January 30, 2019

All of us are guilty of “schedule watching”, and some names on the schedule make us shudder.
How we handle these “difficult” patients is an indication of the quality of our care.
Most people are not difficult, but many of our patients find themselves in difficult situations. It’s important for us to realize that our patient’s experience of illness can be frightening, frustrating and threatening. These people are under stress and their emotions can run “hot”.
A study in a large multi-specialty clinic compared CG-CAHPS scores among multiple specialties. The vast majority of patients across most specialties identified being treated with respect as their highest priority. In another study, physician empathy was the strongest factor in patient satisfaction. In my opinion, empathic communication is respectful communication! So, how can we use empathy for our patients with difficult situations?

The Angry Patient

Some of the most common difficult situations involve angry patients. Anger is often based in fear – losing a job, financial distress, loss of self image.
We can’t let anger be contagious! When we respond to the angry patient in a calm way and use empathy we can most often defuse the situation. Letting the patient ventilate is critical. Empathy involves acknowledging the patient’s emotional state (without assigning blame – don’t throw anyone under the bus!) It may take several empathic statements to allow the patient to calm down.
Empathy lets the patient know that they have been heard but not judged. Treating the patient with empathy and respect is critical. These interactions are not easy but can be rewarding.

The Noncompliant* Patient

We are all frustrated by the patient who just won’t (or can’t?) get better! Multiple treatments may have been recommended but not followed. One study of noncompliant* patients found that 27% could not afford the recommended treatment, 39% disagreed with the doctor, 32% found the instructions too difficult to understand, and 20% stated that the recommended treatment was against their personal beliefs (this adds up to more than 100%; many people gave several reasons).
A simple question, “how will that work for you?” can help us learn whether a given treatment is likely to be workable for the patient. This lets us offer other options with a higher chance of success.
Noncompliance* can be a result of limited health literacy (LHL). The average American high school graduate reads at a 5th grade level; only one in every eight Americans can understand health instructions at the same level we do. We can address this problem by following the AHRQ “Universal Precautions” for health literacy. These are: patient instruction materials written at an appropriate (5th grade)** reading level and use of a “teach back” technique to assess the patient’s understanding.
Respect and empathy will help us to better help patients by understanding their unique situations.

The Patient with Multiple Complaints

In the Clinician-Patient Communications workshops we present, this is a common frustration. This involves a mismatch between the patient’s and the clinician’s agendas for the visit. We look at the schedule and see a nice single problem (or in my specialty, orthopedics, a single joint) listed. The patient may have more than one concern (hint: most do).
Setting the agenda involves a scary question: “what other concerns do you have today?” We’re afraid of opening Pandora’s Box and losing control of our schedule. Getting the patient’s agenda at the front end of the visit helps us to prioritize and maintain control. A follow on question is very important: “what is the most important thing you want to make sure gets done today?” This allows the patient to have control of the agenda while we keep control of time. We can offer a second visit if needed for multiple concerns.

Recommendations:

Obviously there are many more “difficult situations” we encounter regularly. For a more comprehensive look at how to have these conversations, I recommend two books to you:
Practical Plans for Difficult Conversations in Medicine. Robert Buckman MD, PhD
Field Guide to the Difficult Patient Interview (Second Edition). Frederick Platt MD and Geoffrey H. Gordon MD
Particularly for surgeons, empathy does not occur easily or naturally. Training workshops that allow us to practice these techniques are probably the most effective way of incorporating empathy into our daily practices. We can start by understanding that it’s the situation, not the patient, that’s difficult.
*The preferred term for this situation is “non-adherence”. Adherence implies that following the plan is voluntary. Patients who have participated in the treatment decision are more likely to adhere to the plan.
**This post is written at a 9th grade reading level.

 

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