'Problem' Patients: Dealing with Angry, Edgy Patients Blog | May 25, 2011 By Trisha Torrey Good to see

you today, Mr. Lee. How does your shoulder feel? It still hurts. Im sorry to hear that. Have you been taking that prescription I wrote for you? Sometimes. Has your therapy helped at all? Therapy was a waste of time. Not only cant you get your patient to open up, but its clear that there is something else besides his shoulder pain getting in the way of the conversation. Youre wondering what Mr. Lee expects from you if he wont be more helpful. Youre ready to finish up the appointment as quickly as you can and move on. But if you do that, Mr. Lee will just return next time with even more of a chip on his painful shoulder. What makes Mr. Lee behave this way? As weve highlighted in previous parts of this series, the basis for the anger is history, Mr. Lees ability to trust the care he will receive, and your ability to deliver it by managing his expectations. Mr. Lee is refusing to cooperate because for some reason, he feels his trust has been violated. Trust is built when patients feel respected. Lack of respect creates lack of trust. Maybe Mr. Lee was left too long in the waiting room. Some older patients dont like the 20-something medical assistant calling them by their first names. Other patients are frustrated because you wont discuss the information they found on the Internet. Still others have modesty issues and may be embarrassed. Another reason patients get angry is because their expectations have not been met. Mr. Lee didnt realize that his last prescription would require two weeks before his shoulder pain began to subside. No one explained he would need to take his pain meds with food or he would suffer nausea. When the nurse took his vitals and he mentioned he had begun eating cherries because he read somewhere that they would ease his pain, she laughed at him. In all cases, Mr. Lee expected one reaction but got another.

There are extremes, too. These descriptions probably dont fit you, but may describe your colleagues: doctors who are arrogant, or belittle their patients, use words their patients dont understand, or who are dismissive. Your patient may be angry because he has dealt previously with a colleague who behaves in these ways. Not your fault but youre paying the price. Is there any way to improve Mr. Lees disposition and behavior? For most angry patients there is. The best approach is to be direct face it head on. When Mr. Lee puts up those seemingly impenetrable walls, pause, look him directly in the eye, and ask him, Mr. Lee. I sense an unspoken problem here and it strikes me that you are frustrated or angry. What can I do to help? Yes, he may clam up, and you may not get any further information. But most patients, when provided with an open door, will walk right through it. Theyll tell you whats going on. Know that whatever is bothering one patient is bothering many others as well. If you listen carefully, youll know what adjustments will need to be made across the board. Hell tell you, I didnt know that., or You didnt tell me . It may be You told me. But it didnt work. Or How was I supposed to know that. You may need to hear between the lines of his answers. I didnt know means he feels like you didnt explain it to him, and he thinks you should have. It didnt work means he expected it would, and you didnt help him understand that it might not. Your tendency may be to defend yourself. For example, you may remember telling him that it would take a few weeks before his pain pills would work. Or you know that it says right on the bottle that the medicine should be taken with food. The problem is, even if you are right, your patients perception is that you are wrong and thats why he is angry. You are the professional, and you are responsible for making Mr. Lee feel better about it. What is required here is good, solid, memorable communication. If he complains about the waiting room look into the delays. If he is embarrassed or feels disrespected, figure out why and make adjustments. When your patient describes something to you, relate his story back to him, telling him you want to be sure you understand. When you give him instructions, ask him to repeat them back in his own words. Be sure you manage his expectations by describing the benefits of adherence, or the consequences of bad choices. Be clear about side-effects and which ones require immediate follow up. A good relationship with your patient is like a good marriage. It requires that solid, useful, fair, two-way conversation. When you respect your patients, and model good communication, youll find their demeanors improve a benefit to everyone.

