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Managing Conflict in the Patient Care Setting
Keri T. Holmes-Maybank, MDMedical University of South CarolinaJune 18, 2013
Review the famous Groves article “Taking care of the hateful patient.”
Recognize physician characteristics that lead to a greater perception of a patient as “difficult.”
Recognize patient characteristics and patterns of behavior classified as “difficult.”
Practice the collaboration, appropriate use of power, and empathy approach recommended for managing conflict by Elder.
Learning Objectives
Illness can alter the patient’s psyche leading to uncharacteristic behavior.
Acknowledge and accept emotional responses to patients.
Physician awareness and acceptance of personal emotions may improve emotional intelligence and physician-patient relationships.
Most important is how the physician behaves toward the patient, not the emotion she is experiencing.
Empathy and collaboration are the keys to effective conflict management.
Key Messages
Dependent Clinger Entitled Demander Manipulative Help Rejecter Self Destructive Denier
Groves “Hateful” Patient
Appropriate need for reassurance Escalates to unreasonable, BOTTOMLESS
need for explanation, affection, and attention Constant reassurance Increasing dependency See MD as inexhaustible resource
Warning signs: Extreme gratitude MD feels special
Dependent Clingers
MD becomes exhausted, patient feels rejected, ramp up needy behavior with more desperate attempts at contact
Repugnance Dislike AVERSION
Dependent Clinger – MD Feelings
Empathy
Set limits early without feeling inhuman, without patient feeling deceived or disappointed
Difficult to refer to psychiatrist Interpret as abandonment/rejection Reassure you will still see them
Dependent Clinger - Suggestions
Overtly hostile, superior Intimidation, devaluation, induce guilt Control by threatening punishments
◦ Withholding payment, demands for more tests/consults, or litigation
Lack of control Compensation for MD power/knowledge Ultimately fear abandonment Entitlement = faith and hope in well-adjusted
Entitled Demander
Fear Depression Wish to counterattack
Entitled Demander – MD Feelings
Do NOT debate or belittle Acknowledge entitlement to have realistic
good care Very respectfully and non-confrontationally
to explain how behavior may compromise health
Cooperative decision-making process Rechannel energy into following the
regimen
Entitled Demander - Suggestions
Smugly satisfied with failure Do not want cure, want unending relationship with
MD No regimen will help Pessimism increases with MD’s efforts and
enthusiasm Manipulation Want MD close but keep them at significant distance -
fear Relationship will not end if they have symptoms Deny assistance/advice while spiraling into poor
health
Manipulative Help Rejectors
Anxiety treatable illness being missed, then irritation, then depression and self-doubt
Guilty Inadequate Demoralized Depression
Unproductive, time-consuming, exhausting
Manipulative Help Rejecter – MD Feelings
Don’t accuse of manipulation = doctor shopping
Share pessimism – say treatment may not be curative
Consistent, firm limitations – unrealistic expectations or demands
Regular follow-up
Patient’s fear of abandonment put to rest
Manipulative Help Rejecter - Suggestions
Simple explanations Hard to refer to psychiatrist Make sure they have follow-up with MD Empathy Patient education Encouragement and support
Manipulative Help Rejecters - Suggestions
Unconscious self-murderous/injurious behaviors
Spiral of self-destruction while requesting assistance
Glory own destruction Pleasure in defeating MD attempts to
preserve life Profoundly dependent Self-hate, project hate through the MD
Self-Destructive Denier
