Communication with Patients

Dr Nehal Mehta

Objectives

Recognize and describe the patient and provider roles in difficult relationships

Describe a framework (mnemonic) to improve communication with patients and overcome challenging interactions

What is a difficult patient? One who…

Raises negative feelings within the clinician Causes the clinician to experience self-doubt

(threatens clinician’s competence or control) Has beliefs, values, or characteristics that differ from

those of the clinician Does not assume the role expected by the health

care professional

A difficult patient is one who impedes the clinician’s ability to establish a therapeutic relationship, but…

… It Takes Two! The difficult patient must be viewed in context of the

clinician and the clinician-patient relationship.

Physicians: Receive biomedical training, focused on identification

and treatment of the disease May not receive adequate psychosocial training,

focused on communication and relationship-building Often have negative emotional responses to patients

that are not fully recognized and lead to unconstructive behaviors

If the clinician feels threatened leads to over control of the interview or situation

If the clinician has discomfort with psychological issues leads to avoidance

If the clinician dislikes the patient leads to superficial behavior

The most common element of an adversarial clinician-patient relationship is FAILED COMMUNICATION.

Obstruction in communication•Multiple symptoms involving multiple body systems

•Vague and shifting complaints

•Undue concern about minor symptoms

•Poor response to usual methods of treatment

•Hostile, demanding, dissatisfied

•Manipulative, exploitative, controlling

•Seductive

•Unrealistic expectations of care

•Raises new problems as visit ends

•Resistant to physician’s recommendations

•Self-destructive

Communication with difficult patients

The “ANGRY Patient” Pay attention to pre-visit signs: long waits and staff

cues. Is it true anger, or just pain and frustration? Anticipation of Bad News? DO NOT GET DRAWN INTO THE CONFLICT KNOW YOUR TRIGGERS!

Strategies to Defuse Anger1. Allow the patient to vent their anger. 2. Acknowledge the anger “I can see you are really

angry about this.” 3. Validate the anger “understandably you are very

angry as this is a very frustrating situation you are in.” 4. Offer to explore the situation in more depth – it is often

found that there are many layers to the anger and frustration the patient is experiencing.

5. During the interchange keep calm6. Use a neutral tone of voice, adopt an open body

posture7. Do not become defensive (do not take it personally)

Non-Compliant Patients Defined

The patient deviates significantly from most patients (with similar medical problems) in degree of compliance with medical advice, treatment, or follow-up in a way that directly or potentially jeopardizes the patient's health or quality of life.

The patient's medical problem is potentially serious and poses a clinically significant risk to length or quality of life

At least one treatment exists that if followed correctly, will markedly reduce this risk

The patient has easy access to the treatment or treatments

“The most helpful things I have ever done with noncompliant patients have been to ask questions, not to lecture, and to be willing to listen to what patients say.

These activities are often very difficult to do within the time constraints of clinical practice.

Sometimes I have to "suspend" the clock and my usual clinical approach and just tell the patient that I'm frustrated and concerned and that I need to know what he or she understands about the disease process and problems being faced. And then I'll just be quiet and listen as nonjudgmentally as possible. “

The “Seductive” or The “Manipulative”Patient”

The “Seductive Patient”

Even non-psychiatric care involves “transference” phenomenon Transference=feelings experienced by the patient toward the

physician that recapitulate other important relationships within the patient’s life

Caring and compassion misinterpreted as sexual suggestion Innocent flirtations NEVER appropriate Emphasize that this is a strictly professional relationship  Utilize chaperone throughout interactions Obtain consultation/referral if needed Institute and enforce written office guidelines

The “MANIPULATIVE” Patient

These patients often play on the guilt of others, threatening rage, legal action or suicide.

They tend to exhibit impulsive behavior directed at obtaining what they want, and it is often difficult to distinguish between borderline personality disorder and manipulative behavior.

The keys to managing encounters with manipulative patients are to be aware of your own emotions, attempt to understand the patient's expectations (which may actually be reasonable, even if his or her actions are not) and realize that sometimes you have to say "no."

Case One

R.D. is a 5 year old girl with lobar pneumonia and effusion, hospitalized with respiratory distress and hypoxia. You are called to her bedside because of worsening respiratory status. On exam, she appears ill and uncomfortable. She is febrile, tachypneic, with diminished breath sounds on the right base and both subcostal and intercostal retractions. Her parents, whom you have never met, are at the bedside and appear worried.

What is the goal of communication with the patient and parents?

