hen faced with a patient who is doing poorly from a clinical standpoint, many clinicians do not reflect on the psychosocial factors that may be influencing the patient’s course. They may simply throw up their arms and attribute a patient’s clinical decline to his or her social milieu in a global or at times derogatory fashion, referring to such a patient as “nonadherent,” a “difficult patient,” or a “social nightmare,” without digging deeper.

Table 18-1.Generating a differential diagnosis of psychosocial vulnerabilities.

While there are many reasons for the observed variation in quality and health outcomes, one of the most important and frequently least appreciated factors is the patient’s social context

Eliciting the patient’s story can also improve patient trust, satisfaction, and adherence. It enriches and brings meaning to interactions and allows providers to be more effective and engaged.

Patient’s perspectives—a complex mixture of very personal beliefs, values, and assumptions reflecting multiple influences—can determine how they develop a relationship with their clinician, and whether they feel understood and respected or misunderstood and discounted. Clinicians, in turn, have their own individual perspectives on health and illness, and ascribe specific meaning to their role as healers

Personal concepts of health determine what preventive and self-care behaviors are considered appropriate, which symptoms seem worrisome, and when to seek help from health care professionals.

The same factors that influence how people think about health and illness also impact other aspects of their lives, and eliciting information about these influences can uncover perspectives important to health care.

We should also clarify our own boundaries; it is not uncommon for a relationship between a clinician and a patient to evolve into one of unhealthy dependence or unrealistic expectations.

However, if clinicians consciously strive to transmit a sense of trust, caring, and respect, along with a desire to enter into true partnership, they increase the likelihood of forming productive relationships with patients. Some guidelines to consider in this process include the following:

Significant proportions of people from African American, LatinX, and Asian communities and those with lower educational attainment have reported that they were treated with disrespect, were treated unfairly, or received worse care because of their position in society.

Caring—Patients who are poor and/or have historically faced racism and discrimination frequently receive care in teaching hospitals and community health centers with high provider turnover.

What Is the Therapeutic Alliance? ++ In the field of medicine, a therapeutic alliance exists when the patient and provider develop mutual trusting, caring, and respectful bonds that allow collaboration in care and treatment.

The clinician has the ability to collaborate on treatment plans and to facilitate entry into the various health and social systems that can help address vulnerabilities. The therapeutic alliance can help patients feel assured that clinicians will not abuse the disclosure of information (e.g., leading to rejection or legal action) but will help them access resources critical for their health.

CASE ILLUSTRATION 2

Key dimensions of the therapeutic alliance include: ++ Mutual trust—Patients need to trust in their clinicians’ integrity and competence, and clinicians need to trust that patients enter the relationship trying to do their best. Empathy—Demonstrating empathy, or recognizing and understanding the beliefs and emotions of another without injecting one’s own, allows the clinician to connect emotionally with the patient without pity or overidentification. Respect—Expressing respect for patients and treating them with dignity are important and require creating a context in which communication can occur as equals. Collaboration—Collaboration requires a meaningful partnership in which the clinician and patient perceive that they are working together toward a common goal and committed to resolving conflicts that inevitably emerge about treatment goals.

The third mechanism, also an indirect one, is mediated entirely through the therapeutic alliance. In this path, the vulnerability affects components of the relationship or therapeutic alliance with the provider (such as open disclosure, mutual trust, caring, and engagement), thereby limiting the benefits of a collaborative relationship on care.

A second path is an indirect one, where the vulnerability attenuates the benefits of medical treatment on coexisting medical conditions; that is, the vulnerability presents a barrier to optimal acute, chronic, and/or preventive care, thereby accelerating disease course.

The first path is a direct one, a situation in which the vulnerability in and of itself leads to poor health.

Figure 18-1. Creating a context for effective intervention in the clinical care of vulnerable patients.

Unfortunately, vulnerable patients experience a triple jeopardy when it comes to health care: they are more likely to be ill; more likely to have difficulty accessing care, and when they do, the care they receive is more likely to be suboptimal.

Social characteristics—living in poverty, having a low level of education and limited literacy skills, being from a community that has experienced racism and discrimination, having no health insurance, speaking little English, among other factors—make individuals vulnerable to contracting illness and to facing overwhelming obstacles in the care of that illness.

CASE ILLUSTRATION 1

nderused skills such as soliciting the patient’s attribution for a problem, offering praise and support, listening carefully to the patient’s description of a problem, and explicitly confronting problematic or confusing behavior inform the patient that a serious attempt is underway to understand and successfully manage the patient’s concerns.

Indications for referral include inability to make a diagnosis, an objective assessment that the patient is not benefiting from evaluation or treatment, or the clinician’s feeling of being threatened or in danger.

What did you say or do that contributed to moving beyond the difficulty? What did the patient contribute to changing your relationship in a positive direction? What was it about the environment or circumstances of your encounter that improved the situation or your relationship? What changes did you make in your internal appraisal or perception of this patient that made a difference? What will you do differently the next time?

CASE ILLUSTRATION 4 (CONTD.)

Descriptions of behavior that hit home can provoke emotional responses in patients, but penetrating long-held psychological defenses can spur growth.

Over time, patients learn to respond to the support offered and begin to take a more active role in their care. Of course, there is always the risk that a passive–aggressive individual attempting to control the relationship will choose to seek another clinician who can be more easily manipulated.

The next step is to ask what the patient thinks would be helpful in solving the problem.

“Am I encouraging patients to take a more active role in their care?” and “Am I giving patients the chance to say why they’re not using the treatments I thought we agreed on?”

