A 45-year-old male has been in your waiting room for nearly an hour. He has been suffering from chronic back pain for several years and scheduled an appointment to discuss the pain treatments which have been ineffective. You have been managing an urgent patient issue that has impacted your schedule. When the patient is finally placed in an exam room, your staff warns you that he is “very angry.” You find out during the exam that the patient has been terminated by the previous clinician and he is requesting medications that you don’t think are indicated long-term.
Many factors can make clinical encounters challenging, both for patients and clinicians. Patient factors such as strong emotions, somatization, unrealistic expectations, and mental health issues commonly contribute to encounters being difficult. Additionally, we need to take into account environmental or situational factors such as busy patient schedules, multiple people in the exam room, language or literacy issues, and clinician issues such as fatigue/burnout, anecdotal previous patient experiences, and defensiveness. There may also be substantial variability in perception: what may be difficult for one clinician may not be difficult for another. Some find angry patients easier to manage than those with chronic pain or somatization, whereas others may find a patient with a laundry list of complaints the most challenging. Interestingly, recent studies have demonstrated that younger clinicians and those less focused on psychosocial determinants of health are more likely to describe any given encounter as difficult.
WHAT IS THE FIRST STEP IN A DIFFICULT ENCOUNTER?
Although it may sound obvious, it is important to first recognize that you are perceiving an encounter as difficult. This may occur as early as seeing a patient name on your schedule or may not occur until you are in the middle of a visit. No matter when the sense of difficulty is recognized, it is important to reflect on why the patient and/or encounter is evoking your strong emotions. Emotions are never wrong but can be detrimental to a clinician-patient relationship depending upon how they are identified and managed. While a patient’s anger may be a frequently cited emotion in a difficult encounter, it is important to remember that anger is often the result of an underlying primary emotion such as fear or sadness.
USEFUL TECHNIQUES
Acknowledge Emotions
Acknowledge the patient’s and your emotions. Don’t be afraid to call out an emotion, such as, “I can see you are angry.” If the patient corrects you and says, “No, I am not angry just frustrated,” take that as a positive as you have already begun to deescalate the situation. Let the patient know you are having challenges as well, “I am having difficulty as I really want to help you, and I am frustrated we haven’t found a better solution for you.”
Seek to Understand Before Being Understood
While your emotions are important, your primary objective is to delve into the patient’s concerns and what is evoking their emotions. Clearly identifying their goals is essential in establishing a shared agenda for the visit.
Reflective and Active Listening
Summarize what you are hearing from the patient, “I hear you saying you are frustrated as your pain has not improved and it is limiting you at your job.” Brief summary statements are an effective way of expressing empathy. Pay attention to your body language as nonverbal communication contributes more to interaction than the words you say—stay calm, lean in, and pay attention.
It's Okay to Say I Am Sorry
While sorry statements are not necessarily a form of empathy, it may be appropriate to say things as, “I am sorry I kept you waiting so long,” and then follow it with an empathic statement, “I know you must be very frustrated.”
This Is a Partnership
You may discover that in your exploration that the patient has unrealistic expectations (i.e., “I want to be pain free.”) and you can work toward an agreement to work together on a reasonable goal. “I want to be transparent—I may not be able to relieve all of your pain, but we can work together to improve your symptoms such that you can return to work and enjoy your life outside of work.”
Recognize It Will Take Time
Building a relationship and/or behavior modification takes time. Set reasonable goals on what may be accomplished in one visit.
Communication Skills Require Practice
Remember that we all have differing skills and patient communication is a clinical skill that is developed with practice. There are plenty of wonderful workshops on communications skills. We encourage you to take an opportunity to be videotaped as it is a powerful way to understand nonverbal skills in particular.
When All Else Fails, Take the Appropriate Steps
Despite your best efforts, not all relationships may be salvageable. You are never required to maintain a relationship that is potentially dangerous or abusive to you or your staff. You can attempt to set limits on patient behavior that is particularly disruptive.
However, you may need to terminate the relationship. Remember there are important guidelines to follow when terminating a relationship. Most state medical boards have guidelines you must follow to terminate a relationship that you must comply with. A listing of all state guidelines is beyond the scope of this article.
You should never terminate a relationship based on characteristics that may be considered discriminatory such as gender, race, ethnicity, age, or disability. You must be careful to consider the underlying medical conditions, ongoing treatment needs, and availability of other resources. Examples of conditions where termination may be difficult or ill-advised include pregnant patients, patients undergoing chemotherapy and patients suffering complications post-procedures.
Draft a termination letter that is succinct but spells out that you will provide emergency care and non-controlled refills for 30 days. Suggest resources for identifying a new clinician and assure them that all records will be transferred. If there are serious treatment or monitoring recommendations state them. But avoid restating your reason for termination in the letter and make sure your staff knows your plans. It is best to have proof of receipt of this communication and retain that in your documentation.
Please know that Copic is always available for guidance. Contact our Patient Safety & Risk Management team at 720.858.6396 or gr**@***ic.com.
Information in this article is for general educational purposes and is not intended to establish practice guidelines or provide legal advice.
Article originally published in Copiscope Issue 227, 4Q24.
