Difficult Patient Interactions.pptx

Difficult Patient Interactions OBJECTIVES Recognize when a patient encounter is going poorly and follow the steps to improving the interaction. Discuss how interactive styles, somatization, difficult feelings, and clinician’s and patient’s feelings about each other can lead to difficult...

Difficult Patient Interactions OBJECTIVES Recognize when a patient encounter is going poorly and follow the steps to improving the interaction. Discuss how interactive styles, somatization, difficult feelings, and clinician’s and patient’s feelings about each other can lead to difficult interactions. Explain the strategy to improve each type of difficult encounter. Demonstrate emotional resilience and compassion when communicating with difficult patients and their families. On some occasions the interviewer- and usually the patient also- becomes aware that the encounter is going poorly. When we sense that ”stuck” feeling, it is helpful to think of the interaction as a “sick interview”- one that lends itself to appropriate diagnosis and treatment. Each type of difficulty calls for particular techniques, some general rules apply.Try to Address the Acknowledge problem by understand that there is a Remain calm. applying what the problem. appropriate problem is. techniques.  Clinician' s& Style Patient's Process Topical Interactiv Somatiza Difficult Impairme Feelings Problems nts Problems e Styles tion Feelings About Each Other Orderly, Occult Technical Controlle Physical Anxiety Sad Reticenc Impairmen Sexual d Disease e ts Functioni Dramati ng Primary Organic c Somatizati Anger Mad Impairmen Long- on ts Ramblin suffering, (delirium g Masochisti & c Secondary Depressio Humoro dementia) Guarded Somatizati on n us , Positive Paranoid Languag Vaguene ROS Factitiou e Barrier ss Attracti Superior s Denial Disease on Dependent & Demanding Orderly & Controlled Dramatizing or Manipulative Long-suffering or Masochistic Guarded or Paranoid Superior INTERACTIVE  These pts strive to impress DEPENDE the clinician with the urgent quality of their requests. NT & They need special attention, massive reassurance, and DEMANDI constant advice. NG Trying to fulfill their You may first identify them as every request may optimistic, compliant, and drive you to “good” patients, because they exhaustion. often begin by making you feel that you are the only one who has ever cared about them or understood their problems. When their need for your constant attention is unmet, they become Soon you find they depressed or withdrawn, expect limitless or they blame you in a amount of attention complaining or vengeful and care. way.  Specify limits of your “contract” with the patient Avoid making promises you cannot keep HOW Emphasize patient responsibility Remind the patient that available TO time is limited, despite your interest and concern DEAL Do not take credit for remission of the patient’s symptoms, because you will likely be blamed for a relapse  Some people cope with their stress by attempting to gain as much knowledge as possible about their situation and to use this knowledge as a way of handling their anxiety. They are punctual for appointments, conscientious in taking medications, and preoccupied with the right and wrong ways of carrying out your instructions. ORDERLY & Sickness CONTROLLED threatens loss of control for people who cope in this way. These patients must be allowed to take charge of their medical care and be given positive feedback about their efforts and abilities. They may present a list of carefully thought-out questions or a precise diary, detailing the frequency and severity of each symptom. They find the scientific approach congenial to their way of thinking and respond well to a professional, systematic sequence of history taking, physical diagnosis, lab studies, and therapy.  Take an orderly and systematic approach to your clinical interview, providing “road markers” (where you are where you are going) Explain every symptom, disease, lab test, or HOW procedure in detail Don’t leave any loose ends Explain the purpose of each maneuver during TO the physical exam especially if it appears unusual or prolonged DEAL Summarize frequently Take notes to indicate your interest and thoroughness Avoid mentioning any vague hypotheses, unusual aspects, or jumbled considerations you may have The dramatic style is a pattern of behavior that may M charm, fascinate, and frustrate you, and eventually A make you angry. N I D The person may have a need to be at stage center P R and may resent your interest in other duties and other U patients. A L M A A The pain is “the worst pain I have every had...it’s with T T me all the time, day and night, nothing seems to I help…I haven’t been able to sleep in weeks.” V I Z E Sometimes these patients are described as histrionic, I hysterical, or manipulative. Such patients may look N upon illness as a drama. At a deeper level, though, the patient may consider sickness a personal defect- a G sign of being weak, unattractive, or unsuccessful.  