MD caught between ideal of saving patient and unwanted wish for patient to die
Malice Objectivity challenged by hatred, or
indifference (protects MD emotionally)
Self-Destructive Denier – MD Feelings
MD limited because patient will only allow so much care
All reasonable care for patient Compassion – terminal illness Do not abandon
Recognize without shame the feelings the patient provoke in MD
Cannot give perfect care
Self-Destructive Denier - Suggestions
Physician develops positive or negative feelings toward patient based upon personal experiences in her life
Use it to gain knowledge about where patient is coming from
Countertransference
Patient feels threatened = behavioral regression
Projects these feelings onto MD Patient feels relieved when these feelings
are reflected by MD Example: Patient feels helpless = complains
incessantly = MD feels helpless If MD recognizes can react supportively
Projective Identification
Patient autonomy Patients more educated Boundaries are being crossed by email and
info about physicians on internet Defensive medicine
Shift in Healthcare
Productivity pressures Changes in health care financing Fragmentation of visits Interrupted visits Outside information sources challenge the
physicians authority Less trust in their physicians Feel rushed or ignored may repeat
themselves or prolong visit
18% of encounters classified as “difficult”
Parts of Healthcare System Increase “Difficult” Behavior
Greater perceived workload/overwork Lower job satisfaction Lack of training in communication/poor
communication skills Inexperience Discomfort with uncertainty Poor attitude
Physician Characteristics Who Report Higher Rates of “Difficult” Patients
Professional identity ◦ I am unable to make better ***◦ Conflicts with my professional standards
Personal qualities ◦ Feel taken advantage of◦ Difficulty making relationship with patient
Time management ◦ Takes too much time
Comfort with patient autonomy ◦ Patient sets the agenda
Confidence in skills ◦ Too hard to solve
Trust in patient ◦ Lose trust in patient
Reasons for Perceiving the Encounter As Difficult
Increased dissatisfaction with services Become more demanding Repeated visits without medical benefit Seemingly endless complaints Unmet expectations Insatiable dependency Report worsening symptoms
“Difficult” Patients in New Era
Do not seem to want to get well Power struggles Focus on issues seemingly unrelated to
medical care Worried every symptom represents a
serious illness Reported greater symptom severity Chronic pain (+/- narcotics)
Patient Behavior
Psychiatric ◦ Axis II◦ Depression◦ Somatization (alcohol, borderline)◦ Mood d/o (insist on physical cause)◦ Anxiety (multi complaints, think cardiac, not enough being
done)
Lower social class Female Thick clinical records Older More medical problems Greater use of health care services Poor functional status
Patient Characteristics
Cluster A (odd or eccentric, fears social relations)◦ Paranoid◦ Schizoid◦ Schizotypal
Cluster B (dramatic, emotional erratic disorders)◦ Antisocial◦ Borderline◦ Histrionic◦ Narcissistic
Cluster C (anxious or fearful disorder)◦ Avoidant◦ Dependent◦ Obsessive-compulsive
Appendix B◦ Depressive ◦ Passive-aggressive (negativistic)
Axis II, Personality Disorders
“Difficult” GroupDissatisfaction Difficult
patients
Not-difficult
Physician's technical competence 9% 1% P<.001Bedside manner 7% 0.7% P<.001Time spent with clinician 13% 3% P=.002
Explanation of what was done 12% 3% P<.001
Higher number of visits 4 2 P=.004
Jackson, JL, Kroenke K. Difficult Patient Encounters in the Ambulatory Clinic: Clinical Predictors and Outcomes Arch Intern Med. 1999;159(10):1069-1075.
Helpless Inadequacy Frustration Anger Guilt Dislike
What Happens to the MD?
