How To Handle Difficult Post-Op Patients

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Difficult patients are challenging enough but when the difficult patient is also a postoperative patient, the challenge becomes a medico-legal risk. Difficult patients are not difficult because they have special medical needs. They are difficult because they challenge our defenses, stretch our tolerance and patience, or demand much more of our time than we can give. However, it is possible to care for these challenging patients if you know how.
Taking on a difficult patient can spiral into a battle of wills and wits that you are destined to lose. That is why it is necessary to understand your own limitations and personality. You have to manage your emotions and be as professional and calm as possible, regardless of what your patient says or does. It is important to avoid emotion that clouds your judgment and over-personalizes your interaction with the patient. This takes practice and a willingness to learn from mistakes.

When A Patient Has Unrealistic Expectations
When it comes to a patient’s unrealistic expectations, it is obviously best to manage this in a proactive manner. For surgical candidates, knowing the medical and psychiatric history of the patient is the bare minimum. You have to understand the patient’s past patterns of behavior in order to ascertain future behavior. These patients (or their families) demand results and need to be kept up to date on the specifics of their treatment. They often attempt to have control over every aspect of their care.
Try to build trust early on in order to avoid future conflict. Acknowledge that you are a partner in the patient’s care but that you are also a trained professional with a set of skills and specialized knowledge. Avoid the appearance of condescension. Be thorough with explanations and be sure to dispense patient education handouts about their condition or proposed surgery.
Informed consent should be very thorough. An informed consent is a shared decision between you and your patient. This is not a task to delegate to your office staff. Having the patient sign a long list documenting potential risks and complications without a full discussion with the surgeon is not an informed consent. Informed consent occurs when you have explained, and the patient understands, the diagnosis, recommended treatment, alternative treatment, expected outcome, the risks and complications, and the benefits and risks of doing nothing. Use terms that the patient understands and use a translator if necessary. Document the discussion and note if others (such as family) were present.

Keys To Interacting With Frustrated Or Angry Patients
Anger is a common emotion expressed by patients and their families. The most typical reaction by health professionals confronted by the angry patient or family is either to get angry themselves or to withdraw physically and psychologically. Neither is a helpful coping strategy.
Look for the underlying source of anger. Fear and frustration are probably the most common sources of anger, especially during times of pain or suffering. The anger is often released on the healthcare provider and staff. Other sources of anger may be genuine (e.g. waiting six hours to see the doctor).
It is important to recognize the direction of anger. Recognizing the difference between internal and external anger is critical to effective management because internal anger may lead to potentially harmful patient consequences.
The patient may direct his or her anger internally because of fear and guilt. You may hear the patient admit that he or she is not taking care of him- or herself. Other patients may express concern that they feel they are abandoning their family or job. This internally directed anger could lead to withdrawal, self-neglect, anxiety, depression and/or a combination.
Others may direct their anger outward toward physicians. In either case, one should engage rather than withdraw from the patient. The natural tendency for the physician or health professional is to cut short the office visit, find ways to avoid contact with the angry patient or family member, or try to mask his or her own anger in order to continue to interact with the patient. Speaking with other colleagues about the situation (without violating HIPAA) is often insightful and can help relieve the stress of the situation.
Occasionally, a postoperative patient may become angry over the financial burden that may result from undergoing a surgical procedure. How your office handles billing and collection is critical to maintaining good relationships with patients.
Your office staff should inform new patients of your billing practices and how insurance claims are handled. Be willing to discuss fees and allow payment over time when necessary. Do not deny treatment for a post-op patient because of an unpaid bill. Before sending an account to collection, personally review the chart for evidence of a disgruntled patient. Avoid antagonizing an already unhappy patient as aggressive billing practices can easily convert an unhappy patient into a plaintiff.

