Dealing with difficult patient interactions

The relationship between a physician and patient can be deep and fulfilling, but sometimes it can turn sour quickly.

The years-long relationship between Ada D. Stewart, MD, a family physician with Cooperative Health in Columbia, South Carolina, and the incoming president of the American Academy of Family Physicians, her patient slipped into this category due to a denied request.

Stewart is and the incoming president of the American Academy of Family Physicians. The patient had been receiving prescriptions for chronic pain medications from Stewart and had been doing well with her pain management contract, but when the patient wanted something that would help her sleep, that fell apart.

The patient was seeking Lorazepam, a benzodiazepine that she had taken years before, but new guidelines discouraged prescribing with opioids due to the increase in the risk of death. When Stewart denied the patient’s request, the situation grew tense.

Stewart says the woman insisted this drug was the only thing that could help her and that she couldn’t take any other drugs. When Stewart held her ground on the issue, the woman accused the doctor of not caring.

“So, I had to kind of get myself together, because number one is as a physician, and one who has established a relationship with her over the years and knowing that I care, my first reaction was, how can you say that?” Stewart says. “You know, I definitely care. So, it was hurtful for me.”

Empathy

Most physicians who are in primary care have patients they find more challenging than others for a variety of reasons, according to Dennis L. Gingrich, MD, a Penn State College of Medicine professor with 40 years of clinical experience.

“Some [reasons are] unrelated to the patient’s interaction or personality and simply related to the complexity of their illnesses,” he says “But sometimes you can get that sinking feeling if you look at a patient coming up on the list and think either, ‘this is going to take a long time’ or ‘it’s likely to be a challenging conversation’ or ‘I may not be able to meet this patient needs today, based on past experience.’’

In addition to these kinds of patients, some patients become rude, belligerent, or even violent. Gingrich says that situations with these patients can be a result of anything from them just having a bad day to almost psychopathic behavior. When dealing with these patients, he says three things need to be assessed: the situation, the patient, and the physician’s actions.

This is what Stewart did when dealing with her patient. Rather than express her immediate, internal reaction, Stewart calmed herself down and considered the patient’s mindset. She then explained the situation in a way so that the patient understood she was denying the drug in order to avoid possible deadly interactions.

“You have to kind of sit back and look at the patient and be empathetic to their particular issues and give them a balanced way,” she says. “Yes, recognizing their thoughts, but still making sure that you explain to them what’s actually going on and why you’re doing what you’re doing.”

Gingrich says that the alternative, getting angry at your patient and expressing it, almost never works, but often finding the cause of the patient’s frustration and doing what you can to try to alleviate the situation.

“If [the patient’s problem is] something like an office practice or a personal manner in which you work with patients, it might be something that can be adapted to this particular patient and there may be a flexible solution,” he says.

Another aspect is to communicate to the patient that they are a partner in solving the problem. Gingrich says that he tries to personalize communication with his patients by using their name, making eye contact, and using a measured, reassuring, calm voice. He says this usually calms the interaction.

“Angry patients [use] a lot of energy trying to maintain that anger and if you don’t feed the fire by getting angry back, it generally dissipates,” he says.

A safety plan

But it’s still important to read the patient’s mood and other visual cues to ensure that the anger really has dissipated. If they’re not calming down, or if they are getting more belligerent and possibly even violent, then you need to try and focus on what is causing this increase in aggression, Gingrich says.

“The two things that are most commonly involved from a patient’s perspective would be psychological illness such as personality disorder, or alcohol or drug overuse,” he says. “Both of those situations will cause patients to blur behavioral boundaries. And that’s something that if you’re the primary care physician, such as a family physician, that you would need to address medically anyway over the longer term.”

In extreme cases of dealing with a belligerent patient, a physician may need a safety plan not only for themselves, but for their staff and other patients as well.

“It can get scary,” Stewart says. “And there’ve been episodes within hospitals where physicians and nurses have been harmed and you have to recognize that is a real problem now.”

Stewart says that her first concern in those situations is to ensure that the patient is not between her and the door of the examination room. But still she tries to calm the patient down. If that fails, she’ll excuse herself from the room and contact the proper authorities.

If a physician works in a health system that provides security, they can be contacted for help, but local law enforcement is often amenable to offering security services in extreme cases when safety is a concern, Gingrich says.

The police or security have also been known to give preemptive protection in cases where violence is expected, he says. “That’s very rare, but it does occur occasionally.”

Discharging a patient

But once out of that situation, if a physician doesn’t feel safe caring for a patient or simply can no longer provide care, that patient must be discharged from the practice.

The first step is to explain to the patient what is and what is not an acceptable behavior in the practice and clearly define the consequences of unacceptable behavior and what will lead to a discharge from the practice, Gingrich says.

“That needs to be done usually in person with the patients and asking them if there are any questions and documenting that conversation in the record,” he says.

If they must be discharged, there are a number of rules that must be followed. First, they must be notified in writing, through a certified letter with a return signature, that they are being discharged and why.

“The statement should not say ‘we’re discharging you from the practice because you’re a miserable person,’ it should say something more like, we are sorry that we do not seem to be able to consistently meet your needs and still maintain our practice clinical rules,” Gingrich says.

Then the patient should be given time to find another clinician who will assume their care, usually about 30 days. At the same time, the front-office staff should also be made aware of the discharge, so that if the patient calls seeking an appointment after the 30 days, they are not scheduled for one, Gingrich says.

If a physician works in a larger health system, they should check with the system to see if the patient’s discharge from the practice means the patient is discharged from the whole system, says Gingrich.

At Stewart’s health system, if a patient is being discharged from one physician, they will try to place them with another physician within the system. They also give the discharged patient a 30-day supply of whatever prescriptions they are on and offer to send the patient’s medical records to another physician free of charge.

“We’re not abandoning them and not just dumping them out without any follow up or without care,” she says.

Gingrich says that the key to these interactions, whether it is simply an uncomfortable interaction or a situation where a patient needs to be discharged, is just to be empathetic.

“Challenging patient situations are difficult for all physicians to deal with because we are trained to provide the best care possible for every patient,” he says. “And it’s difficult if there’s a barrier to doing it. I think it’s important for us all to know that utilizing empathetic, patient-centered communication skills and approaching these situations thoughtfully will, in general, provide the best overall patient care for our practices.”