Behavior
Difficult Clinical Encounter
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Difficult Clinical Encounter
, Difficult Patient Visit, Difficult Physician-Patient Encounter
See Also
CALMER Approach to Difficult Clinical Encounters
Somatization
Excessive Worry
Personality Disorder
Drug Seeking Behavior
Risk Factors
Medical Provider factors
Provider Burnout
, exhaustion,
Fatigue
or sleep deprivation
Time pressure
Provider insecurity or sense of challenge to medical opinion
Provider discomfort with diagnostic uncertainty
Provider with limited training in psychiatric conditions
Provider difficulty with communication (especially
Expressing Empathy
)
Patient factors
Patient angry, demanding or manipulative
Noncompliance with recommended therapy
Somatization
Excessive Worry
Drug-seeking behavior or
Chemical Dependency
Chronic Pain Syndrome
Multiple presenting complaints at each visit
Personality Disorder
(e.g.
Borderline Personality Disorder
)
Management
Gene
ral
See
CALMER Approach to Difficult Clinical Encounters
Listen and allow patient to speak uninterrupted
Name and validate the emotion you sense the patient is feeling
Problem solve with the patient on preventing similar difficult encounters in the future
Management
Dependent and insecure patient
Signs
Patient praises provider and requires increasing time and needs from the provider
Provider Approach
Establish and maintain professional boundaries
Schedule regular appointments, and reassure patient of continued care
Encourage patients active involvement in decision making and medical plan
Management
Entitled and demanding patient
Signs
Patient bypasses standard medical protocols, assumes special medical access and angry when not catered to
Provider Approach
Address specific emotions and their underlying causes (e.g. acute illness, serious comorbidity, pscyhosocial stressors)
Assure the patient of sound medical care
Discourage mis-directed anger
Management
Manipulative patient who rejects help
Signs
Recurrent presentations for potentially serious symptoms, yet refuses or non-compliant with recommended approach
Provider Approach
Refocus attention
Patient to provider connection
Symptomatic relief over medical cure
Set reasonable expectations that patient is willing to pursue
Informed Consent
when this is likely to result in worse outcomes
Management
Self-destructive patient with sense of hopelessness
Signs
Despite maximal management, patient continues self-destructive behaviors, and health problems progress
Provider Approach
Manage underlying
Mood Disorder
(
Major Depression
or
Anxiety Disorder
)
Address specific underlying causes (e.g. limited funds or medical system access)
Establish reasonable goals and congratulate patients when progress is made
References
Breen (2010) Intern Med J 40(10): 682-8 [PubMed]
Haas (2005) Am Fam Physician 72(10): 2063-8 [PubMed]
Knesper (2007) Psychiatr Clin North Am 30(2): 245-52 [PubMed]
Lorenzetti (2013) Am Fam Physician 87(6): 419-25 [PubMed]
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