, VA,
American Psychiatric Publishing, 2004, chap 10
Step 8 in Managing Difficult Patients
Handle your emotions
Find constructive ways of venting frustration
Prepare yourself for seeing difficult patients
See managing difficult patients as a clinical
and administrative skill to master
Roberts L.W., Dyer A.R. Caring for "difficult" patients, in Concise Guide to Ethics In Mental Health Care. Arlington, VA,
American Psychiatric Publishing, 2004, chap 10
Coping with Difficult Patients-
Learn and Be Proactive
Analyze cases
» What worked?
» What didn’t? Why?
Seek input from colleagues
» M & M Conferences
» Balint groups1
» QAI/Performance improvement
Videotape
http://americanbalintsociety.org/
The Transtheoretical Model of Behavior Change
Stages of Change
Prochaska J.O., DiClemente C.C. Stages and process of self-change of smoking: Toward and integrative model of
change. Journal of Consulting and Clinical Psychology 1983: 51(3): 390-395.
Stages of Change
1 Precontemplation
The problem exists, but person
minimizes or denies it.
Contemplation
Person thinks about problem
and initiating change
costs & benefits
Stages of Change
Preparation/Determination
Person commits to a time and
plan for resolving the problem
Action
The person makes daily efforts to
overcome the problem
Stages of Change
Maintenance
Person has overcome the
problem but needs to stay
vigilant to avoid relapse
CALMER
“Six Steps to Serenity” for
Teachers to Help Residents Work
with Difficult Patients
Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach: Teaching learners six steps to serenity when dealing
with difficult patients. Family Medicine 2004;36(7):467-9.
CALMER Questions for Providers
What stage of change is the patient
exhibiting?
What feelings do you have as you think about
the patient?
How might your feelings influence your
relationship with, and treatment of, the
patient?
What might be underlying the patient’s
behavior?
Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach: Teaching learners six steps to
serenity when dealing with difficult patients. Family Medicine 2004;36(7):467-9.
CALMER (6 Step Action Phase)
Catalyst for change (vs. responsible for it)
Alter your thoughts ( change your feelings)
Listen and then make a diagnosis
Make an agreement with the patient
Education & follow-up
Reach out & discuss your feelings with
trusted colleagues after seeing the patient
• Attendings; peers; team Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach: Teaching learners six steps to
serenity when dealing with difficult patients. Family Medicine 2004;36(7):467-9.
Catalyst For Change
Focus on how you can help the patient
move to the next stage of change?
The only thing health professionals can
control is their own reaction to people,
situations, events
Health professionals can only be a
catalyst
You are not responsible for
changing patients’ behavior
or outcomes Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach: Teaching learners six steps to
serenity when dealing with difficult patients. Family Medicine 2004;36(7):467-9.
Alter Thoughts to Change Feelings
What can you tell yourself to feel less angry, frustrated, resigned, disgusted with patient?
“We feel what we think”
The way to control reactions (feelings) is to change thoughts “I can’t stand this” “This is difficult, but I can get through it”
Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach: Teaching learners six steps to
serenity when dealing with difficult patients. Family Medicine 2004;36(7):467-9.
Listen & Then Make a Diagnosis
Difficult patients are
draining, leading health
professionals to not “listen”
clearly to what they are
saying (biases, beliefs)
Listen carefully to really
hear or see what the patient
is describing or exhibiting
Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach: Teaching learners six steps to
serenity when dealing with difficult patients. Family Medicine 2004;36(7):467-9.
Make an Agreement
Let go of your agenda, even though you
may be right
» Recognize what stage of change they are in
» Agree on “doable” or achievable
recommendations
Confirm patient’s understanding of plan
» Patient’s behaviors
» Your actions/system actions
Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach:
Teaching learners six steps to serenity when dealing with difficult
patients. Family Medicine 2004;36(7):467-9.
Education & Follow-Up
Based on your CALM analysis, how
can you best educate the patient? » Help patient understand rationale for tx
Prescribe “homework” based on
patient’s stage of change
» Include plan for follow-up
Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach:
Teaching learners six steps to serenity when dealing with difficult
patients. Family Medicine 2004;36(7):467-9.
Reach Out/Discuss Your Feelings
How do you feel about the patient and their behaviors?
How can you take care of yourself when patients elicit feelings?
Reach out and talk about your feelings with someone you trust
» We all experience frustration at times with some patients
» You don’t have to do this alone!
Pomm, H.A., Shahady E., Pomm R.M. The CALMER approach: Teaching learners six steps to
serenity when dealing with difficult patients. Family Medicine 2004;36(7):467-9.
If all else fails…
Terminate or Transfer? “How should doctors handle the difficult patient? Well
fire them of course. Difficult patients are dangerous
patients (i.e., more likely to sue). They …harm office
morale and consume time and energy. Cut them
loose…There really is no down side to firing
disgruntled patients.” Christophil M.D. October 4, 2009
“When I had an office-based practice, I fired a patient
every two months. It was always a relief for me and my
staff. Once a patient has been fired by 5-6 doctors, he
just might start to think he should examine and change
his behavior.” Steve Parker, M.D., October 4, 2009
http://www.kevinmd.com/blog/2009/10/doctors-handle-difficult-patient.html