Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Psychological evaluation wikipedia , lookup
Moral treatment wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Abnormal psychology wikipedia , lookup
That Son of a Bitch – Dealing With The Difficult Patient. Derek C. McCalmont M.D., FACEP, MS Management Service Chief Henry Ford West Bloomfield Hospital ED March 7, 2012 Goals for the next 30 min. • • • • Identify some common difficult patients Identify some common difficult doctors. Understand where both are coming from. Develop strategies to make these interactions easier on both sides. • Earn 30 min. of CME credit! Why Do We Bother? http://www.youtube.com/watch?v=TmwqWB Jahto&feature=email Why should I care? • One out of 6 visits are considered “difficult” • Physician burnout (and lower work satisfaction) 12x more likely • Difficult patients have lower satisfaction with their care The Bottom Line • Difficult patients represent a relationship problem, not a clinical one. • It is the clinician’s responsibility more than the patient’s to address and resolve the relationship problem. • Physician’s have more access to and control over our own reactions than we have over the patient’s. It’s Not A Contest! Who Are These Patients Demographically? • • • • • • • • Older More often separated or divorced Women>men More Acute and Chronic Problems More medications More x-rays and tests More visits Lower satisfaction with their care Who Are These Patients Diagnostically? • More likely to have mental disordermultisomatoform disorder, panic disorder, dysthymia, generalized anxiety, major depression, alcohol abuse or dependence. • Personality disorders- Borderline, OCD, Dependent, Self-defeating, narcissistic, paranoid etc. • Chronic Pain What About The Easy Patients? • Objective signs and symptoms of a treatable disease. • Make no emotional demands on the clinician • Cooperates in the treatment process • Displays gratitude for the help received A Common Definition? • One who impedes the clinician’s ability to establish a therapeutic relationship. • One who’s behaviors are perceived to challenge provider’s competence and/or control. • One who- by a variety of behaviors related to profound dependency stimulates negative feelings in most doctors. Who Are These Doctors? • • • • • • At some level- all of us. Younger (less experienced) Female Overworked Lower job satisfaction Medical rather than a biopsychosocial approach (most of us). • Lack of communication skills training (most of us) • Lack of self-awareness (most of us) Clinician Awareness • Negative emotional reactions not fully recognized • Negative reactions are the primary controllable determinant in these interactions • Increased physician awareness=decreased perception of difficult patients=increased physician satisfaction We Have All Been There • Being self-aware and patient centered and incorporating knowledge about the patient’s personality are baseline requirements for working with all difficult patients. Do’s • Allow more time for these patient encounters • Continue to listen • Continue to educate • Encourage the patient to gain control • Maintain hope • Frame referrals to Psych in terms of the stress produced by mysterious or intractable symptoms. Dont’s • Brush them off • Tell them nothing is wrong • Use “stress” or “anxiety” as a diagnosis without considering what can be done about it. • Be angry • Be punitive • Propagate despair. Patient 1 • 37 y.o. female • CC- Chest Pain • HPI- Pressure-like sub-sternal pain radiating to the left arm for two days unrelieved by NTG • PMH- Unremarkable • PSH- Smokes 5-10 cigarettes daily. Denies alcohol or drug abuse. Dependent Clingers • Escalate from appropriate request for reassurance to excessive demands for attention, medications etc. • Naïve about their effect on physicians. • Run the gamut from healthy to life threatening. • Self perception of bottomless need and physician/healthcare as inexhaustible. Strategy • • • • Identify as early as possible Specify limits of physician knowledge/time Provide specific follow-up appointments Remind patient to utilize office visits for recurring problems. Patient 2 • 56 y.o. male • CC- Abdominal Pain • HPI- Patient with epigastric pain of 2 hours duration with nausea. • PMH- Hypertension, GERD Entitled Demanders • Like Clingers- profound neediness • Use intimidation, devaluation, guiltinduction to obtain attention/testing/meds • Less naïve about their effect on physicians • Threatening (litigation/complaints) • Exude a repulsive sense of innate deservedness Strategy • Recognize Hostility is born of fear of abandonment • Entitlement is their religion- don’t blaspheme it. • Support but re-channel the entitlement. “You deserve the very best care we can give you but you need to help”. • Avoid logical/illogical arguments Patient 3 • 32 y.o. male • CC Low back Pain • HPI- Left LLB Pain radiating down left leg for 5 days. • PMH- Chronic back pain with radiculopathy • Current Meds- Vicodin (out) • Allergies- NSAIDS, Ultram Manipulative Help-Rejecters • “Crocks” • Feel that no regimen will help • Frequent flyers happy to report that yet another treatment has failed • Pessimism increases in proportion to physician’s efforts Strategy • Suspect depression • “Share” the pessimism. Agree that treatment may not be entirely curative. • Provide simple reasoning. Avoid complicated explanations. • If needed schedule psych follow-up but also PCP follow-up AFTER psych vist to avoid abandonment issues Patient 4 • • • • • • 65 y.o. male CC- Constipation HPI- No BM for 3 days PMH- Metastatic bone CA. Current Meds- none PSH- Lives alone. Family lives nearby but not involved in care. Dr. Cox Responds http://www.youtube.com/watch?v=RK8dMRL VWvg&feature=email Self-Destructive Deniers • Unconsciously self-murderous behaviors • Profoundly dependent but have given up hope of ever having their needs met • Non-compliant with medical regimen and take pleasure in defeating family and physician attempts to save their lives. • Prize their independence and deny infirmity Strategy • • • • Limited Options Acknowledge your own frustration Best you can while you can Psych consult- usually refused. Final Thoughts • Difficult patients and their frustrated physicians fail each other. We flop together. We lose hope. And there is no more useless doctor than one who has lost all hope. • Difficult patients are an opportunity to further define ourselves as clinicians. To be compassionate, not hostile in the most trying of circumstances.