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How to Approach Difficult Patient Encounters: ROAR

2018; Elsevier BV; Volume: 155; Issue: 2 Linguagem: Inglês

10.1053/j.gastro.2018.06.052

1528-0012

John G. McCarthy, Joseph G. Cheatham, Manish Singla,

Healthcare Systems and Technology

Managing difficult patients requires significant patience. Studies related to gastroenterology clinics are lacking, but primary care physicians report approximately 1 in 6 patient encounters as difficult.1Jackson J.L. Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes.Arch Intern Med. 1999; 159: 1069-1075Crossref PubMed Scopus (261) Google Scholar, 2Hinchey S.A. Jackson J.L. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes.J Gen Intern Med. 2011; 26: 588-594Crossref PubMed Scopus (92) Google Scholar Difficult patient encounters are associated with more burnout and less job satisfaction.3An P.G. Rabatin J.S. Manwell L.B. et al.Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes study.Arch Intern Med. 2009; 169: 410-414Crossref PubMed Scopus (83) Google Scholar Throughout our training as gastroenterologists, we learn the ways to manage severe stricturing Crohn's disease, liver transplant failure, and complicated gallstone removal, but formal training regarding difficult encounters is hard to implement. For many young physicians with competing time pressures, the "easy patient" is the one that arrives with plenty of objective findings (ie, laboratory results, imaging, and biopsies), resulting in the diagnosis of a readily treatable condition without need for complex reciprocal dialogue. Instead, our review is meant to provide help with the "difficult patient," or more appropriately defined, the "difficult patient encounter." The label "difficult patient" attributes responsibility for a negative exchange solely on the patient, and fails to appreciate the role of the physician's projected frustrations. Both patient factors and physician factors contribute to difficult encounters.4Haas L.J. Leiser J.P. Magill M.K. et al.Management of the difficult patient.Am Fam Physician. 2005; 72: 2063-2068PubMed Google Scholar Addressing the "difficult patient encounter" allows us to explore a combination of factors between patient, physician, and situation.5Cannarella Lorenzetti R. Jacques C.H. et al.Managing difficult encounters: understanding physician, patient, and situational factors.Am Fam Physician. 2013; 87: 419-425PubMed Google Scholar Difficult encounters involve patients with more functional impairment, higher health use, and lower satisfaction with care.6Hahn S.R. Kroenke K. Spitzer R.L. et al.The difficult patient: prevalence, psychopathology, and functional impairment.J Gen Intern Med. 1996; 11: 1-8Crossref PubMed Scopus (272) Google Scholar James E. Groves defines "hateful patients" in his article in 1978 as those who evoke dread in their providers.7Groves J.E. Taking care of the hateful patient.N Engl J Med. 1978; 298: 883-887Crossref PubMed Scopus (529) Google Scholar He further defines 4 patient stereotypes: "dependent clingers," "entitled demanders," "manipulative help-rejecters," and "self-destructive deniers" who evoke feelings of aversion, fear, depression, and malice. By combining patient recognition and emotional self-awareness, Groves argues that providers may avoid errors in diagnosis and treatment. In a follow-up editorial 40 years later, Richard and Peter Gunderman reexamine Groves' article, and caution that treating a patient as "hateful" stems from an improper perception of both the patient and the provider's calling.8Gunderman R.B. Gunderman P.R. Forty years since "Taking care of the hateful patient.".AMA J Ethics. 2017; 19: 369-373Crossref PubMed Scopus (7) Google Scholar They cite sentiments embodied by Osler and Saint Teresa, such as seeking love, compassion, and a higher purpose as ideal outcomes when responding to such patients. Although patients may not be truly hateful, few gastroenterologists are truly Saint Teresa. For the betterment of both the patient and the provider, we therefore need a realistic approach. This article offers honest and personal reflections in our gastroenterology practice and strategies to address difficult patient encounters. As specialists, we are fortunate to frequently know ahead of time the primary complaint of the patient referral, and we can take a focused view on their gastroenterological concerns. Often, we have prior knowledge that alerts us that one of our difficult patients is coming in to be seen. Because the majority of us use electronic medical records, we have a significant amount of patient's history (medications, surgeries, previous appointments, allergies) before the encounter. Rather than the traditional SOAP approach (Subjective, Objective, Assessment, Plan) to such an encounter, we suggest a ROAR approach—Reflective, Objective, Assessment, Reassurance (Table 1).Table 1Helpful Phrases to Use With ROAR!MnemonicPhrases to UseReflectiveI'm sorry, it looks like you've had a tough year.This past year must have been very frustrating.Looks like