[02.18] Dealing with Difficult Interactions V2.pdf

Subjective

The label "difficult" is considered this, meaning it varies from person to person.

The relationship between two persons

An interaction being labeled "difficult" is a function of and based on this.

Discomfort with what has happened or what might happen

Perceptions of a difficult interaction are based on this.

Differences in expertise and experience

These factors can also account for variations in perceiving an interaction as difficult.

Personal and practical needs

When a patient comes for consultation, they expect these two types of needs to be addressed.

Need to be recognized and respected, need to feel important

These are examples of a patient's personal needs.

Need for specialized knowledge and medical expertise

These are examples of a patient's practical needs.

Praisers

What type of patients are happy after a consultation and make sure to tell you so, often being the most rewarding to have?

Patrons

What type of patients are happy after a consultation but will not explicitly say anything?

Talkers

What type of patients are not satisfied, are unhappy, and will make sure you know it, offering the greatest opportunity to improve the interaction?

Walkers

What type of patients are unhappy and unsatisfied, just leave, and never return, making them the most challenging?

Discovering factors that contribute to the "difficult" label, exploring techniques that can lead to more satisfactory relationships, and learning new skills

Clinicians can have fewer difficult interactions by trying these strategies.

Patient-related factors, doctor-related factors, and the interview setting (environment)

These are the three main factors that influence and affect doctor-patient communication.

15%

What is the estimated prevalence of "difficult" patients?

Approximately 1 out of 7

This fraction of patients can be considered "difficult".

Repeated visits without apparent medical benefits, not seeming to want to get well, abrasive personalities, demanding, focusing on issues seemingly unrelated to medical care, poor adherence to treatment

These are characteristics exhibited by "difficult" patients.

Angry, defensive, frightened, resistant patients

These "difficult" patients may exhibit these feelings as part of a grief reaction to loss of health and fear/loss of control when someone gets sick.

Grieving patients

What type of "difficult" patients are mourning a loss or suffering with pain, where tears are expected forms of expression?

Manipulative or demanding patients

What type of "difficult" patients play on the guilt of others, threaten rage, legal action, or exposure to social media, or even consider hurting themselves?

Bad outcomes or experience of a friend or relative

The demands from manipulative or demanding patients are usually related to these.

Somatizing patients / "frequent fliers"

What type of "difficult" patients have multiple, vague, or exaggerated symptoms and often engage in "doctor-shopping"?

Mood Disorders, Anxiety Disorders, Borderline Personality Disorders

A considerable number of patients labeled "difficult" may meet the DSM criteria for these conditions.

Red flag signs

Physicians should always take note of these, which may indicate conditions like Mood, Anxiety, or Borderline Personality Disorders.

A physician's conditions, attitudes, knowledge, and skills

These also play a significant role in challenging and difficult interactions.

Overworked and sleep-deprived physicians

These physicians are prone to overlook patient concerns and details.

Burned-out, stressed, and frustrated physicians

These physicians are more likely to react negatively to patients.

Dogmatic and arrogant physicians

These physicians have strong personal beliefs that may prevent them from assessing patient information without bias.

Inadequate training in psychosocial medicine, lack of knowledge about the patient's condition, poor communication skills

These physician-related factors may also contribute to difficult patient interactions.

Manage their stress levels and delegate responsibilities

Physicians need to learn how to do these, if needed, to avoid negative reactions to patients.

Exploring one's own personal issues and being aware of one's own beliefs and practices

These actions help physicians avoid triggers in difficult interactions.

Literacy issues and language barriers

These situational factors may cause problems in communication and lead to frustration.

Companions during the consultation

These individuals may be distracting, especially if they are demanding, affecting the doctor-patient interaction.

Breaking bad news

This specific situation requires preparation and planning, as patients may react in different ways.

Environmental issues

Physical surroundings are considered this type of factor that influences doctor-patient communication.

Natural disasters and other crisis situations

These are examples of circumstances beyond our control that can make interactions difficult.

Fear, conflict, surprise, and change

These are the four main factors that make an interaction difficult for us.

Fear of the unknown, not knowing how the person will react, hurting someone's feelings, feeling hurt

These are specific fears that contribute to an interaction being difficult.

Conflict

Few people enjoy this, and most go out of their way to avoid it.

Surprise

Catching someone off guard can make an otherwise smooth interaction difficult.

Change

Interactions involving having to make this often make people feel uncomfortable.

Uncomfortable

Generally, difficult interactions make us feel this way.

Afraid we’ll make the situation worse

This is one reason why we avoid difficult interactions.

We don’t want to feel bad, and we don’t want others to feel bad

This is another reason we avoid difficult interactions.

We may hear things about ourselves that we don’t want to hear

This personal discomfort contributes to avoiding difficult interactions.

We, and the other person, may get emotional

The potential for this is a reason to avoid difficult interactions.

We don’t know how the interaction will end, and we fear the consequences

This uncertainty about the outcome is a reason for avoiding difficult interactions.

Transference/countertransference issues

These are potential psychological challenges in difficult clinical encounters related to displacing feelings onto the doctor or vice versa.

Transference

The process of displacing attitudes and feelings originally experienced in relationships with persons from the past to the doctor.

Countertransference

The process by which doctors unconsciously ascribe motives or attributes to patients that come from the doctor’s past relationships.

Professional Post Traumatic Stress Disorder (PTSD) / Secondary Traumatic Stress (STS)

These are potential challenges related to psychological trauma in clinical encounters.

