How To Manage Difficult Patients

By John V. Guiliana, DPM, MS, Hal Ornstein, DPM, and Lynn Homisak, PMAC

Is there a particular patient or two you dread seeing in your office? If a vote took place among physicians as to what kind of patient provokes the most distress in healthcare providers, we would bet many providers would answer “patients who fail to comply.” In fact, providers often react with anger and frustration when patients ignore their professional recommendations. Aside from the potential legal ramifications, a patient’s lack of compliance often triggers feelings that our professional opinion is devalued and may even cause us to begin to question our own self-worth. When our own self-esteem is under attack by a non-compliant patient, we may unleash our anger and frustration by withdrawing from the patient or inducing guilty feelings. It may even cause us to preach to the patient. By definition, non-compliant patients place their medical outcomes at risk. There are many reasons for noncompliance: • not convinced of need for care; • language barriers; • care is perceived as too costly; • problem with understanding the treatment plan; • undesirable side effects; • personal conflict with the provider; and/or • philosophical, cultural or religious beliefs. As we all know, patient noncompliance is more likely to occur when we give advice or treatment recommendations that either negate a perceived positive experience or cause a negative experience for the patient. For example, when you emphasize to a patient that he or she needs to stay off of the foot, it may interfere with his or her positive experience of shopping or playing basketball. Conversely, taking an antifungal medication that could potentially cause some liver problems also may elicit a perceived negative experience. Why Responding Is Better Than Reacting When you are dealing with a non-compliant patient, it is essential to control your reactions. Providers should respond and not react. In responding, you consider the true meaning behind the patient’s noncompliance and respond accordingly. This is in contrast to reacting without forethought, which often leads to taking more of an adversarial stance or position. Responding requires active or empathic listening skills. Ask youself what the patient is really saying. Why is he or she saying it? In other words, we must listen carefully in order to identify the patient’s real motive for noncompliance. Indeed, if you deal with this directly, you’ll have a far better chance of converting the difficult patient to a compliant one. Remain Warm, Friendly And Understanding As providers, we must turn inward and analyze our own feelings toward difficult patients. While the degree to which we control or express our feelings is certainly a fine line, it is nonetheless a critical line of understanding. Not demonstrating enough feelings about noncompliance generates a perception of being cold, aloof, withdrawn or critical. Demonstrating too much feeling, such as agitation, anger or frustration, may lead to abrupt and complete breakdown of the relationship. Patients look for warmth, friendliness and understanding. Some may be able to fake warmth and friendliness, but understanding requires true effort and active listening. With this in mind, let’s consider the following key points in developing a relationship with these patients and helping them overcome non-compliant behavior. 1) Show respect. While the idea of showing respect seems obvious, it is probably one of the most seriously violated principles in our nation’s healthcare delivery according to patient surveys. Ignoring, avoiding or depersonalizing the patient will tend to escalate the conflict. The key is to maintain the dignity of the patient. Remember that ultimately it’s the patient’s right to either choose or defer treatment. If you feel that you are too emotionally charged to address the issue, take a few minutes alone to calm down and gather your thoughts. 2) Learn how to listen actively. Listen empathetically in order to capture the patient’s viewpoint accurately. Only then can you begin to understand the reason behind his or her noncompliance. Ask “open-ended” questions in order to draw out the person’s primary emotions. Use lead-in phrases such as “So I can do what’s best for you,” “Help me understand why you didn’t follow through with our treatment plan,” etc. You’ll find that the patient’s answers to these open-ended questions will give you a wealth of information that can help you to begin empathizing with the patient. Indeed, we must strive to develop a sense of what the patient is actually feeling. Start off by repeating what the patient has told you in your own words. This conveys your understanding and helps facilitate empathy with the patient. This helps to start dissolving any resistance or other barriers between you and the patient. 