Difficult patient & breaking bad news
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Transcript of Difficult patient & breaking bad news
Difficult Patients
Dr Faisal Al HadadConsultant of Family Medicine
&Occupational Health
PSMMC
Introduction
Difficult patient: the one with whom the physician has trouble forming an effective working relationship.
This term has become politically incorrect.
In one study, American doctors rated 15% of primary care patients as 'difficult'.
Types of Difficult Patients
Somatizing patient: patients who express personal distress in the form of somatic symptoms and refuse to believe that no organic disease is present.
Dependent clingers: are excessively dependent on the doctor, desperate for reassurance but will return continually with a new array of symptoms.
e.g. "Thank you, my back's much better but I've got chest pain now."
Types of difficult patients
Entitled demanders: Patients who make excessive demands by frequent visits, pressure for tests, medications or referrals. They are frequently complaining when every request is not met.
e.g. "I must see a specialist for my ingrowing toenail right now!"
Manipulative help-rejectors: continually return to the surgery to report that treatment failed. Where any symptom is relieved, it is rapidly replaced by another.
e.g. "None of the painkillers have helped my back, I'm allergic to
those other pills, Pain Clinic did nothing. You've got to help me!"
Types of difficult patients
Self-destructive deniers: whilst suffering from a potentially serious condition, will make no effort to alter their self-destructive behaviours.
Angry Patients
Seductive Patients
Grieving Patient
Risk factors
Risk factors related to the doctor:
Perception of high workload
Poor job satisfaction
Poorer postgraduate qualifications
lack of training in counseling and communication skills
Risk factors
Risk factors related to the patient:
Psychiatric disorders (particularly somatoform disorder, panic disorder, dysthymia, GAD, MDD and probable alcohol abuse or dependence)
Functional impairments
High use of health care
Lower satisfaction with care
Cues indicating difficult patient
A new patient who comes after leaving another physician and extravagant in his praise for you while expressing great hostility toward the former doctor ?Demander
Frequent visits for problems that never respond to treatment; persistent complaints of symptoms with repeatedly negative tests and unhelpful consultation ?Somatising
Disagreement over prescription drugs. The relationship with the doctor is good as long as they receive their prescription. The medications may be taken for a spurious diagnosis ?Dependent
Cues indicating difficult patient
Cues from our own feelings. When a patient evokes a feeling of anxiety, pressure, boredom, or frustration; or when we particularly want to please and impress a patient.
Breaking Bad News (BBN)
Dr Faisal Al Hadad
Case Discussion
Abdullah is a patient of yours who comes to see you one day with his wife Sharefa. Sharefa is also a patient of yours who was admitted to hospital for investigations for liver. The results of the liver biopsy showed a well differentiated hepatocellular carcinoma. This result had been disclosed to Abdullah only. He has come to you today asking for your assistance in telling his wife the results of her investigations.
How would you handle this situation?
Before Consultation
Ensure appropriate physical setting (quite and private consultation room)
Avoid interruptions during the consultation
Ensure enough time for the consultation
Be aware of the details of the patient and all necessary information
What information is to be conveyed and in what order?
Ensure family support during consultation
During consultation
Fire a warning shot then pause before going on
Find out how much the patient knows
Find out how much the patient wants to know
Clarify the information you are giving and check understanding.
Elicit the patient's concern
Honestly and accurately
During consultation
Effective communication skills: Clear language Eye contact Empathy Attentive listening Unhurried manner Body language Appropriate touch Appropriate use of silences Encourage patient to ask questions Summarizing
During consultation
Explanatory leaflets
Avoid unnecessary distress
Avoid overload patient with information
Leave the patient with an early follow-up plan and a realistic hope.
After consultation
Roger Neighbour (1987)Inner Consultation
Connecting
Summarizing
Handing Over
Safety Netting
House Keeping
Thank you