Secondary Traumatic Stress (STS)

The phenomenon whereby individuals become traumatized not by directly experiencing a traumatic event but by being exposed to the trauma details of another.

Professional Burn-out

This is a potential challenge characterized by exhaustion and reduced effectiveness in clinical encounters.

“Ground-hog day” or déjà vu quality

This potential challenge describes situations where the same issues are discussed repeatedly without resolution.

Possibility of litigation or legal action

This is a potential legal challenge that can arise from difficult interactions in clinical encounters.

Look at the big picture, consider the patient’s context, fears, worries, and perceptions, and anticipate a higher than normal level of stress

These are ways to prepare for difficult interactions.

Misunderstanding or disagreement

A difficult interaction starts with this.

Negotiation

This happens when one or both sides are willing to make an adjustment to resolve a disagreement, and each side seeks to understand what is really important to the other.

Non-negotiable disagreement

This occurs if each side takes a firm stance regarding their absolute constraints, often involving a difference in values.

Conflict

If a disagreement is not resolved, this develops.

Accommodation, Avoidance, Collaboration, Compromise, Competition

These are the five basic ways of resolving conflict, according to Thomas and Kilmann (1976).

Accommodation

What conflict resolution method involves one party surrendering one’s own needs to accommodate the other party?

Avoidance

What conflict resolution method involves postponing conflict by ignoring it or changing the subject, and can be useful as a temporary measure to buy time?.

Collaboration

What conflict resolution method involves both parties working together to find a mutually beneficial solution, often seen as the only win-win solution to conflict?

Collaboration

This conflict resolution method can be time-intensive and difficult to achieve when there is not enough trust, respect, and communication between the involved parties.

Compromise

What conflict resolution method involves both parties agreeing to bring the problem into the open and having a third person present to help resolve the conflict?.

Competition

What conflict resolution method involves one party asserting its own viewpoint at the potential expense of another, and can be useful when achieving one's objectives outweighs one's concern for the relationship?

Know your purpose

This general rule in preparing for difficult interactions involves knowing what you want to accomplish, such as getting more information or resolving an issue.

Frame your message

This general rule involves planning how you want to say your message, setting up the conversation and timing, and preparing the other person for what is coming.

Use an assertive approach

This general rule involves being accountable for what you say, expecting others to be accountable, using "I" statements, and avoiding blaming others.

Use cooperative language

This general rule emphasizes being mindful of the language you use and being respectful.

Use active listening skills

This general rule involves letting the other person or party know that you are listening and understanding what they are saying.

DESC and DISC statements

These two types of "I" statements may be used in responding assertively to situations, taking accountability for what one is saying.

Describe the situation, Express your feelings, Specify the change you want, Consequence

What does the acronym DESC stand for in assertive communication?

Describe the situation, Indicate the problem the behavior is causing, Specify the change you want, Consequence

What does the acronym DISC stand for in assertive communication?

HEA(R)T Protocol / H.E.A.T. Model

This protocol is used when confronted with difficult patients, aimed at handling complaints, reducing anger, and problem-solving.

Hear them out

The "H" in HEA(R)T stands for this, meaning to let the other person air out or ventilate concerns.

Empathize

The "E" in HEA(R)T stands for this, meaning to respond to emotions appropriately through active listening.

Acknowledge/Apologize

The "A" in HEA(R)T stands for this, regarding an oversight and inconvenience.

Respond appropriately

The "R" in HEA(R)T, or (R) in HEA(R)T, stands for this, meaning to inform the other person what can be realistically done at that point.

Take responsibility for action / Thank your patient for bearing with the inconvenience

The "T" in HEA(R)T stands for this.

Stay calm

This is a primary tip when faced with a difficult interaction or situation.

"I know how you feel", "I feel your pain", "It's going to be alright”

These phrases should be avoided when faced with a difficult interaction.

End the interaction

What should you do if emotions or behaviors escalate and you feel threatened or unsafe?

"This conversation is making me feel uncomfortable right now" or "I don’t feel safe right now and can’t continue this conversation"

These are sample phrases to use when ending an interaction due to feeling unsafe.

Prompt assessment, referral, and treatment

These actions are very important when patients have mental health problems that need to be addressed by health professionals.

Saying "no"

In some difficult interactions, physicians may find themselves agreeing because they couldn't do this.

Offer the balm of regret

With any refusal, realizing that "no" hurts, you should try to offer this.

"I won’t give you that, but I’d give you this"

This is known as the "Toddler Principle" in the art of refusal.

"Broken Record" Technique

This refusal technique involves simply restating your same message over and over again as necessary, without prolonging explanations or talking in circles.

Be firm, yet calm

This is a key aspect of the art of refusal.

Take responsibility for "won’t" versus "can’t"

This advice suggests clarifying if the refusal is due to a choice or an inability.

Escalation

This eventually happens if none of the refusal strategies work, leading to dealing with someone who might be very angry.

Respect the angry person’s perceptions as real to him/her

This is a key step in how to de-escalate an angry person.

Move the upset/angry person to a neutral environment

This is a practical step for de-escalation.

Create a cooling-off period

This is another de-escalation technique.

Stay out of the angry person’s physical space

This is important for safety during de-escalation.

Use non-threatening tone of voice and body language

This helps in de-escalating an angry person.

It is the patient who is angry, not you

This is the first important reminder when recognizing and dealing with angry patients.

Do not leave the anger unexplored

This is a crucial action when dealing with angry patients.

Use your own feelings

When dealing with angry patients, if you are feeling angry, it is very likely the patient is too, suggesting you should do this.