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.