and difficult patients Sue Rendel Definitions Different types of difficult patients Why are they important What is the source of the problem How to deal with heartsink and difficult patients ID: 531611
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Slide1
Heartsink and difficult patients
Sue Rendel Slide2
Definitions
Different types of difficult patients
Why are they important?
What is the source of the problem?
How to deal with
heartsink
and difficult patients.Slide3
Definitions
“There are patients in every practice who give the doctor and staff a feeling of
heartsink
every time they consult. They evoke an overwhelming feeling of exasperation, defeat and sometimes plain dislike that causes the heart to sink when they consult.” O’Dowd 1988 BMJ
Heartsink
patient
Difficult patient
Dysfunctional consultationSlide4
The classic four types of difficult patients
Grove 1978
Dependent clingers
– Repeated requests for attention, reassurance, urgent demands for explanation, affection and medication.
Entitled demanders
– Patients that exude an innate sense of deservedness; they use intimidation, devaluation, and guilt induction to place the doctor in the role of “the inexhaustible supply depot”.
Manipulative help-rejecters
– Patients who return to the surgery again and again, almost smugly satisfied to report that, once again, the treatment or regimen hasn’t worked. Their pessimism appears to increase in direct proportion to the doctor’s effort and enthusiasm.
Self-destructive deniers
– Appear to find their main pleasure in defeating the physician’s attempts to preserve their lives. This may represent a chronic form of suicidal
behaviour.Slide5
D Colquhoun
The never get betters
Not one but two
The
medicosocially
deprived
The wicked manipulators
The sadSlide6
Gerrard T and Riddell J
Black Holes
Family complexity
Punitive behaviour
Personal links to the doctors character
Differences in culture and belief
Disadvantage, poverty and deprivation
Medical complexity
Medical connections
Wicked manipulative and playing games
SecretsSlide7
Why are they important?Doctor factors
Because they can generate negative emotions:
S
tress/anxiety
Fear
Anger
Low Morale (Heart Sinks)
HelplessnessSlide8
Why are they important? 2
Patient reasons
Because they can end up having unnecessary investigation and/or
treatment
A heart-sink patient is probably an unhappy patient (life, doctor, ill health, past negative experiences)
My life as a heart-sink patient, BJGP
vol
61 2011
Acknowledge lack of help, act on it and don’t just order more tests to get me out of the room
Societal reasons
Resource intensive
Money
TimeSlide9
What is the source of the problem?
The patient?
The doctor?
Doctor patient
relationship?
Societal forces?Slide10
Patient factors
Unrecognised psychiatric disorders (
eg
, anxiety or depression)
Undiagnosed physical illness
Somatisation
Alcoholism
Borderline personality disorder
Previous experience of poor or disappointing care
Well-founded need for information or in-built critical approach to problems
Egotistic elements and an excessively demanding attitude.
Female>male
Age >40
Single, widowed or divorced
Marital/family problems
May be very isolated
Lower tolerance for minor illness
Concomitant serious illness
Experience of serious relationship dysfunction and rejection in early
lifeSlide11
Doctor factors 1
Mathers
et al BJGP June 1995
60 GPs from Sheffield area
Structured interview and questionnaire
Number of heart-sink patients 1 – 50
per list (FTE)
4 variables significant: Workload
J
ob satisfaction
Training in counselling/communication skills
Post graduate training (MRCGP,
MRCPsych
)Slide12
Doctor factors 2
Strong assumptions as to how patients should behave and how medicine should be practised
Narcissism or arrogant
personality, convinced of their rectitude
Poor communication
skills, doctor centred fail to understand role of psychosocial factors
Over patient-centred, needs to be liked by everyone, creates dependency.
Cultural gaps that go unrecognised
Lack of
experience
Stress or overwork
.
Both of the above may lead to over prescribing, investigating, referrals etc.Slide13
So what do you think?
Do you have characteristics that might predispose to the doctor factors?
How would you identify them?Slide14
Doctor patient relationship
Parent, child, adult (Berne, Games People Play)
Doctor and patient may be emotionally attached to each other
Collusion, relationship might be filling a need in
both co-dependencySlide15
Heathcare system factors
Growing multicultural societies: communication problems and different or unrealistic expectations from
doctors
Increase of patient mistrust following high-profile cases
Pressure to reduce the cost of care and increase physician productivity decreasing the amount of time for consultations
Lack of continuity of
care
Easy access to wide-ranging, and sometimes confusing, information via modern technologySlide16
How to deal with difficult/heartsink patients.
Steinmetz and
Tabenkin
The ‘difficult patient' as perceived by family physicians.
Family Practice
2001;
18:
495–500.
