A recent consultation with a patient did not go well. One initial seed of patient dissatisfaction could not be appeased and it just spiralled as the consultation went downhill. The patient left feeling unhappy, threatening to sue me if they died in the night, and I was left with a sinking sensation in the pit of my stomach.
The truth is, it was always going to be a challenging consultation, but I felt I could have handled it better. There is no point being a doctor who can only manage the easy patients and the straightforward problems. So where did I go wrong?
These types of encounters are negative for the doctor and the patient. They can leave us feeling inadequate, helpless or even ashamed. Our reaction to the challenge can affect our clinical judgement, often resulting in over-investigation due to concerns about ‘what might go wrong’ with this patient. We can be prone to make more mistakes during these types of consultations too. The patient can leave feeling abandoned or completely misunderstood. How we can we avoid getting into these situations in the first place?
In 1978 the NEJM published an article confrontingly titled “Taking care of the hateful patient” and categorised these types of patients into four categories – dependent clingers, entitled demanders, manipulative help-rejecters and self-destructive deniers. In the 30 years since this publication, times (and language) have moved on, and there has been a wealth of research into how to approach these encounters.
Recognise when it isn’t going to plan.
There is no point waiting until the family is agitated/angry/tearful/abusive before it suddenly dawns on you that this is a ‘challenging consultation’. It’s important to recognise the signs early on in the consultation so that you can implement your management strategies.
Recognise the factors that contribute towards a challenging consultation.
Adams and Murray have created a framework for contributing factors to a difficult encounter.
You, the doctor. Adams and Murray highlight traits in doctors that provoke difficult consultations including; angry or defensive doctors; fatigued or harried doctors; and dogmatic or arrogant doctors. The well-known acronym HALT is also crucial when it comes to challenging situations. If we are Hungry, Angry, Late, or Tired, we are setting ourselves up to be ill-equipped to deal with an unexpected consultation outcome. Whilst these factors may be outside of our control, even just being aware of them and their potential contribution can help keep us focused.
The patient. Patients and families prone to difficult consultations may be angry, frightened, manipulative, grieving, or frequent attenders. Some parents may come to hospital with unrealistic expectations. They may have other aspects of their life that are increasing their stress, or previous healthcare experiences that have put them on the back foot. But it’s important for us to recognise that it is a challenging consultation rather than a challenging patient. The patient/family may be having a bad day, or we may be having a bad day, but we must focus on the consultation in front of us and not get bogged down by negative feelings towards them. There are certain types of conditions that lend themselves to potentially challenging consultations. In adults, this might be recurrent lower back pain, in children this might be abdominal pain. Often these consultations feel more challenging than someone with a simple asthma exacerbation or a finger dislocation.
The situation. Multiple people in the examination room creates an environment where stress is increased for the patient with lots of additional people voicing their concerns. It can also be intimidating for the doctor. And a busy ED can make it difficult to conduct a challenging consultation with external pressures and other patients to look after. Cultural barriers and language difficulties may also contribute and mean that the way you feel you are delivering information is not the same way it is being received.
In Elder et al, 2006, the most common reason GPs gave for finding the encounter difficult included: being unable to make the problem better; feelings of being taken advantage of; conflicting with professional standards; difficulty in making a relationship with the patient; and taking too much time.
A management framework – the principles
The Elder et al study aimed to produce a framework for dealing with difficult consultations. They were looking at GPs and interviewed 102 GPs in the US and identified types of patient behaviours that led to challenging encounters. The most commonly cited behaviours (full table is below) were: worried well; demanding care; multiple complaints; drug-seeking; and chronic pain.
The aim of their framework was to achieve quality patient care, good patient flow, and physician well-being. Their management framework was broadly classified into three streams: collaboration; appropriate use of power; and empathy.
Collaboration. This is achieved when patients and doctors work together to achieve good clinical care including investigations and management/treatment plans. Strategies to achieve this include taking a thorough history and examination and prioritising their concerns. When it comes to investigations and treatment be consistent and explain the reasons clearly to the family. Be honest and fair and facilitate the family making a decision. Set small, achievable goals for the patient and provide short term symptom relief where possible. And remember all the other support options for the patient i.e. pain team, mental health team.
