In this blog, I want to share with you strategies to help you better understand and treat the patient that you may deem “difficult.”
So what do I mean by difficult? I am not referring to a difficult diagnosis but rather a difficult emotional status of the patient. One of my mentors, John Ruch, DPM, describes this patient as the “delicate flower.”
To illustrate, these patients present with an impressive podiatric history, which usually includes prior surgeries and treatment from multiple podiatrists and orthopedists. Be prepared for the garbage bag of shoes, orthotics, splints, braces and creams that patients will use for a show and tell of what they have been through with their condition. These patients are usually middle-aged women but certainly there are exceptions.
Concomitant problems that are commonly associated with these patients include: chronic pain, depression and fibromyalgia. It is easy for one to dismiss such patients by stating they are crazy. They may have some emotional problems but their pain and podiatric problem(s) may be real too. Everybody needs the benefit of the doubt.
Eight Tips For Managing Difficult Patients
The following is a list of helpful tips for managing these patients.
1. Schedule an appropriate amount of time for the patient encounter. If you know the patient has scheduled a second opinion, has been referred by another podiatrist/orthopedist or tells your receptionist that he or she has a complicated problem, double the allowed time that you would usually book for a “run of the mill” new patient. You are never going to get through a detailed history and physical with imaging and old records to review in 15 to 30 minutes.
2. Listen to your patient. When exasperated patients present with a complicated problem, you need to let them “burn out.” I let them talk and listen until they have said everything they feel they need to say to describe their problem. If you try to finish sentences for them, change the subject, appear to be uninterested (ie, yeah, yeah, whatever), then the encounter will be counterproductive and will ultimately feed the emotional underpinnings of the patient.
3. Don’t minimize the problem. Regardless of what the problem may be, it is important and serious to the patient. Granted, we are not dealing with a 6 cm abdominal aortic aneurism that is about to rupture but the patient has made the commitment to see you for your expertise and recommendations. So giving the patient the message that “it is just a corn” will be counterproductive.
4. Get to know the patient and problem. I have found it is sometimes beneficial to see the patient a few times before performing any major surgery/treatment. There are times when the diagnosis is confusing. When one is considering multiple surgical treatments, physicians can get a better handle on things by taking a fresh look at patients. This may involve repeating the exam, watching them walk and asking pertinent questions.
5. Do not promise what you cannot deliver. If you do not have the experience to help these patients, refer them to someone who can. The best thing you can do for your patients is to be honest with them and give them realistic expectations. Sometimes the truth hurts. Sometimes you do not want to tell your patient to live with the foot condition (pain, deformity, etc.) just because you think you can fix everything. Do not forget that, at times, less is more and sometimes the best treatment is no treatment. I am sure you have heard the famous Voltaire quote: “The perfect is the enemy of the good.”
6. Don’t bite off more than you can chew. When it comes to a complicated revisional surgery, prepare your patients for multiple surgeries. You will need to tell your patients they have a very difficult problem that may need two or three stages of surgery to complete. Now your patients are prepared (mentally and emotionally) for additional procedures that may need to be done. Yes, in the ideal world, it would be nice to have one surgery, one six-week period of non-weightbearing and one short-term disability from work. However, sometimes that is not practical and can undermine the ultimate goals of pain relief and better function of the foot.
7. Be a good communicator. Since these patients are emotional, they may be angry, crying, placing blame for their past mishaps and rambling, repeating the same information over again during your history taking. It is your job to see past this. Take all the information and distill it down to the core of the problem. Be understanding and verbalize that to your patient. You may say, “Mrs. Smith, it sounds like you have suffered a lot with this condition. You know that you have a very difficult problem and that we are not going to get you better overnight. This is going to be a commitment for both of us.” Encourage verbiage that includes both parties (doctor and patient) as a team.
8. Look forward. It is okay to acknowledge to your patient that he or she had a bad outcome or failure of a prior surgery. Tell Mrs. Smith you are sorry her prior surgery did not work out and neither of you should dwell on it. Your job is to understand why the prior surgery failed and have a game plan to make things better. You want to direct all of your energy toward the future. Rehashing “should have, would have, could have” is not productive.
I hope these insights will help you in your everyday practice. Since I have a referral practice for my podiatry colleagues, I may see two or three of these patients a day. My staff does a good job to screen new patients so we do not double book these patients or have them back to back, which can take its toll on me.
Most of you really do not want these patients because of the extra time, stress and difficult nature. However, helping them can be some of the most rewarding work that you will ever do in private practice. You know it is all worth it when you discharge that “delicate flower” and she hugs you and whispers in your ear: “Thank you for changing my life.”