Difficult Pts

Question 1

What are most problematic situations caused by?

Answer 1

1. unsatisfactory communication between providers & patients

2. personal issues the provider or patient unknowingly brings into the visit.

Question 2

true false:

Most difficult interactions are both diagnosable and repairable.

Answer 2

True

Question 3

How can providers approach clinical interactions with self-reflection and less judgment and frustration?

Answer 3

1. Develop the self-awareness to separate one’s own past experiences and relationships from the current clinical interaction.
2. Carefully examine how visits are progressing while monitoring one’s own responses to the patient and the interaction.

Question 4

What are the general guidelines for working with difficult pts?

Answer 4

1. Seek broader possibilities for the patient’s emotion or problems
2. Respond directly to the patient’s emotions
3. Solicit the patient’s perspective on why there is a problem
4. Avoid being defensive
5. Seek to discover a common goal for the visit

Question 5

What are the non-verbal indications of an angry pt?

Answer 5

1. Rigid posturing
2. Piercing stare
3. Refusal to shake hands
4. Gritting teeth

Question 6

What are the verbal indications of an angry pt?

Answer 6

1. Very confrontational

2. Occasionally abusive language

Question 7

What are the subtle behaviors of an angry pt?

Answer 7

1. Refusing to answer questions
2. Failing to make eye contact
3. Crossed arms
4. Turning away from provider
5. Increase physical distance

Question 8

What are potential causes of an angry pt?

Answer 8

1. Anger towards provider
2. Difficulty in getting to the office
3. Problems with the office staff
4. Anger toward the illness from which the person suffers
5. Anger at the cost of health care
6. Problems with consultants to whom the provider referred the patient
7. Unanticipated problems from a procedure or medication recommended by the provider
8. Previous unsupportive or condescending treatment by a physician
9. Absent or miscommunication between members of the healthcare team
10. Other significant news or problems unrelated to medical service, such as work-or family-related conflicts

Question 9

What is the provider response to an angry pt?

Answer 9

1. Defensiveness
2. Expressing reciprocal anger
3. Withdrawal from the relationship
4. Denial of their own behavior

Question 10

How should a provider manage an angry pt?

Answer 10

1. Elicit the patient’s reason for being angry:
2. Empathize with the patient’s experience:
3. Solicit the patient’s perspective:
4. If appropriate, apologize
5. Educate pt

Question 11

What are the signs of a “silent pt”?

Answer 11

1. Patients offer little verbally, but the non-verbal cues are very important
2. Patient seems withdrawn, fails to make eye contact, distracted, or not acknowledging the providers attempt for interaction
3. Patient can also appear anxious, with nail-biting, pacing, or folding and refolding papers
4. Patient can appear sad, with deep sighs, red eyes, and tears

Question 12

What are potential cause of a ‘silent pt’?

Answer 12

1. Adverse reaction to prescription medication
2. Alcohol or other drug intoxication
3. Alzheimer or other dementia
4. Anger
5. Cultural or language barrier
6. Depression
7. Distraction secondary to depression
8. Fear
9. Hearing Impairment
10. Passive or shy personality
11. Preoccupation with auditory or visual hallucinations
12. Quiet person
13. Stroke, TIA
14. Taught by authority figures “silence unless spoken to”
15. Differences in gender or social class
16. Mistreatment in previous medical relationship
17. May represent denial

Question 13

How should a ‘silent pt’ be managed?

Answer 13

1. Explore the behavior by using reflective statements
2. Explain the reason why it is important to collaborate with provider
3. If patient distracted, ask about hallucinations
4. If patient nodding head a lot, could be related to hearing impairment

Question 14

How should a silent pt be educated?

Answer 14

1. Explain that silence create a barrier to effective care
2. Emphasize the importance of becoming involved in their own health care
3. Explain that the provider doesn’t solely make decisions, that it is a team effort

Question 15

What are the signs of a ‘demanding pt’?

Answer 15

1. Patients make requests or demands for diagnostic tests, referrals, or for specific treatments
2. Sometimes their demand is for secondary gain
3. Patient is frustrated with lack of relief
4. Often providers feel rejection, distrust, blame, or humiliation due to demanding patients. This leads them to become defensive.

Question 16

What are the potential causes of a ‘demanding pt’?

Answer 16

1. Anger
2. Fear
3. Frustration
4. Personal responsibility for health outcome
5. Doubt

Question 17

How should a demanding pt be managed?

Answer 17

1. Don’t respond to the presumed cause, evaluate or reevaluate the demand to identify the patient’s affect
2. You may ask, “How had you hoped I could help you?”
3. When providers believe that the demand is related to secondary gain, they can gently confront the patient and offer a plan that provides ample time for recovery

Question 18

How should a demanding pt be educated?

Answer 18

1. Patient respond to instructions when they believe it will be helpful in solving their problems
2. Once patient’s concerns are met and partnership formed, they will benefit more from the information the provider is giving

Question 19

What are the signs of the “Yes, but” pt?

Answer 19

1. Non-verbal behavior is usually engaged when problems are being discussed
   A. Leaning forward, bright affect, and dynamic gestures
2. When discussing evaluation & treatment
   A. Withdrawn, no eye contact, language become less animated
3. Verbally during discussion of evaluation & treatment
   A. Becomes quiet, volunteers little, and has no solution to problem
4. After provider makes recommendations the often respond
   A. “I’d like to do that but….”

Question 20

What are potential causes of the “Yes, but” pt?

Answer 20

1. Passive-aggressive behavior

2. Hx of emotional, physical or verbal abuse

Question 21

How should the “Yes, but” pt be managed?

Answer 21

1. Patient must take responsibility for their own health
2. Ask patient what they think would be helpful in solving the problem
3. With passive-aggressive behavior the provider can seek agreement on the nature of the problem, and then make a specific contract for what the patient will do

Question 22

How should the “Yes, but” pt be educated?

Answer 22

1. Once patients given information about collaborative model and understand it the outcome is great
   A. Most find the approach satisfying, engaging, and motivating
2. Those with passive-aggressive behavior can begin a process of introspection and self-awareness

Question 23

What are the indications for referral of a difficult pt?

Answer 23

1. Inability to make a diagnosis
2. Objective assessment that patient is not benefiting from evaluation or treatment
3. Provider’s feeling of being threatened or in danger