Exam 3

Question 1

Definition of a difficult patient

Answer 1

The one with whom the physician has trouble forming an effective working relationship

Question 2

How will you know if you are dealing with a difficult patient?

Answer 2

Difficult patient evoke a feeling of anxiety, pressure, boredom or frustration

Question 3

Situational issues of a difficult incounter

Answer 3

language and literacy issues
multiple people in exam room
breaking bad news
environmental issues

Question 4

Physician characteristics of a difficult encounter

Answer 4

angry or defensive
fatigued or harried
dogmatic or arrogant
tired (end of a long day)

Question 5

Patient characteristics of a difficult encounter

Answer 5

angry
defensive
frightened
resistant
manipulative
somatizing
grieving
"Frequent flyers"

Question 6

2 steps to help with difficult pt

Answer 6

reframe your thinking

incorporate coping strategies

Question 7

qualities of a successful physician-patient encounter

Answer 7

collaboration
appropriate use of power
empathy

Question 8

Coping strategies to improve encouters

Answer 8

Collaboration
Appropriate use of power
Empathy

Question 9

Strategies of Collaboration

Answer 9

Set priorities
Do thorough exams
Be consistent, honest, fair and clear with decision making
Coach pt to small achievable goals and symptom relief
Enlist the help of a team that includes pt families and other healthcare providers to improve quality

Question 10

Strategies of appropriate use of power

Answer 10

Set clinical management rules which include limits and priorities to visits (num. and length)

Good Documentation

Question 11

Strategies of empathy

Answer 11

Be compassionate, but firm
Be pt centered
Reinforce positives
Keep a professional distance
Understand psyche and emotions
Recognize and deal with your true feelings
Be alert for countertransference reaction in yourself
Involve colleague in your management plan
Improve yourself

Question 12

important factors to remember with the care of all pts

Answer 12

Listening to the pt

Clarifying the pt’s concerns

Question 13

What is key in any pt visit?

Answer 13

Listening

Question 14

Behaviors of challening pts

Answer 14

Silence
Confusion
Altered mental capacity 
Talkative
Crying
Angry / Disruptive
Demanding
Language barrier
Low Literacy
Complaining
Poor adherence
Needy
Drug-seeking
Seductive
Person Problems

Question 15

Disabilities that make a pt visit challenging

Answer 15

Impaired hearing
Impaired vision
Limited intelligence

Question 16

Tips for working with the silent pt

Answer 16

Silence is ok
Watch for nonverbal clues
Depression or dementia
Silence may be the answer

Question 17

Characteristics of a confusing pt

Answer 17

They have everything wrong with them
Completely positive ROS
Hx is vague, difficult to understand, ideas are poorly connected and language is hard to follow
Difficult to get clear answers

Question 18

Tip for working with the confusing pts

Answer 18

Focus on the meaning or function of the symptom
Emphasize the pt’s perspective
If you suspect psych or neuro d/o then use the MMSE

Question 19

Definition of decision making capacity

Answer 19

Ability to understand information related to health, to make medical choices based on reason and a consistent set of values, and to declare preferences about tx

Question 20

To have decision making capacity, pts must be able to

Answer 20

Understand relevant information about proposed dx test or tx
Appreciate their situation
Use reason to make decisions
Communicate their choice

Question 21

Tips for visit with a pt with altered cognition

Answer 21

Obtain a consent before talking about their health with others - HIPAA
When conflicting info comes from a spouse, child or caregiver, may need to divide the interview into 2 parts

Question 22

Tips for visits with pts who have impaired capcity

Answer 22

Find a surrogate informant or decision maker, such as a DPOA for health care or a health care proxy
Apply basic principles of interviewing to your conversations with pt’s relatives or friends

Question 23

Characteristics of the talkative pt

Answer 23

Hard to get the whole story

Question 24

Tips for working with the talkative pt

Answer 24

Give pt free time for about 5 min and listen closely
Focus on what seems important to the pt
Interrupt only if necessary
Learn how to set limits
Summarize
Don’t show your impatience, simply suggest the importance of scheduling another appt

Question 25

Tips for visiting with the crying pt

Answer 25

Crying signal strong emotions Most people who cry are able to compose themselves and move on, unless crying b/c of acute grief or loss Crying makes people uncomfortable (pts and providers)

Question 26

If pt is on the verge of tears

Answer 26

Pause Respond with empathy Offer tissue Give pt permission to cry

Question 27

Pt factors of anger

Answer 27

Pt illness Grief Loss of control Feel powerless

Question 28

Provider factors of anger

Answer 28

``` Late Inconsiderate Insensitive Angry Unresponsive Cost of visits ```

Question 29

Tip for visiting with the angry or disruptive pt

Answer 29

Avoid joining in on hostility toward another provider, clinic or hospital Validate their feelings w/o agreeing with their reasons

Question 30

Needs of the angry pt

Answer 30

``` Empathy Legitimization Non-judgmental attitude Respect of pt autonomy Support Flexibility ```

Question 31

7 steps for satisfying angry pts

Answer 31

1. Handle problem privately 2. Listen to pt's complaints 3. Disarm anger with kindness 4. Delegate up when necessary 5. Follow through on promises 6. Involve the pt in prevention 7. Be grateful

Question 32

If angry pt is overtly disruptive

Answer 32

``` Alert Security Stay calm Appear accepting Avoid being confrontational Listen Try to understand what pt is saying Suggest moving to a more private area ```

Question 33

Characteristics of the demanding pt

Answer 33

Call frequently | Often come with an agenda or list of wants

Question 34

Tips for visits with the demanding pt

Answer 34

``` Frequent, short visits Negotiate agenda and goals Set limits Reinforcement Compromise Be flexible Acknowledge his/her feelings Avoid Arguments Explain you rationale Firm boundaries may be necessary for some ```

Question 35

Characteristics of a good interpreter

Answer 35

ideally neutral person familiar with both languages

Question 36

Characteristics of a poor interpreter

Answer 36

Family members Friends Untrained

Question 37

Why should you not sure a pt's family member or friend as an interpreter?

Answer 37

Confidentiality violated Meanings distorted Transmit information incompletely May try to speed up the interview

Question 38

Important aspects to remind the interpreter of

Answer 38

Explain that every word must be interpreted, not condensed or summarized

Question 39

Tips for a visit with pt who needs an interpreter

Answer 39

Review information most helpful to you | Make your questions clear, short and simple

Question 40

Guidelines for working with an interpreter

Answer 40

Choose trained interpreter Use the interpreter as a resource for cultural information Orient the interpreter to the components you plan to cover in the interview Remind interpreter to translate everything the pt says Arrange the room so that you and the pt have eye contact and can read each other's nonverbal cues Seat the interpreter next to the pt Allow interpreter and pt to establish repport Address the pt directly Keep sentences short and simple Verify mutual understanding Be patient

Question 41

Acronym INTERPRET

Answer 41

``` Introduction Note goal Transparency Ethics Respect beliefs Patient focus Retain control Explain Thank everyone for their time ```

Question 42

Do not confuse degree of literacy with

Answer 42

Level of intelligence

Question 43

Tips for pts with low literacy levels

Answer 43

Ask how comfortable they are filling out medical forms Have pt read written instructions back to you and ask them if they understand what is written

Question 44

Low health literacy leads to

Answer 44

poor health outcomes

Question 45

What are 3 ways to improve health literacy

Answer 45

Analogies Simple Language Ask Questions

Question 46

What is health literacy?

Answer 46

The degree to which an individual has the capacity to obtain, communicate, process and understand basic health information and services to make appropriate health decisions