Dealing with Difficult Patients

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Difficult patients. We’ve all had ‘em. Sometimes they’re amusing. Sometimes they’re infuriating.

How do we deal with them?

Unfortunately, much of this skill comes with experience. So allow me, with more experience than I’d care for, to give you some tips I’ve picked up along the way.

1. Graduates of the University of WebMD

These patients insist that they know more than you. Often they actually don’t. You need to feel out these patients. Sometimes they are willing to learn something from you. Sometimes they will not listen to a word that you are saying. Always provide your patients with the information they need to make a decision, be understanding, reference research and allow autonomy. “I understand you think you have (insert obscure disease) because of what you read on the internet/heard from your psychic, but the research about that is inconclusive. What we do know is (insert explanation), so I recommend (insert recommendation).” If they’re not budging, hey it’s their prerogative. Don’t get angry, don’t feel bad or sad. You’ve done your best. Ultimately it is their life. Just be sure you documented everything clearly!

2. Noncompliance

Oh, the noncompliant patients. “You need to take your insulin, check your blood sugars and watch what you eat or you’ll lose your leg.” 6 months later… “You need to take your insulin, check your blood sugars and watch what you eat or you’ll lose your OTHER leg.” Sometimes you have patients that despite all of the negative outcomes that will occur and have occurred because of their noncompliance, still don’t listen to you! So, what are you going to do? There are a few general principles. First, continue to explain to them the consequences of noncompliance. They may already be very aware of this, but you must continue to beat a dead horse, it is your job to educate. Next, try to simplify their medication regimen. If you know your patient doesn’t take his or her medication, don’t make them take 4 pills with breakfast, 2 pills with lunch, 3 pills at dinner and 2 before bed. Even the best patients struggle with that. As much as possible, try to get all of the pills long acting and at the same time. When that doesn’t work, try to get family involved. The family is with these patients when they leave your office. Tell them the consequences and teach them how the medications should be taken. The family of your patient doesn’t want anything bad to happen to your patient so they may be your best ally. Get them hooked up with visiting nurses or a visiting aide, if their insurance allows for it. These people will come to your patient’s home and assist with compliance. When all else fails, accept you cannot make someone do something they are unwilling to do.

3. Angry patients

Sometimes patients can be downright mean and even violent. If a patient becomes violent, it’s time to get security involved. You shouldn’t put up with that behavior. If patients are just angry, try to figure out why. Often it is a communication barrier. It is your job to stay calm, cool, collected and try to understand why the patient is angry. Sometimes by taking the time to listen and explain what you can and cannot do for the patient, he or she will calm down. Sometimes patients are angry about something out of your control. If they are threatening to call a lawyer or administrative personnel, let them know they are more than welcome to do so. When you are doing your best as a provider, you should not be afraid of these threats. Patients hope that by threatening you they will get something out of you, but you should hold true to best practice. If you start to feel unsafe, get security to handle the situation. We are not prison guards, we are providers.

4. Difficult family/patient dynamics

First thing first, if you ever suspect abuse from caregivers, inform social services. The patient is your primary concern. When your patient is unable to make decisions, you should speak with their power of attorney. If the family is not in agreement about what to do, give them the information they need to make a decision along with your recommendations if applicable. However, don’t get involved in a family feud. Ultimately, decisions belong to your patient or his/her power of attorney. When you don’t know what to do, social workers are your best friends. They are trained to handle difficult family situations, let them help you.

5. Difficult conversations

As a provider, inevitably we have to give bad news at times. Talk to your patient and their family the way you’d want someone to talk to you and yours. Be realistic, empathetic and honest. Don’t be awkward or wishy-washy and definitely don’t give false hope. If you are telling them they have a possibly terminal diagnosis, let them know their chances of fighting it. Let them know their options of treatment if there are any and what can honestly be expected for each of their options. If you are recommending hospice, let them know the prognosis is poor and you want to keep them comfortable. Let them know you will continue treatment until they decide otherwise. Make sure patients and family have the ability to make the decisions; you are just providing recommendations and information. If you have to tell a family that a patient has deceased, have the family sit down, while you sit next to them. Answer questions they have honestly and be empathetic. You’re allowed to cry. Sometimes, nothing you can do will necessarily make it much easier for the family or patient to digest, but approaching difficulty situations poorly will make the situation worse, so do your best and follow the golden rule.

6. Mistakes

People make mistakes. The worst thing you can do is try to cover it up. If you suspect harm was accidently done to a patient, inform your administrative personnel. Find out what can be done to amend the situation. Everyone wants to avoid legal involvement. When talking to the patient or family apologize, even if it wasn’t your fault and let them know what you can do to try to right the wrong. Sometimes your sincere empathy and efforts to fix the situation can appease the patient and family enough to avoid legal action.

The bottom line is that sometimes as physician assistants we find ourselves in some sticky situations. All we can do is be kind, understanding, informative, use our resources and continue to practice medicine to the best of our ability.

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