How To Deal With The Unruly Patient

John Guiliana, DPM

Whether there is a personal issue fueling the anger or lingering resentment over an insurance-related dilemma, this author offers pertinent insights on the roles of empathy, certain phrasing and body language in conflict resolution. He also discusses key steps to take when patient discharge is necessary.

Interpersonal conflicts are one of the toughest challenges for business owners as conflict resolution can be a very elusive skill. However, learning how to deal with interpersonal conflicts caused by “difficult people” will ultimately enhance your business’s productivity and patient satisfaction.

   The “difficult person” is perceived in many different ways. “Difficult people” may be arrogant, demanding, unrealistic or condescending. Sound familiar? Usually, the difficult person is someone who is working from the negative side of his or her personality rather than a conscious desire to be difficult. These folks are often unaware of how they are projecting themselves and how they affect others. Rarely do people make conscious decisions to be difficult.

   In the business world, we are constantly faced with trying to work with others who may challenge our ability to get things done. There is great value to be gained when we take the time to try to understand another’s viewpoint. By changing our attitude toward them and changing our viewpoint about what makes them “difficult,” we can find a wealth of knowledge to improve our own ability to work with people.

Emphasize Empathy And Active Listening

When it comes to dealing with an angry person, one should first address his or her issue and feelings on the subject in order to start having a constructive dialogue. The angrier the person, the more important it is to acknowledge his or her anger through the use of empathy statements and listening responses first before moving on to the issue. Problem solving with angry people often results in wasted time unless they are ready to participate calmly.

   Resolving a conflict often begins and ends with listening. Successful active listening leads to a sense of empathy of the other person’s needs and position. Empathy, or “emotional knowing” of the difficult person’s position, helps break down the barriers that preclude an amicable outcome.

   During a dispute, actively listen for the primary emotions of the person. Anger is usually a secondary emotion. Common primary emotions include confusion, frustration, anxiety, loss of control and self esteem issues. These buried emotions are often revealed if we just let the other person speak. By empathizing and identifying with those feelings, we may then be able to accurately paraphrase the primary emotion back to the person, resulting in a bridge of understanding.

   In a managed care environment, loss of control is often a root cause of anger. As a result, the receptionist’s post is often referred to as “the hot seat” in many practices. Health issues and fear of the unknown lower a person’s threshold for anger, potentially precipitating a conflict. Condescending people are often manifesting self-esteem issues. One must address these various underlying causes before a conflict can diffuse.

Do Not Lose Control

Difficult behavior is designed to affect you emotionally so you will become aggressive or defensive. When we lose our cool and defend ourselves or become aggressive, we actually end up doing what the other person wants us to do. We lose because we enter into an ugly game in which there are no winners. Self-control is critical. This means controlling our own behavior. You are entitled to be angry or upset if you choose but you can learn to control your behavior as well as the way that you express that anger or upset so something good comes from it. Here are some tips to consider.

   • When dealing with someone who is attempting to provoke a confrontation, make a conscious attempt to slow down your responses. Do not reply immediately since your first gut level response is likely to be an angry or defensive one. Before you respond, ask yourself this question: “How can I deal with this situation in such a way that I create less anger and upset on both sides?” Then respond.

   • Pay special attention to the speed and volume of your speech. When people get excited, they tend to speak quicker and louder, and that causes the other person to escalate also. As the conversation increases in speed, there is less and less thought, and more chance that people will say things that are destructive. Take your time.

Pay Attention To Your Phrasing And Tone

Language is an exceedingly powerful tool. Whether you communicate orally or in written form, the way you express yourself will affect whether your message is received positively or negatively. Even when you are conveying unpleasant news, the impact can be softened by the use of positive language.

   Negative phrasing and language often have the following common characteristics.

• It tells the recipient what cannot be done.
• It has a subtle tone of blame.
• It includes language like “can’t,” “won’t,” or “unable to” that tells the patient what the practice cannot fulfill.
• It does not stress positive actions or possible solutions.
Positive phrasing and language have the following qualities.
• It tells the patient what can be done.
• It suggests alternatives and choices available to the patient.
• It sounds helpful and encouraging rather than bureaucratic.
• It stresses positive actions and positive consequences that can be anticipated.

   If you want to move toward more positive communication, the first task is to identify and eliminate common negative phrasing. The following are quite common phrases that one should avoid whenever possible.

   Expressions that suggest carelessness:

a) You neglected to get ...
b) You failed to ...
c) You overlooked ...
Phrases that suggest the person is lying:
a) You claim that ...
b) You say that ...
c) You state that ...

   If you are going to eliminate negative phrases, you will need to replace them with more positive ways of conveying the same information. Below are a few examples of positive phrasing.

1) If you can send us (whatever), we can complete the ...
2) It seems that you have a different viewpoint on this issue. Let me explain our perspective.
3) Might we suggest that you (suggestion).
4) One option open to you is (option).
5) We can help you to (whatever) if you can send us (whatever).

   Developing a habit of using positive statements rather than negative ones is often a barrier breaking strategy in resolving conflicts.