3) Show concern. One of the most important skills that we should strive to perfect is how we express concern. Caring is perceived by patients in how we respond to their questions, our eye contact, vocal tone and body language. As far as body language goes, demonstrate your attention by leaning slightly forward to the patient. Avoid crossing your arms. Use facial expressions, head nods and vocal acknowledgements that correspond to your concern for the patient. A science known as Skinetics explores how the simple act of touch impacts people. Don’t be afraid to place your hand on the patient’s arm or foot for a brief period. Monitor his or her reaction to the touch and remove your hand if the patient withdraws. Emphasize Objectivity And Empathy 4) Be objective. When dealing with a non-compliant patient, it is important to suppress our own emotions and gather all factual information before making a conclusion. This enables us to respond rather than react. Keep in mind that initial reactions often run the risk of being based on false assumptions. Nothing can break your credibility faster than rushing in to a conflict emotionally charged and filled with false assumptions. People will often mirror our own behavior in these situations. When you calmly gather the facts and remain objective, your patient may begin to behave more responsibly as well. 5) Accept the patient. Accept the patient, not the behavior. Acceptance means acknowledging the patient as a person of worth. We are in a much better position to “bargain” or persuade the patient to alter unacceptable patterns when we come to an understanding that we will unconditionally accept the patient as a person. Using some self-disclosure often helps the patient realize that you indeed accept him or her as a person. For example, use a lead-in phrase such as, “I can appreciate your concern about this medication’s side effects. I am always concerned about medications that I take as well. However … .” This type of self-disclosure allows the patient to realize that it is easy for you to accept their doubts or concerns since you have them as well. Fostering A Sense Of Mutual Cooperation Years ago, patients tended to be more passive when it came to their own health care. At this time, patients did whatever their doctors instructed them to do without asking questions or taking more of the reins of responsibility. As medicine evolved and consumers became more educated, patients, in turn, wanted to take on more of an active role in their care. The continuum shifted to a model of mutual cooperation and even collaboration. Research shows that patients today not only desire this active model, but also are clearly more compliant when there is a stronger sense of collaboration between physician and patient. In today’s digital world, patients often appreciate referrals to Web-based resource centers to help them gain additional information on their condition as well as treatment options. For those who are not computer-oriented, you may give them office brochures about the their given condition. Whenever possible, try to use phrases that encourage patient empowerment. For example, perhaps you could say, “Next week, we will review your X-rays and, together, we’ll come up with the best option for you.” However, keep in mind that the level of empowerment will vary from patient to patient. Some people still appreciate passivity and prefer that you simply give your advice. What About The Consistently Difficult Patients? We all have the experience of dealing with people that seem to push our buttons. Indeed, difficult patients often function from the negative side of their personality. They often fail to recognize how this negative personality affects others. While they are challenging to deal with, there is a great deal of knowledge you can gain by trying to understand the difficult patient’s viewpoint. One particular personality type you’ll encounter is the “Know It All.” These patients project the symptom of arrogance, but this is usually caused by the primary emotion of vulnerability and insecurity. This often has its roots in childhood when the person may have been relentlessly criticized for not being good enough. As adults, the threat of a possible challenge to their knowledge or competence causes an immediate defense shield. Another common personality type is the “Dictator.” He or she may project a “do it my way or else” mentality, but again this is just a symptom. This symptom is prevalent in people with authority, such as those who hold management positions or some other corporate power. These people are living on the negative side of dominance (the positive side of dominance is leadership). As with arrogance, any stress or potential threat will bring on an attack. With this in mind, here are some tips for dealing with the consistently difficult personalities. • When you witness a defensive response or attack, realize that it is useless to argue. Recognize that insecurity is the root cause of the defensive posture or attack. • Don’t continue to push the person. It will only escalate the problem. • If the symptom occurs only when the person is under stress, address the problem at a different time. • Keep your own self-esteem intact. Remember, respond instead of reacting. Keep a cool head and remain calm. Take A Good Look At Yourself: Are You A Difficult Person? Learn to recognize when your own defense mechanisms come alive. Realize that you are probably not being attacked. Try not to react so quickly. In an effort to slow your reaction, you may want to ask for more time to respond to a comment or suggestion. Get back to the patient at a different time. It also helps to recognize your own strengths and weaknesses. Be able to recognize when you’re jumping the gun and overreacting. Again, people often mirror our own behavior. When you have acted inappropriately, apologize with an explanation. While people appreciate a sincere apology, they appreciate it even more when they understand that your inappropriate reaction stems from your concern for their well-being. Final Notes Learning how to deal with difficult and challenging patients not only can help you reduce stress, but more importantly, it can boost your personal fulfillment in facilitating improved treatment outcomes for your patients. n Dr. Guiliana, Dr. Ornstein and Ms. Homisak are partners of SOS (Secrets of Success) Healthcare Management Solutions, LLC. They are nationally recognized speakers and authors on topics pertaining to medical office management.

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