Problem Patients': When Modesty and Honesty Get in Your Way

Blog | May 18, 2011 By Trisha Torrey

This is the third in a four-part series exploring better communications with your patients to enhance their visits to your practice. Scroll down to read more from this series and be sure to join us on Wed., June 1 at 8 p.m. EST for a Twitter chat with Trisha Torrey. It may seem like a stretch to address these two very different concepts together, but soon youll see how closely related the y are, and how understanding the background for both can help you improve relationships with your patients. The first time a doctor told me her patients lie to her, I was stunned. She went on to explain that in her work as an anesthesiologist in an academic hospital, she had to teach her residents how to accommodate for patients dishonesty when figuring out how much anesthesia they would need. Ask patients how many alcoholic beverages they drink in a week, and they will usually own up to only a fraction of their real intake. Why would patients lie, or shade the truth? Like other patient communications problems, the answer is history. We have all spent our lifetimes being judged, or assuming we were being judged, in particular by authority figures. When we were little, our parents judged us. Later, we were judged by peers, then teachers, then bosses, even spouses all people we consider to have some sort of authority over us, no matter whether they did or do not. Most patients regard their doctors as authority figures, too. We believe you will judge us and we wont stack up. If I am overweight, I think you will judge me for eating too much or not getting enough exercise. Im afraid youll be upset if I tell you I take ginseng to boost my energy. Ill hide how much Im smoking because youll be mad. Whether or not it is your intent to judge us, we patients believe you will. We are too embarrassed to tell you the truth, even if you can see right through us. Which takes us to modesty. The single biggest complaint I have ever heard from patients is about providers who violate their sense of modesty. Why modesty? The answer is, once again, history; with the same basis as to why patients are less than honest. We have all spent a lifetime being judged for our appearances. Further, religion and culture dictate that certain parts of our bodies not be viewed by anyone but ourselves or our intimate partners. Patients know, intellectually, that providers should be exceptions to those mores. But emotionally we cant get past the stan dards that have dictated all other aspects of our lives. Some patients refuse to seek medical care at all because modesty issues control them. We are, simply, embarrassed. However, the biggest complaints about violations of modesty arent usually about doctors themselves. They are complaints abou t the female nurse who preps a man for his vasectomy, or the other people in the hallway when the patient is led into another room wearing a backless exam gown. Those are not people we want to be intimate with. We are embarrassed, and blame you for putting us in that embarrassing position. So now that we better understand how history affects patients behavior, how can you, as a provider, improve the veracity of the information your patients share, and remove those modesty barriers? By providing evidence that patients can trust you. By giving us back some of the control we feel we lose when we are being judged. Here are some examples:

 A patient who smokes will lie to you when you chastise him for doing so. Instead of sounding judgmental, ask him how you ca n help him quit. You become the partner instead of the judge. Tell the patient who continually returns to you for pain meds what your barriers are to prescribing them. Be candid. Explai n what can happen to your license and your practice if you over-prescribe. Then ask her what she would do in your shoes. You wont be judging her. Youll be making her think differently. If your practice of medicine requires patients to yield some of their modesty to be examined or treated, build an environme nt where patients feel safe. Hire more male nurses, if necessary. Dont leave exam room doors ajar when patients are disrobed. Provide gowns that cover patients entire bodies if they must move around in hallways. Emphasize respect for modesty issues among your staff. Most patients begin a relationship with a new doctor by trusting, so its up to you to be sure you dont violate that trust. If the trust ship has already sailed, then help patients better understand how they can control the situation so they will begin to return some of that trust you deserve. Remember, its the patients perception that is important. Even if you dont think you are judgmental, your patients may think you are. So be sure they understand that you are a partner. Building and maintaining that trusting relationship begins with you. Next week, we'll look at one of the biggest issues I hear about from physicians: dealing with angry patients. Trisha Torrey is "Every Patients Advocate," the About.com Guide to Patient Empowerment, and author of "You Bet Your Life! The 10 Mistakes Every Patient Makes (How to Fix Them to Get the Health Care You Deserve)." She focuses on helping patients and doctors work more collaboratively to improve outcomes for all.