15 board certified family physicians in
Israel, long structured interview
Empathy
Non-judgemental listening, patience and tolerance.
Direct approach, defining length of time and content in advance
Referral, passing the buck?
Recommend another doctor
Humour
Involve patient’s family
Sharing doctors personal experience with patientSlide17
Another approach
Successful GP Intervention with frequent attenders in primary
care
Bellon
BJGP 2008
7H and T ( 7 hypotheses and team)
GPs analysed their frequent attenders to identify the area in which the issue was likely to be (hypothesis)
Biological, psychological, social, family
, cultural, administrative-organisational, or related to the doctor–patient relationship
.
Then discussed with the team and generated a management plan.Slide18
Dependent clingers
How to recognise them:
frequent attendance for simple problems, reassurance, “pill for an ill”, ask for repeated Rx and services, ask for favours, flatter you to excess “only you can help me doctor”, refuses to see other GPs
Feelings generated in GPs:
how sad, exhaustion “sucked dry”, aversion and avoidance. May be GP fault for allowing/generating doctor dependency
How to handle them:
set boundaries and limits,
eg
number of consults a month, be in the driving seat, encourage self help and self coping, accept problem is theirs not yours, consistent and firm, recognise your own feelings and control them, housekeepSlide19
Entitled demanders
How to recognise them
:
demanding or manipulative, want something “now”, instil a sense of fear, guilt or intimidation by devaluing the
Dr.
threaten with legal action, see doctor as barrier to what they are asking for, “if you don’t then be it on your head”,
somatisers
, personality disorders, can become aggressive think about personal safety. May have had longstanding psychosocial upset leading to abnormal illness behaviour
Feelings generated in Drs:
anger, resentment and fear
How to handle them:
with care, be pleasant and try to establish a rapport, try not to say no straight away, negotiate a management plan, if you do give in to wishes make it clear it is part of the management plan, always think about personal safetySlide20
Manipulative help-rejecters
How to recognise them:
keep coming back to tell you the treatment was no good, despite this they keep coming back to you. They are doctor dependant. Same old story you can often guess before they sit down. They have preconceived ideas and may aim to seek an indissoluble relationship with doctor. What is the secondary gain from this behaviour, often comes from family and friends. Resolution of symptom with be replaced by another. “that will never work” “ Only Dr X can help me”
Feelings generated in Drs:
sense of hopelessness, inadequacy, dissatisfaction, overburdened ,frustration.
How to handle them:
set boundaries and limits, identify what the patient wants and set limits on what they can have, share the load, challenge patterns
eg
by agreeing with their views “ yes you are right that probably won’t help” consider delayed response.Slide21
Self Destructive Denier
How to Recognise them:
usually feel they can’t control their life the doctor can. May have chronic illness but have remediable risk factors they can’t change. Want a miracle pill instead.
Feelings generated in doctor:
anger, frustration, resignation
How to help them:
explore their health belief structure and work out with them what it might take to change, encourage self help, get them to take ownership of the problemSlide22
Identify a patient you have seen that has engendered the “
heartsink
” or left you feeling anxious and frustrated
Describe the patient to your colleague and try to work out between you where the issue is likely to be:
Biological, psychological, social, family, cultural, administrative-organisational, or related to the doctor–patient relationship.Slide23
General management techniques
Discuss your perceptions of the illness behaviour
Discuss the patients methods of denial
Be honest, but kind in your honesty
Discuss your own feelings
Start again with reviewing notes and taking a history include the family history
Compile a life chart using significant events in physical and psychosocial areas
Get the patient to keep a diary
Implementing a holding strategy
Learn to become a mirror not a spongeSlide24
Help outside the consultation
Ask yourself what are the patient’s problems, why does she evoke the feelings she does in you,
Recognise that the feelings generated in you might reflect the patient’s own feelings (countertransference)
Recognise and accept that these feelings are normal
Recognise that not all problems have solutions
Video a consultation with a difficult patient( many are often keen to help you learn)
Discuss the case with others and use groups like
Balint
groups
Video
a consultation with a difficult patient( many are often keen to help you learn)Slide25
Chew-Graham CA, May CR and Roland MO. The harmful consequences of elevating the doctor–patient relationship to be a primary goal of the general practice consultation.
Family Practice
2004;
21:
229–231.
We
suggest that doctors have overestimated the importance of sustaining their relationships with some patients, when doing so only maintains incapacity. Communication skills training in medical schools and in training for general practice
27
is rightly aimed at finding ways to improve the quality of doctor–patient interaction in ways that benefit the patient. However, clinicians need also to find strategies that permit them to recover their authority and to empower themselves in the circumstances and the types of patients that we describe herein. Slide26
And finally…
What are you going to do differently as a result of this session?