What are the challenges of communicating with the patient and parents in this situation?

Unique challenges to effective communication

Inherent stress of high acuity situation Lack of established relationship with patient and parents Potential for frequent interruptions Time constraints And more…

Doctor-Patient-Attendant Communication Informativeness: quantity and quality of health information

provided by doctor. It directly addresses the cognitive needs of the patient and/or parent, and forms the foundation for the physician’s task-related behavior. The physician may say, “She may have respiratory distress because her effusion has worsened, so I am going to get a chest x-ray.”

Interpersonal sensitivity: affective behaviors that reflect the physician’s attention to, and interest in, the patients’ and relatives feelings and concerns

Partnership building: the extent to which the physician invites the parents (and child) to state their concerns, perspectives, and suggestions

Interpersonal sensitivity and partnership building address the affective needs of the patient and/or the relative-that is, the emotional need to feel heard and be understood.

These two components inform the physician’s relational behavior – showing concern and respect. The physician may say, “I can see that you are worried. What worries you the most?”

Some nonverbal ways to show concern and respect include maintaining eye contact, using appropriate gestures, and using active listening skills.

The literature overwhelmingly supports direct communication with the child, provided that the communication is done in a developmentally appropriate manner, taking into account the parent-child relationship and the family’s cultural values.

Case TwoYou finally have a moment to eat dinner. Your phone rings and the nurse on duty says: “Patient J.S.’s mother is here. She is upset and asking to speak to the doctor. Please come ASAP.”

You groan in response. Mrs. S has become notorious on your team, a so-called “difficult relative,” because she is always upset and demanding of the provider’s time. You have been dreading receiving this page. You decide to eat your dinner quickly, and then go to the bedside.

Which characteristics of the patients relative and provider contribute negatively to this situation?

What approach would you use when talking to Mrs. S?

Case Two- Continued

You review your sign-out: J.S. is a 4 month old with bronchiolitis. Parents were not present or reachable by phone during day. You learn from the nurse that Mrs. S is upset because J.S. was placed on oxygen and she was not notified.

When you walk into the room, Mrs. S has her arms folded across her chest. You introduce yourself, and she responds by complaining about her son’s care and how no one is talking to her. You listen for a minute or two, and end up having to interrupt her to get a word in. You mention that your colleague called during the day but no one answered. Mrs. Smith just gets more upset, saying that there was no message and no one is keeping her informed.

What is the goal of the provider’s interaction with Mrs. S? Alleviate parent concerns, provide education about condition and what to expect, establish better method of communication

How is this goal best accomplished? Active listening, validation of concerns

NURS MnemonicGoal: Elicit the patient’s emotions and address

them.

Naming: recognition of emotion “You are angry.” or “That was sad for you.”

Understanding: acceptance and validation of emotion “I can understand why that was frustrating for you.”

Respecting: respect their experience, praise their efforts “You’ve been juggling a lot.” or “You did a great job

recognizing that he was getting more sick.” Supporting: express support, create partnership

“Let’s work together to come up with a better way to address this.”

Case Two- RevisitedUsing the NURS mnemonic, craft a

response to Mrs. S.

“Mrs. S, I can see that you are upset and I can understand why. It must be difficult to arrive at the hospital and learn that your son is now requiring oxygen. You’ve been juggling a lot, with having to go to take care of your other children and be here at the hospital with J.S. What questions can I answer for you now?

I am sorry that we were not able to communicate better during the day. What would be the best way to make sure this type of thing doesn’t happen again?”

Coping Skills that help…

Allow patients to vent their feelings: Listen long enough to show your empathy, but set practical time limits.

Strengthen your communication skills: Remember that as a

physician, you're also a teacher and a coach. Tailor your explanations and guidance to each patient's needs and ability to absorb information.

Become a more effective history taker: They may also provide you with clues about what the patient is skipping over or not saying.

Avoid becoming an enabler: Know when to set limits on patients' demands in order to protect yourself from burnout

Try not to judge: View patients' disruptive actions as opportunities to learn more about their concerns, beliefs and needs.

Remain calm and confident: Stay in control while working with patients who are angry, depressed, manipulative, seductive or overly dependent.

Understand your own strengths and vulnerabilities: Know when to set limits on patients' demands in order to protect yourself from burnout

Be patient & Respect your patients: Know when to set limits on patients' demands in order to protect yourself from burnoutProtect patients' confidentiality, keep promises and show that you respect their feelings.