Navigating Difficult Patient Encounters Pearl | October 04, 2011 | Pearls, Difficult Patients, Patients, Compliance By Sarah Parrott, DO Linked Articles It's your last appointment of the day and you see that a patient has scheduled to be seen for sinusitis. You sigh, because you know this patient well. You know that a simple sinusitis is far from what you will encounter. You know that there will also be four or five other somatic complaints, the social history will reveal a new drama, the patient will admit noncompliance to recommendations from the last appointments. Finally, you know he will expect you to fix each of his new and old problems by the end of the 20-minute appointment. Every clinician has, no doubt, run into difficult patients. Here are 10 simple tips that may help you manage these challenging appointments while maintaining your professional integrity: 1. Remember, you are not the problem. It is easy to let the patient suck you into her perception that you are the problem - because you won't prescribe the requested medication or meet some other unreasonable patient demand. Keep your professional perspective and realize that your decisions are in the patient's best interest. 2. Examine your own response to noncompliance. Many years ago, I realized it was my job to make sure patients understand the most current recommendations regarding lifestyle changes and medicines to control their various diseases. Whether they comply with the recommendations, on the other hand, is out of my control. I give kudos to patients who comply and partner with those who can't to figure out solutions to situations that prevent compliance, but I don't take it personally. 3. Be consistent. In the physician-patient power differential, your reactions to a patient's behaviors must follow a routine. If you disregard your own rules once, the patient will expect it every time. For example, if you never prescribe diet pills or short-acting benzodiazepines, don't give in to a patient's plea for "just this once." 4. Use active listening skills and resist your impulse to interrupt. If the patient feels that you really hear her, she is less likely to leave the visit feeling dissatisfied. 5. Consider underlying depression, anxiety, or substance abuse as a contributing diagnosis. Patients with a large number of somatic complaints might have an underlying psychiatric disorder, even though they are able to function well at work and home. If your patient meets screening criteria, might he benefit from pharmacologic treatment or counseling?

6. Find a trusted sounding board. Physicians are human, after all, and difficult patients can be frustrating. Another healthcare professional might be able to offer suggestions for coping with a specific patient behavior you find challenging. 7. Partner with your office manager to determine the amount of time you need for known difficult patients. Schedule challenging appointments realistically; giving yourself extra time. Remember, if you spend more time with the patient, you can bill a higher level E&M, which might ease the discomfort of the patient's neediness. 8. Above all, stay safe. If a patient is volatile, she might pose a danger to you or your staff. It is perfectly appropriate to call security or police if you feel the patient represents an imminent danger to anyone in your clinic. 9. Consider confronting the behavior. Sometimes a professional confrontation can be therapeutic. Before doing this, however, you may wish to refer the patient for counseling and you must ensure he is emotionally stable. 10. If you consistently "attract" difficult patients, you may wish to seek counseling for yourself. Transference and counter-transference can occur in all professional relationships, but if you experience more than your share then you might need to figure out why. Sarah Parrott, DO, is an assistant professor of family medicine and division coordinator for communications at Kansas City University of Medicine and Biosciences in Kansas City, MO. She can be reached at sparrott@kcumb.edu.

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Problem' Patients: Beware the 'Cyberchondriac' Blog | May 11, 2011 By Trisha Torrey Linked Articles Last week, we looked at the problem of patients who complain about waiting room times. There may be very little you can do to improve the amount of time patients wait for you, but what you can do is make them feel a bit more in control of that time by telling them what to expect, thereby giving them a better feeling of control over that time. Waiting room times are one thing, but what about the "Googlers"? In your perfect world, you may prefer your patients not be looking for medical information online. They cant evaluate it themselves. Much of it is wrong and dangerous. Your schedule doesnt allow for long conversations. It would just be better if they forgot about the Web, and relied on you. However, simply stated, your patients are going online whether you want them to or not. They are looking up every twinge, sniffly nose, and pain on the web, and you cant stop them. The patientGoogling train has left the station. Not only that, they have probably diagnosed themselves, or at least have a good idea of what their medical problem is, even before they dialed the phone to make an appointment with you. You may be the first doctor they see, but you may be providing a second opinion. You cant beat Dr. Google, so you might as well join him. And the way to do that, just like improving your patients waiting room frustrations, is to manage your patients expectations. So how do you handle the patient who brings along a stack of print-outs of information he found online? The most important piece of advice is to not be dismissive. Your patient is feeling empowered because he spent time learning about his symptoms, brushing up on the lexicon, understanding anatomy, whatever it took to try to evaluate the problems he is having. Dismissing his efforts will frustrate him, may anger him, and he may become distrustful which will then sour your entire relationship. You will either lose your patient, or he will be non-compliant or both. Your better approach is to do two things: allow some time, even if brief, for the conversation, and guide him toward the information you know is good and credible. When your patient brings along a stack of printouts, or starts a sentence with I read on the Internet, acknowledge his willingness and interest in learning more. Tell him you appreciate an informed patient

