Three factors that cause difficult patient encounters, and how to manage them

The causes of difficult patient encounters can be broken down into three categories: patient factors, physician factors, and situational factors. Recognizing what’s causing a visit to go poorly is the first step to getting it back on track.

Patient factors

• Angry, defensive, or resistant patients. These patients may seem like they’re itching for a fight. Don’t get drawn into a conflict. Keep calm and look for the underlying cause of the patient’s frustration (e.g., they had to sit in the waiting room for a long time). Then, try to empathize (e.g., “I can understand why you are upset, and I appreciate you waiting for me”).

• Fearful patients. Sometimes the root of a difficult patient’s behavior is fear. If you sense that a patient is fearful about a diagnosis, treatment, etc., encourage the patient to talk about it and assess whether the fear is in proportion to the situation. This may help to establish a context for the fear, allowing the patient to deal with it more constructively.

• Manipulative patients. Some keys to managing visits with manipulative patients are to be aware of your own emotions and triggers, attempt to understand the patient's expectations, and realize that sometimes you have to say “no.”

• Somatizing patients. Keys to productive encounters with somatizing patients include describing the patient's diagnosis with compassion, emphasizing that regularly scheduled visits will help to mitigate any concerns, and managing any comorbid psychological conditions as well. Refrain from suggesting “it’s all in your head,” and avoid the cycle of vigorous diagnostic testing and referrals.

• Grieving patients. You can help grieving patients by validating their emotional experience and making sure they understand that grief is a process that takes different lengths of time for different people. Look for signs of depression and maladaptive behaviors that prevent patients from progressing through the normal grieving process, and treat them. Encourage open communication, avoid inappropriate medication to suppress emotions, and caution against major lifestyle changes too early in the process.

• “Frequent fliers.” The first step to a productive interaction is to identify the underlying reasons for the frequent visits. Let the patient know that you have noticed a pattern of frequent visits, which are often due to concerns about undiagnosed symptoms, a need for reassurance, a need for relief from chronic pain, or a need to talk. Ask whether any of these reasons apply or whether the patient has other ideas. Showing understanding will foster an open discussion. Develop a plan with the patient for regularly scheduled return visits, and have your staff provide patient education or check-ins as needed.

Physician factors

• Angry or defensive physicians. An angry physician can derail a visit just as quickly as an angry patient. When you’re stressed or burned out, it’s easy to become angry. Be mindful of your emotions going into an exam, and keep an eye out for things you know can trigger your anger during the visit. Recognizing the source of the emotion can help you manage it.

• Fatigued or harried physicians. If you’re feeling fatigued, harried, or overstretched, look for commitments you can bow out of gracefully or work you can delegate.

• Dogmatic or arrogant physicians. If you find yourself disagreeing strongly with a patient on a plan of care, pause and assess whether you’re emphasizing your own beliefs or values ahead of the patient’s.

Situational factors

• Language and cultural differences. An inability to communicate directly is inherently frustrating, but there are ways to break down these barriers. Work with trained interpreters (rather than family members) whenever possible, and speak to the patient, not the interpreter (face the patient and make eye contact while speaking). Try to be sensitive to different beliefs about health, illness, gender issues, and religion.

• Multiple people in the exam room. When patients bring companions to the exam, speak directly to the patient, avoid taking sides in any conflict, and confirm all parties understand the care plan.

• Environmental issues. Noise, chaos in the clinic, or a lack of privacy can all contribute to a difficult encounter. Try to minimize distractions in the clinic where possible.

• Breaking bad news. When you have to give patients bad news, make sure you’re well-prepared for the questions that will likely arise, give the news directly, and then allow adequate time for patients to process the information and their emotions.

Read the full article in FPM: “How to Manage Difficult Patient Encounters.”