you've had a lot of providers.I believe you—something is wrong; we haven't figured it out yet.ObjectiveHistory of present illnessLaboratory valuesPhysical examinationRadiology studiesAssessmentWhat do you think is going on?Here's what I'm worried about…Here's what I'm reassured by…Here's our plan based on that…ReassuranceWe're not done today.Let's see if this works; if it doesn't we'll change the plan.Here's a follow-up plan.I'm excited to see your progress!I'm here to help if things get worse. Open table in a new tab When beginning the encounter, we encourage providers to reflect the distress of their patients. Phrases such as "I'm sorry, you seem frustrated," or "It seems that you have had a difficult year" can help patients to feel that their concerns and fears are valid. Early statements in the encounter that validate your patients' frustrations can lead to the patient relaxing and accepting that, as a provider, you are there to listen and help. When addressing patient's objective history, engage them in reciting their own histories. Share their medical records with them; go over positive and negative studies, laboratory results, and endoscopies with patients so that they can feel some ownership of their histories. This also helps to reinforce the time and energy you are putting into their care. When giving your assessment, list the things that are reassuring and the things that are "confusing" or "inconsistent." Make sure to give both yourself and the patient the opportunity to understand that the diagnosis is not final; we emphasize the value of time as a diagnostic tool. In our practice, we encourage patients to express what they feel may be the cause of their symptoms; this often uncovers patient anxieties that had not surfaced yet in the encounter (ie, a patient may be worried that their functional dyspepsia is actually caused by gastric cancer because they just had a friend diagnosed with gastric cancer). In completing the encounter, give patients the opportunity to reach back out. Reinforce that you are there to reassure their fears, and that you are there to help. Promptly returning messages, via secure messaging or phone calls, confirms to the patient that you care. Use phrases like "Let's see if this works, and if it doesn't, we'll change the plan" or "I'm excited to see your progress!" We have a lot of training in implementing the objective and assessment portions of the encounter; below is a collection of tricks to reflect and reassure our patients. Emotions are important inputs that help us to make decisions as clinicians. A practitioner's fear of abetting opioid addiction when caring for a patient suffering from chronic pain may lead to concern, which may lead to probing questions regarding the patient's chronic pain coping mechanisms, which may lead to a durable healthy approach to the patient's pain. It is equally important to realize when emotions are obstructing delivery of patient care. Frustration can be a common barrier to a clinician's effectiveness if it is allowed to overwhelm empathy for the patient. An approach that can be helpful is to openly communicate your frustration to the patient in a constructive manner. This can mean admitting that your approach is ineffective, and engaging your patient on their input on the plan: "I'm frustrated because the plan we came up with isn't working, what do you think is happening?" The hope is that the patient may reveal her source of frustration: "I've had doctors not believe me before," or "I have too much going on to change my diet." This requires patience, self-reflection ("Is my frustration valid?" "Is my patient capable of understanding how her actions affect others?"), self-awareness ("Why am I frustrated, upset, anxious, and irritable?"), and the willingness to be vulnerable and open to the patient. Importantly, during self-reflection, it is common to come to the realization that the source of frustration is from something outside of the patient's control (eg, hospital parking). Although we cannot attest that it will be successful in every difficult encounter in which frustration arises, it is an optional approach that can result in positive patient outcomes. As providers we suffer from furor medicus: the feeling that we have to do something! This may lead us to always order new diagnostic tests or changes in therapeutic interventions so that both you and the patient do not feel a sense of inertia. Instead, in the patient without significant changes in their medical status, emphasize what is working! Provide reassuring details about their care ("You're not losing weight anymore," "Your bleeding has decreased") and use follow-up appointments as your most effective intervention. It is helpful to find commonalities to relay empathy toward your patient and to bolster your own resiliency. Depending on your patient's psyche and emotional stability this information can be shared with the patient: "My son is also learning how to drive… the whole family is scared to go anywhere these days!" or "Traffic is always bad when schools start