When Patients Have Pain Or Less Than Adequate Results
Pain is the most prominent complaint of many frustrated patients. Some may just be looking for narcotics or other pain medications. You have to ask yourself whether the patient’s actions are in the form of narcotic seeking behavior or the result of a chronic pain syndrome that requires referral to a pain specialist.
Do not doubt the patient’s pain, organic or otherwise. The best response is to acknowledge that the patient truly has a pain issue and to tell him or her that there may be more productive ways of dealing with a pain issue than turning to medication. Obtaining second opinions on these cases is of course essential.
If you are suspicious that the outcome may lead to litigation, it might be wise to contact the risk management department of your malpractice carrier for some advice. Again, proactive strategies are far more effective than reactive ones.
As with any difficult patient situation, communication techniques are especially important so both the patient and physician do not become further embittered and frustrated. Use the “BATHE” approach to create an empathic dialogue:
Background. Use active listening to understand the story, the context and the patient’s situation. Try to understand the patient’s point from an emotional perspective.
Affect. Name the emotion in a paraphrase: “You seem very angry.” It is crucial to validate feelings so the angry person feels you are listening. Attempting to defuse the patient’s anger by countering with your own anger or ignoring the patient’s anger is counterproductive. Acknowledging the patient’s right to be angry will help start the healing process and solidify the therapeutic relationship.
Troubles. Explore what scares or troubles patients the most about their present and future. Just asking the question, “Tell me what concerns you” will help them to focus on circumstances they may not have considered.
Handling. Knowledge and positive action can help mitigate fears and reduce anger. How are they handling the pain or less than adequate outcome? Are they losing optimism?
Empathy. By displaying empathy and concern, you can help the person feel understood as well as less abandoned and alone. Avoid trite statements like “I know what you are going through.” Paraphrasing the patient’s comments is an effective way to convey that you heard and are seeking to understand.
It is essential to follow the patient closely. Seek second opinions but do not do so just to “turf” the patient elsewhere. When possible, you should direct the second opinion rather than merely allowing the patient to decide who he or she sees. Diligent follow up with the second opinion provider as well as the patient is required.

What You Should Know About Noncompliant Patients
Noncompliance accounts for approximately 125,000 deaths in the U.S. every year. There are numerous reasons why a patient might be noncompliant.
Having pain involves loss of control. Some patients cannot accept this and will try to regain control by refusing to follow instructions, treatment or testing. This is when you have to be patient enough to repeat your explanation of the necessity of the followed course. You should also be willing to compromise a bit by forgoing a specific test or medication if it will not adversely affect care. Doing so may win cooperation.
If the patient continues to refuse, then you have to decide whether the individual is of sound mind and understands the risk of refusing treatment or following directions. If not, then the situation is more complicated and it is advisable to carefully weigh the long-term risk and benefit to the patient. Involve family members and colleagues in making this decision.
As much as most physicians would hate to admit it, many noncompliant patients are simply the victims of poor provider-patient communication. It is critical to use all of the components of good communication skills for all patients. These include good eye contact, vocal tone and posture. Not only should you restrict the dialogue to layperson’s terms, you should always allow time for questions.
For the patient who understands the risks but simply refuses to comply, it might be prudent to consider discharge. However, be certain not to abandon the patient. A proper discharge demands a certified letter indicating the reason for the discharge as well as a “grace period” to allow the patient time to find an alternative provider. Rather than referring the patient to a colleague, consider directing the patient to the state medical society for a referral.

Seven Rules For Minimizing The Risk Of Potential Malpractice Claims
Liability risk is something that many physicians worry about in managing all difficult patients. Most medical malpractice carriers would agree that the manner in which one approaches the difficult patient often determines if the physician will ultimately become a defendant. Following some simple rules may help preclude litigation.
Rule #1: Do the right thing. It is so much easier to just do the right thing than think of the proper legal course to handle the situation. You should always stop and think about what you are doing and saying, and approach the problem with compassion and empathy. You and the patient need to find a mutually satisfying solution to all conflicts.
Rule #2: Meticulously document any conflict. This includes what you told the patient about the consequences of the patient’s actions and the treatment and follow-up that you have recommended.
Rule #3: Never lose your temper. If physicians feel the urge to vent, there is always the supply closet. Transferring your anger and temper on to your staff also is not allowed.
Rule #4: Stay out of danger. Do not feel obligated to put yourself in danger of physical assault. Keeping your own temper under control does not mean that you or your staff should accept foul language or violent behavior from a patient. You have the prerogative to ask the patient to leave the practice if he or she becomes unruly or disruptive.
Rule #5: Never be distressed by insistent patients. Sometimes, a patient comes into the office with a list of problems, a list of doctors whose treatment efforts have not succeeded and a list of medications that did not work. These patients often have an even longer list of procedures, tests and medications that they desire. Instead of becoming distressed, you should firmly explain your protocol to the patient along with the rationale for that protocol.
Rule #6: Investigate the patient’s mental state. When a patient has a lot of ongoing and nondescript complaints, be sure to explore the possibility of depression. Providing lots of medications or procedures is not the answer. Consider discussing this and referring the patient for a psychological consult.
Rule #7: Do not shirk difficult patients. As a healthcare provider, you have an obligation to care for your share of these difficult patients.

In Conclusion
All difficult patients demand significant time and psychic energy from physicians. If you know yourself and know your patient, focus on the big picture, be compassionate and always set limits. Maybe your next difficult patient will not be so difficult.

Dr. Guiliana is a nationally recognized speaker and author on topics pertaining to medical practice management. He holds a Master’s in Health Care Management and is a Fellow of the American Academy of Podiatric Practice Management. He is a partner is SOS Healthcare Management Solutions, LLC and practices in Hackettstown, New Jersey. He can be reached at John@soshms.com [4].