American College of Physicians: Internal Medicine — Doctors for Adults ®

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Your patient is out of line-now what should you do?

How to anticipate—and resolve—awkward patient encounters like sexual advances and gift-giving

From the July/August 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Jennifer Fisher Wilson

WASHINGTON—Attending Dennis H. Novack, FACP, was approached one day by a resident caught in an awkward situation. The resident described how a patient, a young woman he had helped through some difficult times, had leaned over and kissed him on the mouth during an exam. Stunned, the resident did not protest. When asked why, the resident told Dr. Novack that he "didn't want to make the patient feel bad."

Dr. Novack and the resident met with the patient to talk with her about why she kissed him. Once they established the motivation for her behavior, they were able to agree upon boundaries and the resident and the patient could continue their physician-patient relationship.

The encounter illustrates how difficult it is for residents who are still learning the boundaries of the doctor-patient relationship to deal with patients who act inappropriately.

But residents can work proactively to learn some techniques to more easily help them identify—and handle—such behavior, according to physicians gathered at a workshop on dealing with patient boundary transgressions at the annual meeting of the Society of General Internal Medicine. Neil J. Farber, FACP, and Dr. Novack led the workshop.

"Physicians in training are more vulnerable to boundary transgressions since they're still unsure of what their boundaries are and may be less likely to set firm limits with patients," said Dr. Novack, who is on faculty in the division of medical education at the Allegheny University of the Health Sciences in Philadelphia. For example, a 1994 study of medical students' perceptions of patient-initiated sexual behavior published in a 1994 issue of Academic Medicine, 71% of female medical students and 29% of male medical students reported facing sexual advances from patients.

At the workshop, program directors and physicians described encounters with verbally abusive patients; patients who hugged, grabbed and kissed them; patients who made seductive advances; and patients who gave large and frequent gifts.

Panelists and participants at the workshop offered the following tips to help residents cope with these and other difficult patient encounters:

Know it when you see it. A critical step, said Dr. Farber, is recognizing when patients have stepped over the line. A rule of thumb: If you feel uncomfortable with a patient's behavior toward you, the patient may be crossing a boundary. "If it's bothering you, figure out why," said Dr. Farber, FACP, the associate chief of general internal medicine at Veteran Affairs Medical Center in Philadelphia and associate professor of medicine at Allegheny University of the Health Sciences. When in doubt, he said, residents should talk with their peers about a patient problem.

Even among their peers, however, many residents don't feel comfortable admitting that they're having problems dealing with a patient. "There's the sense of not wanting to admit something went wrong," Dr. Novack said. "A lot of trainees feel stupid about this and don't say anything."

In addition, residents may be afraid that if the word gets out about a patient problem, their performance review will plummet. Many residents fear that they will somehow be blamed for not having handled a difficult patient better.

While attendings don't usually like to admit that they've have bad clinical experiences with patients, many will empathize with residents who are having interpersonal troubles with a patient. As Dr. Novack explained, chances are that they have dealt with their own difficult patients.

Know yourself. Dr. Novack suggested spending some time identifying your own feelings toward a difficult patient. "Look at the underlying beliefs and attitudes that lead us to get into these interactions," he said. Try thinking about your own relationships and how they might affect your relationship to the patient.

One workshop participant said that residents need awareness of how they portray themselves. As a program director, the woman said, she frequently sees residents who don't portray themselves with much definition or confidence, in part because they are often in a subordinate role with a teacher or attending. As physicians gain experience, she said, this changes.

To become more aware of your own feelings and how others perceive you, Dr. Novack advised joining some sort of support group. Balint groups—therapeutic programs for physicians to meet with peers to discuss their interactions with challenging patients—allow physicians to work together to understand patient attitudes and come up with interventions.

Set boundaries. Keep in mind that some patients may be unaware that their actions are inappropriate or improper. Most of these individuals will change their behavior when their physician uses nonverbal cues, according to Dr. Novack. Certain body language alone—standing up straight and stepping back, for example—can discourage a patient's actions. If such measures fail to deter unacceptable patient conduct, attempt to verbally identify the inappropriate action and set appropriate boundaries as soon as possible, according to Dr. Farber.

Confront the patient. Don't shy away from talking about the issue directly, said Dr. Farber. A patient needs to understand why his behavior is inappropriate—and that you as physician will not tolerate it.

For example, Dr. Novack said, if you resent a patient because he calls four times a day, try to modify that behavior. For minor concerns, for example, the patient may be able to get help by calling a health care hotline, joining a support group or in other ways that will be less intrusive to your practice. For extreme anxiety, the patient may need a psychiatric referral.

One workshop participant explained how she came to an agreement with a patient who continuously gave her small gifts like food and handmade crafts. When the physician said that she was uncomfortable accepting gifts, the patient explained that she found the gift giving therapeutic. She was trying to lose weight for health reasons and found that busying herself with cooking and crafts kept her from overeating—and made her feel good.

In this situation, once the physician had determined that the patient's motivation was seemingly harmless and therapeutic, she could limit the patient to giving low-cost, homemade items without completely banning the gift giving.

Don't procrastinate. A physician at the workshop remembered that as a resident, one prostate cancer patient constantly asked her out on dates, patted her on the back and even tried to kiss her. Even though his behavior embarrassed her and made her feel uncomfortable, she questioned her judgment of the situation and didn't say anything.

When the patient's behavior eventually became unbearable, the physician confronted him about his behavior. By then it was too late, and the patient continued to make advances. Eventually she had to transfer the patient's care to another doctor. At the workshop, the physician concluded that perhaps if she had discouraged the patient's behavior when it first occurred, she wouldn't have had to discharge him from her care.

Look for options. Physicians at the workshop agreed that discharging a patient is a last option, and that there are other ways to deal with these types of patients. For difficult patients who have been shuffled from doctor to doctor because of their behavioral problems, Dr. Novack suggested either referring them to a psychiatrist or sharing treatment responsibility with another physician or specialist.

But physicians at the workshop said that feeling like you have to treat all patients, even those who behave inappropriately, can be overwhelming. "It's empowering to know you're not obligated to take care of a patient," explained one physician.

Ultimately, Dr. Novack said, physicians should not feel as if they have failed when they come up against a patient whose behavior makes it impossible for them to continue with their care. It's part of practicing medicine, he said.

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