Leads to:◦ Unconscious punishment of the patient◦ Self-punishment by the doctor◦ Inappropriate confrontation◦ Desperate attempt to avoid patient ◦ Errors in diagnosis or treatment◦ Decreased quality of care◦ Work burdensome◦ Burnout
MD Feelings
Disproportionate emotional energy can be spent dealing with negative feelings
Strong negative emotional reaction is important clinical data about patient’s psychology (personality d/o)
Sensitivity to MD feelings◦ Improved physician well being ◦ Less destructive patient behavior ◦ Lower risk of litigation
MD Feelings
Collaboration Appropriate use of MD power Empathy
Managing Conflict by Elder
Priority setting ◦ Prioritize patient concerns
Diagnostic skills◦ Thorough history, physical, and testing
Decision making◦ Explain ◦ Be consistent and objective ◦ Be honest and fair◦ Facilitate patient decision making
Team approach◦ Use referrals (mental health, pain, etc.)◦ Enlist/see family ◦ Provide quality care
Coaching◦ Set small, achievable goals ◦ Short term symptom relief
Collaboration
Encourage patient to start taking responsibility
Think of their care as a team effort Adjust expectations of what can be
accomplished Patient education
Collaboration has most impact on clinical interaction
Collaboration
Set clinical management rules◦ Schedule patient frequently, longer visits ◦ Clinic time management ◦ Good documentation
Set boundaries and limits ◦ Set general limits ◦ Make explicit rules when necessary◦ Limit number of patient concerns ◦ Limit time at each visit
Appropriate Use of Power
Understand patients psyche Focus on patient emotions Compassionate and firm Patient centered Reinforce positives Keep professional distance
Empathy
Protects MD from developing negative responses to difficult and challenging behavior
Allows insight into patient issues and why patient has resorted to negative response patterns ◦ Illness can alter patients – uncharacteristic, childlike
Creates an environment conducive to more suitable health care delivery, a healthier lifestyle, better work satisfaction
Empathy
Point person - may get conflicting info from consultants
Tactful assessment of patient’s distress/emotion
LISTEN Interrupt less Regular, brief summaries of patient’s
concerns Reconcile conflicting views of
diagnosis/illness
Additional Recommendations
Acknowledge problem Both parties may contribute to difficulty Use communication skills You can discuss that have poor relationship: “How do you feel about the care you are receiving
from me?” “It seems to me we sometimes don’t work together
very well.”
Use “I” statements ◦ “I feel it’s difficult for me to listen to you when you use that
kind of language.”
Confrontation
1. ***Does my patient prioritize health?***◦ Not if patient works with MD to prevent and treat disease.◦ Unpleasantness alone is not grounds.
2. Is confrontation of my patient ethically permissible?◦ If patients self-corrosive decisions come with expectations of
accommodation.◦ If MD bearing majority of burden in failing treatment.◦ If health deteriorating from patient action or inaction.
3. What if confronting my patient is emotionally gratifying?◦ Recognize countertransference v. projective identification.◦ Assess motives and emotions in real time and discuss with a
peer.
Questions to Ask Prior to Confrontation
Butler CC, Evans M. The “heartsink” patient revisited. Br J Gen Pract. 1999;49:230-233.
Elder N, Ricer R, Tobias B. How respected family physicians manage difficult. J Am Board Fam Med 2006;19:533– 541.
Feldman MD, Berkowitz SA. Role of behavioral medicine in primary care. Curr Opin Psychiatry. 2012;25:121-127.
Kontos N, et al. Fighting the good fight: Responsibility and rationale in the confrontation of patients. Mayo Clin Proc. 2012;87(1):63-66.
Fried TR, Bradley EH, O’Leary J. Prognosis communication in serious illness: Perceptions of older patients, caregivers, and clinicians. J Am Geriatr Soc. 2003;51:1398-1403.
Groves JE. Taking care of the hateful patient. N Eng J Med 1978;298:883-887. Haas LJ, Leiser JP, Magill MK, Sanyer
ON. Management of the difficult patient. American Family Physician. 2005;72(10) Jackson, JL, Kroenke
K. Difficult Patient Encounters in the Ambulatory Clinic: Clinical Predictors and Outcomes Arch Intern Med. 1999;159(10):1069-1075.
Mathers N, Jones N, Hannay D. Heartsink patients: A study of their general practitioners. Br J Gen Pract. 1995;45:293-296.
O’Dowd TC. Five years of heartsink patients in general practice. BMJ 1988;297:528-530.
Strous RD, Ulman AM, Kotler M. The hateful patient revisited: Relevance for 21st century medicine. European Journal of Internal Medicine. 2006 (17)6;387-393.
References