Finally, the patient’s previous experiences with clinicians may have been so hierarchical and paternalistic that the thought of disagreeing or negotiating a position does not come to mind, even when the suggested approach is not acceptable.

When problems are being discussed, this type of patient’s nonverbal behavior is usually engaged and active: leaning forward, bright affect, and dynamic gestures. As recommendations for evaluation and treatment are made, however, the patient typically becomes withdrawn, eye contact diminishes, and language becomes significantly less animated. Verbally, during the discussion of evaluation and treatment, the patient becomes quiet, volunteers little, and characteristically offers no solutions to problems. In fact, as the clinician makes recommendations, the patient often responds with the classic, “I’d like to do that but … .”

CASE ILLUSTRATION 4

Summary ++ Exploring the reasons for a patient’s demands in a nonjudgmental manner allows most demands to be understood and addressed. Knowing the cause of the demand, a plan that is mutually agreeable can then be negotiated. If such a negotiation is not possible, the patient should be informed of realistic limits to what the clinician can offer. The patient can then decide whether she is willing to accept the clinician’s boundaries or should seek alternative services.

Until there is an agreement on the need for education by clinician and patient, however, the patient might perceive education as the clinician’s way to control the visit.

Once validating the patient’s experience, only then should the clinician give a rationale for why she is not in favor of using opioids for chronic pain:

Another useful question is: “How had you hoped I could help you?” This gives the patient the opportunity to express dissatisfaction with the extent of evaluation, treatment, or perceived commitment by the clinician; it often lightens the clinician’s burden, since the patient’s request may be significantly less difficult than what the clinician anticipated.

This point cannot be stressed enough: To provide meaningful reassurance, the patient’s feelings about what caused the symptom must be elicited and validated.

CASE ILLUSTRATION 3 (CONTD.)

Table 4-5.Possible reasons for demanding additional interventions.

Clinicians often experience feelings of rejection, distrust, blame, or humiliation in response to demanding patients, leading them to become defensive.

Sometimes the reason for an unexpected demand involves secondary gain, such as workers’ compensation, a disability claim or lawsuit, or seeking psychoactive medication. Another possibility is that the patient has found something online, talked to a friend, or read something in the press. The patient may be concerned that the clinician is withholding a more expensive test or treatment to limit cost. Finally, it may be that the patient is frustrated with the lack of relief because additional testing or treatment is actually indicated. By listening carefully to a patient’s concerns, the clinician may rethink the diagnosis and/or seek alternatives to the current treatment plan.

These demands are often tied to dissatisfaction with the recommended evaluation, treatment concern about the accuracy of the diagnosis, or a failure to solicit important aspects of the history

CASE ILLUSTRATION 3

Recognizing the sources of these intense responses can be most helpful in assisting clinicians to focus on the patient and avoid unproductive replays of unsettling past experiences.

Further questioning can also result in the diagnosis of an anatomic cause, like sensori-neuro hearing loss, or a psychiatric condition. Testing a hypothesis too early runs the risk of insulting patients and worsening the relationship.

When confronted with a silent patient, exploring the behavior is usually best begun by reflecting, “You seem quiet today.” This offers the patient the opportunity to acknowledge the behavior and share the reason for it.

Silence may be a sign of a passive personality or, in some cultures, may be consistent with an appropriate way to communicate with clinicians.

When patients feel that they have a serious or potentially life-threatening illness, silence may represent denial and serve as a protective function.

Table 4-4.Possible causes of silence in patients.

CASE ILLUSTRATION 2

The patient’s reasons must be sought directly before mistakenly projecting our own beliefs onto the patient. By working hard to avoid being defensive, clinicians can acknowledge and then constructively resolve the cause of the anger. Confronted with such a responsive approach, most angry people are satisfied and resume an effective collaborative relationship with their clinician.

CASE ILLUSTRATION 1

In this case, the clinician can address the denial: “Maybe ‘angry’ is too strong a word. You seem upset, I’d like to help. Can you tell me more about it?” This invitation offers patients the opportunity to explicitly express their feelings and conveys a sense of curiosity (as opposed to judgment) while simultaneously cultivating partnership.

As a result, clinicians may become defensive

They expect timely service, relevant and up-to-date information about diagnostic tests and treatments, and advice on how to cope with their illness. Interactions that fall short, at least from the patient’s perspective, may cultivate feelings of shame and rejection. The resulting humiliation can easily turn to anger.

Table 4-3.

More subtle behaviors that may indicate anger include refusing to answer questions; failing to make eye contact; or constructing nonverbal barriers to communication, such as crossed arms, turning away from the clinician, or increasing the physical distance between them.

CASE ILLUSTRATION 1

Table 4-2.

Table 4-1.

The key to success is to carefully examine how visits are progressing while monitoring one’s own internal thoughts and emotions in response to the patient and the interaction.

Clinicians may view patients as “difficult” based on their similarity to those with whom they have had a close relationship and an interpersonal problem.

Literature suggests clinicians experience up to 20% of their patients as “difficult.”

Increasingly, physicians are using telephone visits for assessment of acute problems, usefully triaging who should come in urgently, who can wait for the next available appointment, and all options in between.

Explanatory model differences virtually always arise when the patient is using another language (akin to the Sapir–Whorf hypothesis which postulates that language inextricably influences and guides the attitudes, cultural beliefs, and views of the user).

Screening devices for depression include the Patient Health Questionnaire-9 (PHQ-9), Beck, Zung, and Hamilton scales.

The “Stages of Change Model” described by Prochaska and DiClemente involves ascertaining the patient’s stage of readiness for change and adapting one’s interaction to the patient’s stage.