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

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Patients uncooperative? Try these communication tips

By recognizing important issues and helping set expectations, residents can improve patient encounters

From the May ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Christine Kuehn Kelly

Resources to improve your communication skills

Anne Yawman, MD, a third-year internal medicine resident at MCP Hahnemann University School of Medicine in Philadelphia, was feeling frustrated with her elderly patient. The woman had difficulty complying with her five-drug regimen for hard-to-control blood pressure and other problems. She often ran out of medications or forgot to bring them with her to clinic visits.

Finally, Dr. Yawman asked her why she was having so many problems sticking to her treatment. "It turned out she had a paraplegic brother at home and was his primary caregiver," she recalled. "His needs came first."

Armed with this information, Dr. Yawman arranged for a home care nurse to see the patient's brother—and attend to some of her patient's needs as well. "Now I'm more up front in asking patients about their lives," she said.

Dr. Yawman's experience illustrates what communication experts say is a key strategy when dealing with uncooperative patients: Try to break through the impasse by talking.

"Problem patients become more understandable when you discover that they live in deprived, chaotic situations or can't afford medications," explained Dennis H. Novack, FACP, a patient communication expert and professor of medicine at MCP Hahnemann. "But you won't know this unless you take time to ask."

Residents get frustrated when a patient fabricates a story or is noncompliant, said Nielufar Varjavand, ACP-ASIM Member, assistant professor of medicine at MCP Hahnemann. "But we must reach out to patients and understand them. If we don't, we aren't doing our job."

Here are some tips to help you connect with challenging patients and gain their cooperation:

  • Look for underlying issues. "Put in the time up front when you first meet patients," said Felicia A. Sapp, ACP-ASIM Associate, a third-year internal medicine resident at Legacy Health System in Portland, Ore. She suggested encouraging patients to tell their stories, which will give you insight into the psychosocial issues that can affect your ability to treat them.

    Victims of recent or childhood abuse, for example, often present with multiple somatic complaints, depression, anxiety, substance abuse or a history of suicide attempts. To uncover possible abuse, normalize the conversation with comments such as, "Abuse is very common, which is why I ask all my patients these questions." (For more on helping abused patients, see "Tips to recognize—and respond to—domestic violence.")

    Total or functional illiteracy is another common problem that affects patient compliance. According to the National Adult Literacy Survey, half of all adult Americans have difficulty reading or calculating numbers. To assess patients' reading skills, ask them to read a sample pill bottle or a few sentences from a pamphlet.

  • Talk about expectations and boundaries. A patient's unexpressed expectations may be at the heart of some difficult encounters, said Craig S. Roth, FACP, associate professor of medicine at the University of Minnesota School of Medicine in Minneapolis. For instance, patients may expect certain medications and tests or believe that others won't work. Although you may not always be willing to meet specific expectations, you can at least communicate in a way that addresses them.

    Barry E. Egener, MD, medical director of the Northwest Center for Physician-Patient Communication in Portland, Ore., said that eliciting the patient's perspective can go a long way in making challenging encounters more smooth.

    Start by acknowledging patients' feelings through active listening by repeating their concerns and interpreting the dilemma. You might say, for example, "I understand that you are experiencing pain and want a narcotic, and you seem disappointed with me for not prescribing the drug you want."

    You can then present your own perspective, try to agree on common goals and define the boundaries of the visit. You could say, for example, "I don't feel comfortable prescribing Percocet for your chronic pain, but there are other non-narcotic solutions we might try. I hope we can work together."

    While the process can be rocky, it's important. "Defining boundaries can be difficult," Dr. Egener pointed out. "Patients can feel like we are rejecting them."

  • Get input about goals. "I ask patients with diabetes what they would be willing to do now," said Dr. Roth. "Most hate the fingersticks, but they are happy to work on other things like diet or exercise." And a patient who has just lost a job or a loved one is probably not ready to stop smoking, despite your most convincing counseling efforts.

  • Recognize your own values. Your own values can create communication gaps with some patients. According to Dr. Novack from MCP Hahnemann, physicians' personal characteristics, past experiences, values, attitudes and biases can greatly affect their communication with patients. Residents who have had to deal with alcohol or drug abuse in their own family, for example, may transfer some of their feelings to patients with those problems. Dr. Novack said he counsels residents to be aware of their own "triggers" in order to help them provide more empathetic care.

  • Ask for help. If your program doesn't offer any training in communication skills, try to observe attendings who have an interest in the topic, said Geoffrey H. Gordon, FACP, associate director of the Bayer Institute for Health Care Communication in West Haven, Conn., and co-author of "Field Guide to the Difficult Patient Interview." You can also ask attendings to observe your patient interactions and give you some feedback.

    Although residents frequently discuss difficult medical cases, they rarely talk about communication problems. Dr. Gordon suggested meeting other residents for lunch once a week to discuss difficult encounters.

    In addition, several organizations will bring patient communication training courses to your organization and residency program. (For more information, see "Resources to improve your communication skills.")

Finally, experts say that while better physician-patient communication helps medical outcomes, it also can improve your job satisfaction. According to Mack Lipkin Jr., MD, codirector of the primary care residency program at New York University School of Medicine in New York, surveys show that physicians who report a high degree of professional satisfaction relate well with patients, are interested in the psychosocial aspects of care and can manage difficult patients. "Overall," he said, "there's no better use of time than to improve patient communication skills."

Christine Keuhn Kelly is a Philadelphia-based freelance writer specializing in health care.

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Resources to improve your communication skills

  • ACP-ASIM offered workshops and courses focusing on doctor-patient communication at Annual Session 2002. An audiotape of the "Patient Counseling for Behavioral Change" workshop can be ordered online at www.soundimages.net.

  • The American Academy on Physician and Patient explores how patient-physician communication functions as a diagnostic and treatment tool. The academy offers courses that use real and simulated patients. For information, call 703-556-9222 or visit www.physicianpatient.org.

  • The Northwest Center for Physician-Patient Communication is dedicated to improving health care quality in the Pacific Northwest through education and research on physician-patient communication. It offers onsite educational programs. For more information, call 503-636-2234 or visit www.tfme.org/nwppc.htm.

  • The Bayer Institute for Health Care Communication has conducted more than 3,500 workshops for more than 40,000 clinicians and health care workers. For information about its onsite workshops, call 800-800-5907 or visit www.bayerinstitute.org/index.htm.

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