Working with a tough patient? Try these strategies
From the June ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.
By Phyllis Maguire
PHILADELPHIA—Consider these scenarios: A patient insists she needs amoxicillin for her sneezing and congestion and mentions that another physician always gives her a prescription. Or you enter the exam room and extend your hand, only to encounter a furious patient who demands to see his regular physician. Or your somatizing patient arrives for this week's visit with a list of 25 symptoms she wants to discuss—and No. 25 reads "and there's more."
When facing tough patients—or any patient, for that matter—broadening the patient interview can often turn the situation around. At an Annual Session workshop, panelists described one model that can help you set the agenda for patient visits, negotiate goals and address patients' feelings about their illnesses or symptoms.
Using an approach known as the "patient-centered interview," panelists said you can improve communication and strengthen the physician-patient relationship. Here is an overview of the model—and tips on how to use it with difficult patients.
The "patient-centered interview"
Most physicians conduct what panelists called the "doctor-centered interview," seeking a full description of symptoms and information on the patient's medical history. But the key to a strong relationship with a patient, they said, is opening up the interview to get more information.
'When we focus on symptoms, we miss most of the psychosocial factors that influence patients.'—Auguste H. Fortin VI, ACP-ASIM Member
"When we focus only on symptoms, we miss most of the psychosocial factors that influence patients," said moderator Auguste H. Fortin VI, ACP-ASIM Member, assistant clinical professor and director of psychosocial curriculum at Yale School of Medicine. "Those factors have a tremendous impact on patient compliance and satisfaction, so if we don't let patients tell their stories, we're not being effective or efficient."
The patient-centered interview consists of five steps that together should take up about 10% of an initial visit. (In initial visits, the other 90% will be devoted to the doctor-centered interview and the physical exam.) Because you probably gather all the medication, allergy, social history and family history information during the initial visit, however, the patient-centered interview may take up as much as 50% of return visits, depending on the patient's psychosocial issues.
Here are the five interview steps that make up the patient-centered interview:
Set the stage. When you enter the room, be sure to use the patient's name. Introduce yourself and identify your role, particularly in an inpatient encounter. Seek ways to put the patient at ease.
Determine the agenda. Ask patients to describe their chief complaint and to list any other issues they want to discuss. Summarize those issues and work with the patient to determine an agenda for the visit.
Dr. Dwamena suggests telling patients how much time you can spend with them so they can organize their priorities.
Be sure to mention how much time you can devote to the encounter, something most physicians are loathe to admit, said panelist Francesca Dwamena, MD, assistant professor of medicine at Michigan State University in East Lansing, Mich. When you tell patients that you're able to spend about 15 minutes together, she pointed out, you give them a time frame that helps them organize their thoughts and priorities.
Open the lines of communication. Use non-focused, open-ended interview skills to encourage patients to talk about their symptoms and complaints.
During this step, it's important to use active listening skills, such as silence, gestures and neutral or nonverbal encouragement. Nodding and saying "hmm" or "I see" at regular intervals, for example, shows patients that you hear them.
To keep patients talking, use more focused interview skills that hone in on what they tell you. Echo back what patients say and regularly make requests like "Tell me more" to gain clarification or more information.
Finally, summarize the patient's story in your own words. Dr. Dwamena reminded physicians to keep these summaries brief. "Patients are already anxious," she said. "If you go on too long, they'll assume you are trying to grab control of the interview."
Elicit and handle emotions. In this section, you need to address the patient's emotions. Convincing patients to express their feelings about a particular symptom or illness is key to establishing an effective physician-patient relationship. That in turn affects compliance and patient satisfaction.
The simplest approach is to ask directly, "How does that make you feel?" You can also take a more indirect route by asking, for instance, what kind of impact the symptom has had on the patient's life and how that limitation makes the patient feel.
You need to address those emotions further with an emphathetic response. Panelists suggested using the mneumonic "NURS": "Name the emotion; let patients know you understand their feeling; respect their plight and offer them support," Dr. Fortin said.
Move to a doctor-centered interview. At this point, briefly summarize the story the patient has just shared, and indicate that both the style and content of the encounter is about to change. The rest of the interview progresses routinely, as you flesh out the history of present illness and gather data.
These patient-centered techniques can be tailored to better cope with several types of difficult interviews, panelists said.
Angry patients. When faced with an angry patient, for example, start talking about patients' emotions at the very beginning of the interview.
"Go for the elephant in the room, which is the looming emotion," Dr. Fortin said. Acknowledge patients' feelings, and apologize for any factors—like long waiting times—that might be tied to you. "At the same time, don't make excuses," he added. "Your goal is to calm them and to try to find common ground."
Be aware that anger often masks fear, particularly in male patients. In one role-playing session, panelist Robert C. Smith, FACP, professor of medicine at Michigan State University, pretended to be an irate patient who initially found fault with every aspect of the office visit. That gruffness faded, however, as the interviewing physician focused on getting the patient to talk about his emotions. The patient eventually admitted how frightened he felt that his chest pain might lead to surgeons cracking open his chest.
While physicians can defuse most encounters with angry patients, there are times when you have to set boundaries, Dr. Dwamena pointed out. If patients become disrespectful or threatening, leave the room.
Somatizing patients. For somatizing patients, agenda-setting is key. When the patient hands you a list of 25 complaints, explain that she needs to focus on the one or two symptoms that concern her most. Conduct a focused—even if brief—exam, making sure you "lay hands" on areas the patient says are affected. Be sure to schedule regular follow-up appointments that are not dependent on symptoms, rather than having patients call when a problem arises (which could be daily).
It's also important to set realistic goals. "Your goal is to keep somatizing patients coming back to your office rather than going to the emergency room or the hospital," said Dr. Smith. "Even when it's obvious you'll never 'cure' them, you can at least be empathetic and help them lead more decent lives."
Antibiotic-seekers. When dealing with patients who inappropriately demand antibiotics, use negotiation strategies. Start by reassuring patients that your shared goal is making them well, and that you have other treatments that will be much more successful.
Self-disclosure can also be useful. Explaining that you wouldn't prescribe antibiotics for yourself or a family member with the same symptoms may help gain patients' trust.
Give patients several treatment options to choose from, such as over-the-counter analgesics, hot liquids and vaporizers. When patients have a say in their treatment, they tend to be more compliant.
One audience member pointed out that during a role-playing session, Dr. Smith violated what is considered an iron-clad patient interview rule: Never interrupt. But Dr. Smith, who has written extensively on doctor-patient communications, countered that interrupting patients is actually a key part of patient-centered interviews.
"You interrupt patients to get them to talk about all the issues they most want to address," he said. By doing so, you stop them from wasting time talking about a minor complaint.
"That kind of interruption helps focus the patient," Dr. Smith continued. " But you should not interrupt patients to change the subject."
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