Difficult Clinical Encounter

Aka: Difficult Clinical Encounter, Difficult Patient Visit, Difficult Patient Encounter, Difficult Physician-Patient Encounter

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II. Risk Factors: Medical Provider

  1. Interpersonal Factors
    1. Communication barriers (e.g. language, raport)
    2. Expectation mismatch (e.g. patient expectations for encounter)
    3. Patient lacks trust in the provider
    4. Provider biases (e.g. medical conditions such as Chemical Dependency)
  2. Situational Factors affecting medical provider
    1. Provider lacks training or is insecure about their knowledge
    2. Provider physical or mental health or wellness (e.g. sleep deprivation)
      1. May affect patience, empathy and resilience under pressure
  3. Systemic Factors
    1. Inadequate time for patient care
      1. Compounded by documentation requirements and lack of support resources
    2. Social Determinants of Health (e.g. poverty)
    3. Health Disparities and socioeconomic disadvantages secondary to structural racism
    4. Moral Injury
      1. Knowing what a patient needs, but constraints and barriers are beyond medical provider control
      2. Misinformation and medical mistrust (e.g. Covid19 epidemic) broke the provider-patient relationship

III. Risk Factors: Patient

  1. Excessive Worry
  2. Bipolar Disorder
  3. Somatization
  4. Chronic Pain Syndrome
  5. Multiple presenting complaints at each visit (esp. complex problems and vague complaints)
  6. Patient angry, demanding or manipulative
  7. Drug-seeking behavior or Chemical Dependency
  8. Personality Disorder (e.g. Borderline Personality Disorder, Dependent Personality disorder)
  9. Noncompliance with recommended therapy due to factors within their control

IV. Management: General

  1. See Patient Communication
  2. See Conflict Resolution
  3. See Motivational Interviewing
  4. Recognize negative, counter-productive emotions
    1. See CALMER Approach to Difficult Clinical Encounters
    2. See Tame It Mindfulness Tool
    3. Pause for 10 seconds to allow for calming, deep breathing, centering
    4. If needed, excuse yourself and return to the room after a cool down period
  5. Communication
    1. Focus on the patient's situation, instead of the person
    2. Be aware of triggering language
      1. Avoid phrases that leave a patient without choices (e.g. "you must")
      2. If apologizing, avoid following the apology with "..., but...", which negates the apology
    3. Listen and allow patient to speak uninterrupted, and try to understand the patient's situation
      1. Acknowledge a patient's symptoms and experiences
      2. Name and validate the emotion you sense the patient is feeling
    4. Problem solve with the patient
      1. Find common ground and Shared Decision Making
      2. Negotiate the agenda for evaluation and treatment priorities
      3. Differentiate symptoms from structureal diseases (not all symptoms need extensive workups)
      4. Discuss ways to prevent similar difficult encounters in the future

V. Management: Dependent and insecure patient

  1. Signs
    1. Patient praises provider and requires increasing time and needs from the provider
  2. Provider Approach
    1. Establish and maintain professional boundaries
    2. Schedule regular appointments, and reassure patient of continued care
    3. Encourage patients active involvement in decision making and medical plan

VI. Management: Entitled and demanding patient

  1. Signs
    1. Patient bypasses standard medical protocols, assumes special medical access and angry when not catered to
  2. Provider Approach
    1. Address specific emotions and their underlying causes (e.g. acute illness, serious comorbidity, pscyhosocial stressors)
    2. Assure the patient of sound medical care
    3. Discourage mis-directed anger

VII. Management: Manipulative patient who rejects help

  1. Signs
    1. Recurrent presentations for potentially serious symptoms, yet refuses or non-compliant with recommended approach
  2. Provider Approach
    1. Refocus attention
      1. Patient to provider connection
      2. Symptomatic relief over medical cure
    2. Set reasonable expectations that patient is willing to pursue
      1. Informed Consent when this is likely to result in worse outcomes

VIII. Management: Self-destructive patient with sense of hopelessness

  1. Signs
    1. Despite maximal management, patient continues self-destructive behaviors, and health problems progress
  2. Provider Approach
    1. Manage underlying Mood Disorder (Major Depression or Anxiety Disorder)
    2. Address specific underlying causes (e.g. limited funds or medical system access)
    3. Establish reasonable goals and congratulate patients when progress is made

IX. Management: Supervising Physician of an Advanced Practice Provider with a Disgruntled Patient or Family

  1. Support the advanced practice provider and avoid blame
  2. Review the chart (history, exam and workup) before meeting with the patient and their family
  3. Relax before entering patient room (deep breathing, slow down)
  4. Slow down, sit down and listen, avoiding confrontive Posture
  5. Ask patients how you might help them and what are their key concerns
  6. Independently perform history, exam and exclude emergent conditions (and document these results)
  7. Acknowledge patient/family concerns but set realistic expectations
  8. Consider specialty Consultation when appropriate
  9. References
    1. Shoenberger and Swaminathan (2024) EM:Rap, Case of the Week, 8/12/2024

X. Prevention

  1. See Patient Communication
  2. See Emergency Department Patient Satisfaction
  3. See Risk Management
  4. Medical setting modifications that can reduce patient stress
    1. Provide a comfortable environment (e.g. seating, Temperature, calming music)
    2. Provide an easy check-in process
    3. Communicate delays
    4. Positive, caring, kind staff interaction (e.g. front desk) builds patient trust and diffuses frustration

XI. References

  1. Bailey (2023) Am Fam Physician 108(5): 494-500 [PubMed]
  2. Breen (2010) Intern Med J 40(10): 682-8 [PubMed]
  3. Haas (2005) Am Fam Physician 72(10): 2063-8 [PubMed]
  4. Knesper (2007) Psychiatr Clin North Am 30(2): 245-52 [PubMed]
  5. Lorenzetti (2013) Am Fam Physician 87(6): 419-25 [PubMed]

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