Listen and observe as the patient talks Remain calm, gentle, and firm. Understand your boundaries. Feed back what you hear, using frequent summaries to regain or stay in control. HOW Remain descriptive, not judgmental or evaluative; focus on the how, not the TO why. If the patient asks you a personal or DEAL uncomfortable question, try deflecting and refocusing on pt. Identify the pt’s strengths and feed them back, profiling the “health person within”, as well as the pt who sits in front of you.  These patients seem to reject help as they present a history of continual suffering from disease, disappointment, and other adversity. They see their lives as never-ending bad luck. (Eeyore) With medical care, they may feel that no treatment will help them; when one symptom or illness disappears, another mysteriously takes its place. They will not “buy” reassurance and optimism. Avoid being overly optimistic or cheerful, focusing on the pt’s strengths or accomplishments, or making patronizing comments (”You will feel better in no time”) LONG-SUFFERING OR  Accept the patient’s pessimism with a descriptive statement HOW such as “It sounds as though you don’t think TO there is much hope of DEAL getting better.” “I wish there was something I could do to help.”  GUARDED OR PARANOID They may recite a long list of slights You may find yourself Inclined to be from others and feeling constantly on suspicious of health openly point out how guard, as if to avoid care professionals and the illness was being “caught” in a the medical care mishandled; or they competitive establishment. blame others for the relationship. origin of their problem. When the patient Do not speak makes a provocative They may not trust negatively about statement, make sure the medical system another health care not to contradict, and you may be guilty professional if the argue, or try to by association. patient is complaining convince the patient about someone. otherwise.  Remain friendly and courteous Clearly explain your strategy for diagnosis and treatment Identify your role and clarify its HOW limitations Openly acknowledge the patient’s TO suspicious attitudes; do not ignore them DEAL Clarify your understanding of the patient’s beliefs, while indicating that you do not necessarily agree with them  They behave self- confidently and may They may demand appear the most senior smug, vain, clinician or the or even They come most well-known grandiose. across as specialist, and act people who condescending or feel they are arrogant toward entitled to trainees or younger the best of professionals. SUPERI everything. OR They Their react to relationship situations s are with characteriz anger and ed by hostility. entitlement.  Acknowledge the patient’s HOW point of view TO Avoid the DEAL temptation to argue  This is a process whereby people experience and express emotional discomfort or psychosocial stress in the language of physical symptoms. The clinical interview Many patients and thorough review have symptoms of the past medical SOMATIZAT that are difficult to history are critical to the diagnosis of ION account for on the somatoform basis of ”organic” disorders. disease. Patients with functional somatic symptoms are frequently encountered in clinical practice, and they often consume large  SOMATIZATION CHARACTERISTICS These patients are often difficult to interview. These patients use more medical services, require more sick leave and disability, and perceive themselves as less healthy than other office patients. Their interpersonal relationships, families, and ways of looking at the world are all affected by unending sickliness. Some have syndromes that resolve over a short period while others span many years and many different clinicians, and the story never seems to make sense. Patients may report numerous psychophysiological disturbances (headache, back pain, palpitations, breathlessness, or irregular bowel movements) mediated through autonomic or other known pathophysiologic mechanisms. They may tend to amplify symptoms of acute or chronic organic disease, or they may preferentially report physical symptoms of a condition, while deemphasizing emotional or psychosocial symptoms.  