That Son of a Bitch – Dealing With The Difficult Patient.

1. That Son of a Bitch – Dealing With The Difficult Patient. Derek C. McCalmont M.D., FACEP, MS Management Service Chief Henry Ford West Bloomfield Hospital ED March 7, 2012

2. Goals for the next 30 min. • Identify some common difficult patients • Identify some common difficult doctors. • Understand where both are coming from. • Develop strategies to make these interactions easier on both sides. • Earn 30 min. of CME credit!

3. http://www.youtube.com/watch?v=TmwqWBJahto&feature=email Why Do We Bother?

5. Why should I care? • One out of 6 visits are considered “difficult” • Physician burnout (and lower work satisfaction) 12x more likely • Difficult patients have lower satisfaction with their care

6. The Bottom Line • Difficult patients represent a relationship problem, not a clinical one. • It is the clinician’s responsibility more than the patient’s to address and resolve the relationship problem. • Physician’s have more access to and control over our own reactions than we have over the patient’s.

7. It’s Not A Contest!

8. Who Are These Patients Demographically? • Older • More often separated or divorced • Women>men • More Acute and Chronic Problems • More medications • More x-rays and tests • More visits • Lower satisfaction with their care

9. Who Are These Patients Diagnostically? • More likely to have mental disorder- multisomatoform disorder, panic disorder, dysthymia, generalized anxiety, major depression, alcohol abuse or dependence. • Personality disorders- Borderline, OCD, Dependent, Self-defeating, narcissistic, paranoid etc. • Chronic Pain

10. What About The Easy Patients? • Objective signs and symptoms of a treatable disease. • Make no emotional demands on the clinician • Cooperates in the treatment process • Displays gratitude for the help received

11. A Common Definition? • One who impedes the clinician’s ability to establish a therapeutic relationship. • One who’s behaviors are perceived to challenge provider’s competence and/or control. • One who- by a variety of behaviors related to profound dependency stimulates negative feelings in most doctors.

12. Who Are These Doctors? • At some level- all of us. • Younger (less experienced) • Female • Overworked • Lower job satisfaction • Medical rather than a biopsychosocial approach (most of us). • Lack of communication skills training (most of us) • Lack of self-awareness (most of us)

13. Clinician Awareness • Negative emotional reactions not fully recognized • Negative reactions are the primary controllable determinant in these interactions • Increased physician awareness=decreased perception of difficult patients=increased physician satisfaction

14. We Have All Been There

15. Being self-aware and patient centered and incorporating knowledge about the patient’s personality are baseline requirements for working with all difficult patients.

16. Do’s • Allow more time for these patient encounters • Continue to listen • Continue to educate • Encourage the patient to gain control • Maintain hope • Frame referrals to Psych in terms of the stress produced by mysterious or intractable symptoms.

17. Dont’s • Brush them off • Tell them nothing is wrong • Use “stress” or “anxiety” as a diagnosis without considering what can be done about it. • Be angry • Be punitive • Propagate despair.

18. Patient 1 • 37 y.o. female • CC- Chest Pain • HPI- Pressure-like sub-sternal pain radiating to the left arm for two days unrelieved by NTG • PMH- Unremarkable • PSH- Smokes 5-10 cigarettes daily. Denies alcohol or drug abuse.

19. Dependent Clingers • Escalate from appropriate request for reassurance to excessive demands for attention, medications etc. • Naïve about their effect on physicians. • Run the gamut from healthy to life threatening. • Self perception of bottomless need and physician/healthcare as inexhaustible.

20. Strategy • Identify as early as possible • Specify limits of physician knowledge/time • Provide specific follow-up appointments • Remind patient to utilize office visits for recurring problems.

21. Patient 2 • 56 y.o. male • CC- Abdominal Pain • HPI- Patient with epigastric pain of 2 hours duration with nausea. • PMH- Hypertension, GERD

22. Entitled Demanders • Like Clingers- profound neediness • Use intimidation, devaluation, guilt-induction to obtain attention/testing/meds • Less naïve about their effect on physicians • Threatening (litigation/complaints) • Exude a repulsive sense of innate deservedness

23. Strategy • Recognize Hostility is born of fear of abandonment • Entitlement is their religion- don’t blaspheme it. • Support but re-channel the entitlement. “You deserve the very best care we can give you but you need to help”. • Avoid logical/illogical arguments

24. Patient 3 • 32 y.o. male • CC Low back Pain • HPI- Left LLB Pain radiating down left leg for 5 days. • PMH- Chronic back pain with radiculopathy • Current Meds- Vicodin (out) • Allergies- NSAIDS, Ultram

25. Manipulative Help-Rejecters • “Crocks” • Feel that no regimen will help • Frequent flyers happy to report that yet another treatment has failed • Pessimism increases in proportion to physician’s efforts

26. Strategy • Suspect depression • “Share” the pessimism. Agree that treatment may not be entirely curative. • Provide simple reasoning. Avoid complicated explanations. • If needed schedule psych follow-up but also PCP follow-up AFTER psych vist to avoid abandonment issues

27. Patient 4 • 65 y.o. male • CC- Constipation • HPI- No BM for 3 days • PMH- Metastatic bone CA. • Current Meds- none • PSH- Lives alone. Family lives nearby but not involved in care.

28. Dr. Cox Responds http://www.youtube.com/watch?v=RK8dMRLVWvg&feature=email

30. Self-Destructive Deniers • Unconsciously self-murderous behaviors • Profoundly dependent but have given up hope of ever having their needs met • Non-compliant with medical regimen and take pleasure in defeating family and physician attempts to save their lives. • Prize their independence and deny infirmity

31. Strategy • Limited Options • Acknowledge your own frustration • Best you can while you can • Psych consult- usually refused.

32. Final Thoughts • Difficult patients and their frustrated physicians fail each other. We flop together. We lose hope. And there is no more useless doctor than one who has lost all hope. • Difficult patients are an opportunity to further define ourselves as clinicians. To be compassionate, not hostile in the most trying of circumstances.