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.

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