DIFFERENTIAL DIAGNOSIS OF OCCULT SOMATIZATION PRIMARY SECONDARY FACTITIOUS PHYSICAL SOMATIZATIO SOMATIZATIO DISEASE DISEASE N N Syndromes of Transient Secondary to True unknown functional known chronic Malingering etiology somatic disease (fibromyalgia, symptoms Secondary to chronic fatigue Somatoform other syndrome) disorders psychiatric Diseases with Hypochondri disorders subtle, asis Adjustment multisystem Conversion reactions manifestations reaction Alcohol or (lupus, Psychogenic other multiple pain disorder substance sclerosis, Undifferentia abuse polymyalgia Panic and rheumatica) ted somatoform other anxiety disorder disorders  At the first appointment, obtain a complete patient profile, even though they may want to limit the discussion to symptoms. HOW TO Pay particular attention to the sequence and details of the PMH DEAL Examine the patient to avoid missing disease and to validate the patient’s concerns by showing that you take the symptoms seriously. If the patient presents multiple symptoms and concerns, agree on which of  When people are anxious, they tend to intensify their customary ways of coping with the world. ANXIETY Signs of anxiety that may appear include facial flushing, sweating, rapid speech or silence, cold hands, fidgeting, or even trembling. The anxious patient may be difficult to interview until the anxiety has been acknowledged and discussed. DIFFICULT FEELINGS: Be unhurried and calm in your manner HOW TO Sympathize, but remember that too much sympathy may magnify the patient’s fears Be specific as to what you expect of the DEAL: patient Be specific about what is normal or not normal and explain your actions Tell the patient that anxiety is normal and appropriate  Patients behave in a hostile manner for ANG many reasons. These reasons often have nothing to do with the clinician personally but rather to a situation. ER What makes a patient depressed may make another patient angry, and the seemingly angry patient may, in fact, be depressed. DIFFICULT HOW RecognizeFEELINGS: and acknowledge anger with a statement such as “I can see that you are angry and frustrated”. TO Explore contributing factors and identify and underlying feelings, such as fear, hurt, disappointment, or powerlessness. DEAL Accept the patient’s reason even if you do not personally agree with it. If the pt’s anger is justifiably directed at you, : acknowledge your error.  May be a manifestation of a psychiatric disorder, a response to recent loss, expression of a pessimistic approach to life, or transient feeling state. DEPRESS Major depressive disorder may be the underlying problem in a substantial percentage of patients who complain of ION fatigue, weakness, lack of energy, insomnia, backache, or headache. Feeling worthless, hopeless, apathy, guilt, empty, or lonely feeling Manifested in patient’s manner, tone of voice, posture, and speech. The patient may think slowly and talk little, speck DIFFICULT softly and have a “flat” affect, look down or ways from you, and be tearful. FEELINGS: Screen for suicide risk Do you get pretty discouraged or down? What do you see for yourself in the future? How do you see HOW TO your future? DEAL: IF INITIAL SCREENING POSITIVE: Have you ever thought of hurting yourself? Are you currently having any thoughts of hurting yourself? Did you ever think about how you would do it?  It is a common response to illness. It is evident in statements like “This isn’t really happening to me,” “I can’t believe it” DENI Sometimes denial is strong enough to make them ignore or forget symptoms. AL They may also minimize a worrisome symptom and report it as a trivial event. Some patients play down symptoms while others deny the emotional impact of a diagnosis or prognosis. It can be hard to tell the difference between denial and optimism. DIFFICULT FEELINGS: Accept denial as the patient’s unique and current HOW experience. Inform the patient gently and calmly that many people feel differently, including you. TO Handle the patient’s denial with circumspection and respect because it can be a useful mechanism for coping with bad DEAL: news.  THE CLINICIAN’S HOW TO DEAL FEELINGS Some patients are Two crucial points to Recognize and extremely likeable, others remember about these acknowledge the feelings less so, and some are so feelings: as your personal response bad they will ruin your day First, the pt’s behavior to the patient, thereby when you see them on pattern probably bringing you into the your schedule. engenders similar feelings equations and reminding Some will make you angry, in other people. Therefore, you that these are your and others will make you your negative response problems, not the sad. might be useful clinical patient’s. You will find some very information, helping to Manage patients who tend humorous and others you explain some of the to cause you emotional may even be attracted to patient’s difficulties. roadblocks by planning and thus become Second, your response, ahead and organizing embarrassed or behave particularly if it is strong or physical, temporal, and awkward around. exaggerated, probably also personal factors in your The best approach to such represents an interaction office to optimize the feelings is first to identify with factors in your own situation. and acknowledge them. life and history and Share your feelings with a Ask yourself, “How is this personality- so called supportive colleague who pt making me counter-transference. can help in these uncomfortable? And why?” situations Health care professionals