again." or "Must be tough to see the Eagles win the Super Bowl this year!" This technique aims to help you positively modulate your own emotional response to your difficult patients (ie, manipulative or demanding). Silence is golden during your patient encounters. Silence while focusing on the patient and using nonverbal cues (nodding to convey understanding, concerning facial expressions when your patient expresses emotion, etc) helps to remain patient centered, compassionate, and thoughtful, especially while the patient is talking. Requesting time to think about a patient's comments can be even more effective in gaining some of the above accolades. ("Give me a moment to think about your symptoms.") Use the time to not only work through your differential diagnosis, but to gauge any negative emotions that may have surfaced. Are you unable to make the patient better? Are there conflicts with your professional standards? Do you feel taken advantage of? After reflection, use your management tools such as setting boundaries and limits with patients who are taking advantage of you. Frequent functional complaints in a patient can mask sinister pathology. A patient with irritable bowel syndrome can still develop inflammatory bowel disease or colon cancer, so new bleeding, weight loss, anemia, or elevated inflammatory markers should spur revisiting previously discarded diagnoses. It can be easy to get complacent with patients who never seem to feel better, but remembering that those same patients still present with new pathologies can keep your care safe and patient centered. Many times, during the first interview, we may not have time to thoroughly investigate the social history of our patients. In trying to address their primary complaint, we may spend less effort on whether a patient's mother is sick in the hospital, or the demands of a child with special needs on a patient's time, or even a frequent traveler who constantly has to change diets. When it feels like, despite every intervention and building a strong therapeutic bridge, you are making no progress with a patient, ask a patient about other things going on in his or her life. Ask questions like, "What was happening when your symptoms were the worst?", "How is your family doing?", "What's happening at work?" and "Which parts of our plans are difficult to enact?" Addressing issues not directly related to the primary complaint can lead to an improved therapeutic relationship and greater efficacy for patients. Many of us get irritable when we skip meals or do not get our daily dose of morning coffee. Particularly when preparing for a Friday afternoon clinic standing between you and the weekend, make sure to have eaten lunch so that you are not distracted by hunger or fatigue when trying to build a therapeutic relationship with patients. Because it is difficult to maintain an appropriate diet with busy clinics and endoscopy schedules, use tricks we all learned from internship: keep snacks like granola or fruit at the ready to stave off hunger before clinic. Do not suffer in silence. We all see patients who frustrate us; talk to your colleagues about it. Call your co-fellows from training or your partners in practice and spend some time venting your frustration. It can help to discuss your greatest frustrations or difficulties with others so that it does not feel like you are the only one faced with these difficulties. In sharing how you are doing, you can also collect anecdotal successes from your colleagues. Many of the phrases and mechanisms we use in clinic come from things we have heard other gastroenterologists say. Sometimes, difficult patient encounters can be too discouraging, and lead to a severed patient–physician relationship, where the patient is not receiving compassionate, adequate, and effective care. When it seems that there is no path forward to build a supportive relationship with your patient, it may be time to refer the patient to another gastroenterologist. Although this is usually when both you and your patient are most frustrated, it is this same time that taking a gentle approach with transferring care can do the most benefit: "It seems like we are not making much progress together, but you may do better with one of my colleagues." "I'm sorry that our relationship isn't bearing much fruit, but I think you can still make some progress." In our practice, we turn over care directly to the next provider, ensuring that he or she builds on our successes while avoiding the same struggles. Difficult patient encounters are unavoidable, and it is our calling as gastroenterologists to nurture our relationships with our patients so that both parties are able to minimize frustration, engage in a patient-centered approach, and ultimately engage in successful therapeutic interventions. We hope that this article, and our ROAR mnemonic (Figure 1), will help to provide a roadmap to managing these encounters. When you are able to act with clear intention, focus, and compassion, you can achieve the desired result—a patient who feels truly cared for.