Appropriate use of power. In consultations, both the doctor and the patient have different areas of power. Families exert their power through controlling what information they give to the doctor, and also by whether or not they will follow a treatment plan. Doctors exert their power in their ability to control questions asked, and their choice of which investigations or treatment are offered. When consultations become challenging, our instinct is often to exert our power, and what we need to do instead is use this appropriately. Appropriate use of power would be in controlling the length of time of the consultation and also in setting some boundaries and limitations of what can be offered.
Empathy. Empathy is, of course, essential to having a good consultation. When parents become aggressive or dissatisfied then our reaction can be to allow empathy fatigue to set in (Benson and Magraith, 2005). Acknowledging our own emotions is a good step in improving our own emotional intelligence and allowing us to go back to feeling empathic i.e. “I’m getting annoyed with this consultation and that’s making me lose empathy for this patient, but reality his symptoms are causing significant problems for him and his family”.
Practical top tips for managing challenging consultations:
Control your own emotions: even though you might feel like screaming/crying/fleeing the room, try to get on top of your emotions so that they do not affect the consultation. Speak slowly, calm your breathing and make sure you are speaking in a quiet, calm tone. If you are struggling to maintain your emotions, try to compose yourself during pauses in the conversation. After the consultation take time to reflect and talk to others.
Don’t get angry: getting angry or raising your voice will not help. Neither will telling the parents that you find their behaviour or language rude or aggressive. This simply breeds a cycle of increasing tensions/mud-slinging and is hard to come back from.
Verbalise the difficulty: “We both have very different views about how your symptoms should be best managed and that’s causing some difficulty between us. Do you agree?” As well as just stating the obvious, it is a statement that avoids blame. The aim is to create joint ownership of a problem so that you could work together towards a solution.
Validate your patient: they are getting frustrated and they need to feel like they are being listened to. Make sure you listen, are empathic and respond to ensure they know you have heard. “I hear what you are saying and I can see why you feel that way”. Often repeating this type of validation can help diffuse the situation.
Don’t be afraid of silence: sometimes just a minute or two of silence can help the family to reflect and regulate their own emotions. Resist the urge to fill every pause with your own voice and a response to their last comment.
Try to find some common ground: instead of flagging up the areas of disagreement, try to find overlaps in your and their expectations. When you are both so far apart, then it’s easy to see them as being unreasonable or demanding. Saying “I don’t think I’ve ever met parents who did not have their child’s best interests at heart” can show that you understand where they are coming from. Once some common ground has been found, this can be used as a foundation to make a plan. Encourage them to contribute to a plan that you can both agree on for going forward.
Know when to call it a day
Some times, in spite of doing our best to take all these factors into account, the consultation and the doctor-patient relationship cannot be saved. These case are upsetting for both parties. As a doctor, if all has failed, take time to reflect on the consultation at a later point. Perhaps review the notes and discuss with colleagues.
Be the type of doctor where calling it a day with an unhappy patient is a rare event and something that you feel is worth reflecting on.
Adams and Murray, The general approach to the difficult patient. Emerg Med Clin North Am, 1998, 16:689–700.
Benson and Magraith. Compassion fatigue and burnout: the role of Balint groups. Aust Fam Physician, 2005, 34:497–498.
Davies, Managing challenging interactions with patients, BMJ Careers, 2013.
Elder and Ricer, How respected family physicians manage difficult patient encounters, J Am Board Fam Med, 2006, 19(6): 533-541
Groves, Taking care of the hateful patient, NEJM,1978, 298(16):883-887.
Grewal and Helman, Effective patient communication – managing difficult patients, EM Cases, 2014.
Hull and Brocket, How to manage difficult patient encounters, Fam Pract Manag, 2007, 14(6):30-34.
Nabi, Ten challenging patients and how to deal with them, Pulse GP, 2016.
Smith, Dealing with the difficult patient, PMJ, 20015, 71:653-657.