because youve found that the more your patients understand, the better they are about adhering to treatment decisions, and reporting problems. Then explain that his insurance, and your schedule, dont allow for long conversations (might as well be candid it builds trust), but if he could choose one point to ask about, what would it be? After you review that one point, ask him to choose one more to raise -- at your next appointment. Then, before he leaves, give him a brochure with a list of websites you think address his particular problem, or even a slip of paper that provides a link to a place on your own website with those resources. The more targeted to that one patients particular problem, the better. (e.g. better to have a page full of diabetes links for a diabetes patient, then one link to WebMD for all patients.) If you really want to help your patient, and help yourself, then teach him how to assess whether the information he finds is credible. You dont have to do this yourself. There are many resources online that help patients avoid the snake oil, or promotional sites, or those that are just wrong. (I happen to have such a list for you.) By working WITH your patient on finding credible information, and managing his expectations about how he can have conversations with you about his findings, you will build trust. The bonus? A trusting patient wont be so apt to annoy you or make you cringe at the start of your day. Next week, we'll take a look at when modesty and honesty can get in your way. Trisha Torrey is "Every Patients Advocate," the About.com Guide to Patient Empowerment, and author of "You Bet Your Life! The 10 Mistakes Every Patient Makes (How to Fix Them to Get the Health Care You Deserve)." She focuses on helping patients and doctors work more collaboratively to improve outcomes for all. Have a "problem" patient of your own now or in the past? Trisha Torrey will be participating in a live question and answer session on Friday, May 13 at 12 p.m. EST to discuss her Practice Notes blogs and take your questions. The event is free, but registration is required.

'Problem' Patients: Dealing with the Waiting Game Blog | May 04, 2011 By Trisha Torrey Linked Articles You arrive at your office, ready to take on your day. You hang up your coat, throw your stethoscope around your neck, and pick up a copy of your patient schedule off your desk, glancing down the (as usual, too long) list for familiar names. And then you cringe. Two or three of those patients have the ability to just ruin your day. From waiting room complainers (Doctor, I SHOULD NOT HAVE TO WAIT for twenty minutes to see you! My time is valuable, too!) to non-compliant patients (I know I need to quit smoking, doctor, but what can you give me for this cough?) to "Googlers" (Just take a look at this three-inch stack of print outs of information I found online, Doc!) their requests and demands are irritating and draining. You sigh. Another day of ups and downs - and major frustrations with this growing list of patients who just don't understand that you can't be the hand-holder they expect you to be. They dont grasp the constraints on your practice that wont allow you to spend large amounts of time, magically clear out the waiting room, or dissolve their lifetimes worth of bad habits. Does this sound familiar? Frustration and aggravation are on the rise in practices all over the country. Further, as healthcare reform kicks in, and 32 million new people try to add themselves to your appointment roster, its hard to think the situation will improve any. So what can you do? Is there a way to make this aggravation disappear? Or, are there steps you can take that would at least make some of these difficult patients easier to deal with? For some of them, yes. First, understand that you and your practice are victims of history. The shift in our healthcare system during the past 20 years makes it unrecognizable to most patients. They have spent a lifetime of leaning on their doctors for not just medical care, but some psychological support, too. When they are fearful or frustrated, facing a system they no longer understand, they dont know how to get what they need. Patients have a set of expectations that is unfulfilled, so they get frustrated and act out. As a result, we see higher rates of non-adherence, patients who spend far too much time on the Internet, patients who