Go For A Win-Win Solution

Your efforts should focus on solving a problem, not “getting even with” a difficult person. If you insist on one “winner,” there probably will not be one. (If there is, it may not be you.)
During most conflicts with difficult people, we tend to search for a way to win. A win-lose strategy is often a failed one unless the long-term relationship with the other party is no longer valued. Preferably, one should strive for a win-win strategy. In this strategy, each side makes concessions. For example, you solve the patient’s problem and he or she calms down and eventually sees your side. One should use this type of strategy in all conflicts in which the relationship with the person is valued.

   Be conscious of your message and keep it “interest-based” (the patient’s interest is also included in the message) rather than “position-based” (only your position matters).

   Consider the following hypothetical example of a patient who has arrived at the office without the required referral and is now in conflict as she refuses to pay cash.

   A position-based response might be as follows: “I am sorry, Mrs. Smith, but we cannot see you without the referral because if we do, the doctor will not get paid.”

   An interest-based response may be as follows: “I am sorry about the confusion, Mrs. Smith. If we see you without the referral, your insurance company is going to hold you responsible for the treatment and we do not want to see that happen to you.”
In the conflict outlined above, only the interest-based dialogue reflects the patient’s interest. A small fundamental change in how we phrase our thoughts can help dissolve the conflict in its early stages.

Be Aware Of What Your Body Is Saying

Studies show that most of your communication is based on what people see rather than hear. Your words actually account for a minimal part of the messages you convey. Overwhelmingly the non-verbal factors have the most influence. Albert Mehrabian is noted for finding a 7%-38%-55% rule, supposedly denoting how much communication was conferred by words, tone and body language respectively. In the practice setting, patients can see what you are not saying. If your body language does not match your words, you might be wasting your time.

   Eye contact is the most obvious way that you communicate. When you are looking at the other person, you show interest. When you fail to make eye contact, you give the impression that the other person is of no importance. It could also mean that you lack confidence or are untruthful. Maintain eye contact about 60 percent of the time in order to look interested but not aggressive. If this is hard for you, do what you would do anytime you want to become good at something: practice.

   The position of your head speaks to people. Keeping your head straight will make you appear self-assured and authoritative. People will take you seriously. Tilt your head to one side if you want to come across as friendly, open or sympathetic.

   Your arm placement often suggests how receptive you are to thoughts and ideas. Arms crossed or folded over your chest say that you have shut other people out and have no interest in them or what they are saying. This position can also say, “I do not agree with you.”

When All Else Fails

When the physician-patient relationship breaks down, it could be detrimental to both parties. Physicians have an ethical obligation to maintain the relationship once it is established, an obligation that strengthens over time as the patient begins to depend on the physician.

   Medical ethics, as well as the law, instruct physicians to avoid abandoning a patient. Abandonment has been defined as the physician unilaterally withdrawing from the relationship without formally transfering care of the patient to another qualified physician.1 However, the physician’s ethical obligation does have its limits. A physician may discontinue care of a patient in certain circumstances such as when continuing the relationship may harm other patients, the physician and/or staff. For example, a physician can discontinue patient care if a patient threatens physical violence.

   Even if you have good intentions, the patient-physician relationship may deteriorate to the point where it is best for you to sever the relationship. However, given how much distress discharge can cause patients, discharge should be an absolute last resort.

When You Have Made The Call To Stop Seeing The Patient

When it comes to discharging a patient, the podiatrist should consider the following criteria.

• He or she has done everything possible to address the patient’s dissatisfaction.
• The podiatrist has informed the patient of the consequences of his or her actions, both for the patient’s own health and his or her relationship with the podiatrist.
• The podiatrist feels that the patient would be better off with another physician.

   Before moving ahead, however, a physician should check with the patient’s insurer. There may be limitations on the ability to discharge patients from that plan or some specific mechanisms for doing so. There may also be instances in which it would be prudent for a physician to contact his or her malpractice carrier to discuss the procedure with a risk manager.

   Once you have made the decision to discontinue the relationship with the patient, you must proceed in a way that is ethically and legally sound. There must be care available elsewhere, the physician cannot jeopardize the patient’s health during the process, and the physician must adhere to several elements of the discharging process.

   Key elements of the discharging process are as follows:

• notifying the patient in writing (certified mail) that he or she is being discharged from the practice;
• communicating the ethically valid reasons why the discharge is taking place; and
• a provision to provide care for a reasonable amount of time to allow the patient the opportunity to find new medical ­­­­care. One should ensure expeditious transfer of medical records to the new physician (with patient authorization).

   While there is no standard definition for the amount of time to allot, most practitioners give patients 30 days to find another physician and usually offer them resources or help for doing so. During that 30-day window, the physician is obligated to continue to provide medical care to the patient should the urgent need arise.

Final Notes

Conflict resolution involves comprehensive use of language, listening, eyes and body language. With practice, one can use this important business skill to enhance patient satisfaction, staff productivity and even your bottom line.

   Dr. Guiliana is a nationally recognized speaker and author on topics pertaining to medical practice management. He holds a master’s degree in Health Care Management and is a Fellow and Trustee of the American Academy of Podiatric Practice Management. He is in private practice in Hackettstown, N.J.

1. Pellegrino ED. Nonabandonment: an old obligation revisited. Ann Intern Med. 1995; 122(5):377-378.

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