Addressing Challenging Patient Behaviors in Spinal Cord Injury

1. Addressing Challenging Patient Behaviors in Spinal Cord Injury Maggi A. Budd, Ph.D., MPH VA Boston Healthcare System

2. Goals & Objectives Upon completion, participations we be able to: • Identify the Multi-faceted issues surrounding “Challenging Patients” • Describe characteristics of patients and providers who experience “challenging” patient relationships • Use basic ethical tenets to help conceptualize appropriate “challenging responses”

3. No disclosures or conflicts of interest to report.

4. Operating Framework & Definition • Team Approach: No Disciplinary Turf • Boundaries • Assumptions • “Challenging” vs. “Difficult” • 15-20% of patient encounters1,2,3,4 Goal: Review the literature, increase our awareness of patient and provider characteristics, and provide a framework for building team solutions

5. What “challenges” are of most interest here?

6. Why is this so challenging? • Oath as providers/Work Expectations • Patient Experiences/Patient Factors • Provider Factors • Clinician’s underlying Beliefs and Attitudes Providers’ personalities, values and emotional “hot buttons” influence their reactions to patients (Novack, 1997) • System Factors • Influences of Labeling on Team Perception

7. Groves (1978) Taking care of the hateful patientN Engl J Med Four Distinct Stereotypes: • dependent clingers • entitled demanders • manipulative help-rejecters • self-destructive deniers

8. Characteristics of the difficult patient (Robinson et al., 2006, p. 278) • Multiple (unexplained) physical symptoms • Frequent attending • Somatization disorder • Breaks doctor-patient boundaries • Won’t or can’t get better—sick role issues • Non-compliance (including treatment) • Believes doctors are Gods • Hostility and signing out • Litigious • Manipulative • Has (undiagnosed) personality disorder (borderline/dependent) • May have chronic medical disorders or social disabilities • Chronic pain syndromes with or without drug addiction

9. Patient Factors (Hahn, 1996, 2001) Difficult patients are “frustrating, time consuming, and manipulative” and up to 50% of physicians “admit to ‘secretly hoping’ the patient will not return” These patients are also “high utilizers of health care and are as dissatisfied with their care as the physicians are upset to provide it”

10. Patient Factors (Hahn, 2001 citing Hahn 1994, 1996) Compared to non-difficult patients, three characteristics have been associated: • Difficult patients have twice the prevalence of significant psychopathology (67% vs. 35%) • Abrasive personality style or frank personality d/o occurred in 90% of difficult patients • Most difficult patients have multiple physical symptoms (often somatoform)

11. Risk factors for SCI • Disproportionate premorbid history of maladjustment, psychological disorders, and ETOH • Depression-Suicide 5-10% vs. slightly above 1% for the general population • Anxiety – 25% of SCI vs. 5% of controlled sample • Cognitive deficits (TBI, LD, medication effects) • Pain • Substance abuse

12. Predictors of Difficult Encounters(Jackson & Kroenke, 1999) Four risk factors identified by physicians who perceived encounters as difficult: • Depressive or anxiety disorder (29%) • Multiple physical symptoms • More severe symptoms • Physician with a “distaste” toward psychosocial side of care (23% vs. 8%) All 4 = 47% of the encounters = “Difficult”

13. It is apparent that it is not easy to separate “patient” factors from “other” factors Is there a profile of a “difficult doctor”???

14. An, et al. (2009)Archives of Internal Medicine • 422 physicians from 118 clinics, survey data • 8-Item Burden of Difficult Encounters Measure • Job Stress • Global Job Satisfaction • Time pressure • Intent to leave practice • Latent Cluster Analysis (High, Medium, Low) • Logistic Regression Analysis to compare

15. An, et al. (2009) • A “dose response” was found across all tested end points, including stress, job satisfaction, time pressure, intent to leave one’s practice, and perception of suboptimal care practices • Physicians who perceived a higher volume of difficult encounters were more burned out and dissatisfied with their jobs (also supported in previous studies) • More women; younger in the field • **Limitations: no cause-effect relationship • Value/Relevance: Shared responsibility

16. Provider-Patient Interface: Labeling • Labeling can lead to stereotyping; stereotyping can limit your openness and flexibility and may reduce communication • Label of “difficult patient” can actually lead to professional and emotional distance • Labeling assumes the provider is ideal, the provider-patient relationship is ideal, all working in an ideal system

17. Ogunsemi et al. (2008)Ann Gen Psychiatry • 144 final year medical students • A single-paragraph case description illustrating a normal person, a social distance scale and questions on expected burden. Half received psychiatric dx/half no dx • Label on case: would not rent their houses, unwilling to select as a neighbor, not allow sister to marry, felt they would exhaust them physically and emotionally • Results strengthen the view that stigma attached to mental illness is not limited to the general public; medical students can also be part of the stigmatizing world

18. Progressive View: Dyadic • Provider/Patient interface • Consequence of both Provider and Patient factors; each contributes • Patient-centered care appreciates the asymmetry of the relationship, wherein the provider holds more responsibility for empathy and “focus of treatment” • Bundled approach: organizational, contextual, and provider factors

19. Tools: Standard Practice • Improve provider-patient communication • Increases patient satisfaction & • Improves health outcomes (Kravitz, 2001) • Decreases complaints and lawsuits (Virshup et al., 1999; Levinson et al., 1997) • Improves adherence 19% (Zolnierek & Dimatteo, 2009) • Ask patients about their understanding of the illness/problem and expectations of care (correct misconceptions and unrealistic expectations; exposes barriers/benefits/risks; builds rapport) • Include psychology

20. What to do in real challenges? • Identify the source of the problem • Patient? Provider? Relationships? System? • Psychiatric liaison or Psychology consult to help provide insight and guidance • Clear TEAM treatment plan; setting limits • TEAM is the treatment • CONSISTENCY • Discuss with peers • Try to always respond with respect and frame in ethics

21. Medical Ethics • Autonomy: right to refuse or choose • Beneficence: act in the best interest of the pt • Justice: fairness and equality of health resources • Dignity: Pt and provider have the right to dignity • Truthfulness/Informed consent • Non-malfeasance: “first do no harm”

22. Challenges to effective rehabilitation Psychological (depression; anxiety; noncompliance) Physical (chronic pain; sleep; nutrition; fatigue; substance abuse; sexual problems; agitation) Cognitive (delirium/dementia; attention; initiation; memory; processing speed; unawareness) MISC (excessive demands; anger; apathy/silence; verbal outbursts; decreased participation) Budd, M.A. (in press). Rehabilitation Psychology. In M Gonzalez-Fernandez & JD Friedman, eds, Physical Medicine and Rehabilitation Pocket Companion. Demos Medical: New York.

23. Take Home (& to The Team) Messages • It is not uncommon for providers to view patients as “challenging” particularly when working within a specialized field inherent with abundant stressors such as SCI • Labeling and “pigeonholing” are not helpful; conceptualize each case individually and contextually • Operating from an Ethical Framework is a fundamental place to start for all interventions; always is in the best interest of our patients as well as our professional integrity • TEAM approach will optimize mental and physical health for our patients with SCI across all providers and over time…

24. Reminders Do not take challenging visits personally, recognize that it is normative Dealing with “challenges” signifies mastery rather than weakness

25. Future Directions • Link perceived “challenges” to specific encounters and measure the patient and provider’s perspectives in tandem, and include longitudinal assessment to evaluate the effect of challenging encounters on patient and provider satisfaction, adherence, functional improvement, quality of life and health care costs.

26. THANK YOU very much!! Margaret.budd@va.gov