are simply dissatisfied with the help you can offer - even pain pill seekers who really need a guiding hand far more than they need another prescription. There is aggravation, irritation, exasperation and dissatisfaction all around for you, and your patients, too. Over the next few weeks, were going to take a look at how one simple approach may help you eliminate some of this dissatisfaction. Its a proactive approach that costs nothing, but can lead to improved communications and understanding. Youll feel better about facing some of these difficult patients, and your patients will feel better, too. Well begin with the waiting game. Just like you have other responsibilities, patients do too. When they visit you, they are missing work, or need to pick up the kids after school, and so on. When they complain about waiting room time, what they are really complaining about is that you are taking away their own control of their time. Thats a very uncomfortable position to be in. When you arrive at a very crowded restaurant , why do you ask how long the wait will be? Yes so you can decide whether to stay, or go sit in the bar, or go to another restaurant. You want to control your own time and choices. The same with the supermarket deli. You take a number and wait your turn. You then get a sense of the wait time, and decide whether to stay, or go pick up a few other items. You control your choices. But you can give patients back some of that control by managing their expectations. When patients arrive and check-in, have your receptionist provide an estimate of how much time they will wait. Make sure that estimate is five to ten minutes longer than the real wait time will be. Just like when you go to a restaurant, and youre told how long your wait will last - when its shorter, you are happy. Your patients will be, too. When you need to leave the exam room to find a nurse or retrieve a brochure manage your patients expectations by telling him what you are doing and what will happen next. Otherwise your patient will sit there, anticipating the worst, having no idea where youve gone, or why, or whether hes supposed to get dressed or ? Not knowing what to expect, or what is expected of him, he will become annoyed and irritating to you or your staff. Relieve his mind by telling him what to expect. Managing a patients expectations is a simple step, costs you nothing, but can have a huge impact on your day and your practice.

Next week, well take a look at another problem patient the "Googler" and how you can improve your relationship and overcome your irritation with him, too. Trisha Torrey is "Every Patients Advocate," the About.com Guide to Patient Empowerment, and author of "You Bet Your Life! The 10 Mistakes Every Patient Makes (How to Fix Them to Get the Health Care You Deserve)." She focuses on helping patients and doctors work more collaboratively to improve outcomes for all. Have a "problem" patient of your own now or in the past? Trisha Torrey will be participating in a live question and answer session on Friday, May 13 at 12 p.m. EST to discuss her Practice Notes blogs and take your questions. The event is free, but registration is required. E-mail keith.martin@ubm.com by Thursday, May 12 at 5 p.m. EST to get your spot for this event. DISCLOSURES

Notify me when new comments are posted All comments Replies to my comment Please Login or Register I personally see an endocrinologist 2x/yr. This particular physician is outstanding in his field. He is loved by his patients. He is the doctor that other doctors send their family and themselves too for an endo problem. There are times when you can wait for 3-4hours, yes you read that correctly 3-4 hours past your appointment time. This provider does not participate with any insurance including Medicare. When you speak to or meet other people who are his patients, we laugh about the waiting time. This physician takes the time needed for the individual patient. What we do as his patients is call ahead to the office and ask how far behind he is on schedule so you can adjust your arrival time. The interesting thing is that not one person complains about the extremely long waiting time as he is worth it. Randi A. Schwarz, RN replyRandi Schwarz @ Fri, 2011-05-06 17:24 I agree with the above observations and already do this. But it must work both ways. I am also a Dr "who believes in taking the time necessary to take care of the pt" but If I have pts who do not like to wait and are always complaining about this , they can find another physcian since I am overbooked as it is.. Unfortunately the most demanding pts are usualy those who also take the most time ( and apparenly do not recognize themselves as part of the problem) . They usually want all their problems solved ( or at least addressed) in one visit, usually have many psychosocial iissues (which our communtiy doesnot have resources to address) and even with taking addtional time , I cannot solve their problems . They are also usually on public insurance and may have a entitlement personality . Sounds to me as if Dr Schwartz's endocrinologist has it made since he seems to have well educated pt swho understand and accept the situation ( both the postivies and negatives) and are also probably fairly wealthy or at least

understand how to file their own insurance claims. I am acutally working on how to drecrase pts demands which I cannot /shouldnot be expected to solve since society will not let us be Dr Welby even if we wanted to be such. replyJune Worthington @ Wed, 2011-05-11 04:48 Your observations and description of usual office events, on day to day basis is quite accurate and well described.I know next week will be the "Googlers "discussion. Here is how I feel about this: For ten Googlers there is one, who actually brings in information which sometimes is helpful to you as well. My answer to all the paperwork and details that they bring in is that "it is only information not knowledge", so one needs to educate patients in not relying solely on these informercials off the internet. We worked very hard to become physicians, and for the most part, know how to use this information on a particular patient. Generally, patients understand and feel empowered if you accept their hard work on internet, and your interpretation. replyAnjum Burki @ Tue, 2011-05-10 17:21 Already Registered? Login Now: