Managing difficult interactions with patients

• Focus on listening to your patient and try to understand the reasons for their behaviour
• Set boundaries of acceptable behaviour
• Be mindful of any impact of the patient’s behaviour on staff and colleagues
• Consider ending the relationship if these steps are not effective

Difficult interactions with patients and/or their family members can be complex. It is important to acknowledge that often patients or family members may be upset, angry or demanding for a valid reason, usually out of genuine concern. Demonstrating understanding and communicating effectively are essential to defusing a volatile situation. This factsheet lists some key skills which may assist you in dealing with difficult patient situations.

The first skill is to be alert to the signs of an emerging situation. In many cases, early recognition of a difficult interaction can help you prevent the situation from escalating.

Is it the patient?

There is often a reason behind the behaviour of a person labelled as ‘difficult’. Some common reasons might be the impact of their illness or other stressors in their lives. Some patients have an illness or disability that impact on the way they need to receive medical care.

Patients may be angry, distressed, scared, have unrealistic treatment expectations or be particularly demanding. Sometimes these behaviours may be the result of previous bad experiences. It is beneficial to explore these factors with the patient to try to identify and address the underlying issues.

Is it you?

Everybody has bad days. Our own stress levels, tiredness or hunger may play a part in how we provide care and it is important to reflect on our own behaviour. Difficult encounters are rarely completely one-sided when they escalate out of control.

Is it the system?

Sometimes factors out of your control can exacerbate a difficult situation, such as complications with billing procedures, unexpected costs or long wait times at the surgery or in the hospital. Acknowledging these issues when you see the patient shows that you are empathetic to their situation.

Something as simple as apologising for a long wait time might be all that is needed to reduce a patient’s anger and put the consultation back on track.

Listening is the best thing you can do

If an interaction with a patient or their family members becomes difficult, the best thing to do initially is to start actively listening to their concerns. By giving the patient the opportunity to have their say, without rushing them, you will be acknowledging that their concerns have been heard. By listening actively to the patient, you may also be able to determine whether there is any other issue which is effecting their presentation.

Ask questions

Use reflective listening skills to check that you understand the patient’s concerns. You need to understand what the issues are to address them. Once you have listened to the patient, ask questions to clarify any issues to ensure that you comprehend all the relevant concerns. You could say, “Have I understood everything correctly?” or “Is there anything I have missed?”.

Meet the needs of patients

Where patients or their family members are unwell or have a disability, it may be necessary to consider changing the way you provide care. There may be small steps you can take which may greatly assist a patient to more effectively access care.

Prevent escalation

Try to remain non-confrontational, maintain your cool and don’t get caught up trying to win an argument. If you feel your emotions rising, take a moment to gather your thoughts before proceeding. Do not allow yourself to become involved in any escalating emotions, no matter how taxing the day has been.

Angry patient behaviour

In some situations, it may be appropriate to allow the patients to safely and appropriately express their anger and for you to acknowledge their experience: “I can see that you are very angry about this.” Acknowledging the patient’s experience does not necessarily mean you agree with what they are saying, however where appropriate, you may wish to also express your agreement: “Understandably you are angry.”

Other useful tips to keep in mind:

• Keep calm, use a neutral tone and adopt an open body posture.
• Avoid becoming defensive or taking comments personally. Seek to de-escalate the situation rather than potentially escalating the patient’s emotion by demanding that they behave in a certain way.
• When you understand the reason for the problem and can do something about it, it can help to say “I understand and will take action”.

Violent patient behaviour

Your safety and the safety of those around you is the most important issue when confronted by a violent person. To defuse a violent situation:

• remain calm
• reassure and acknowledge any grievances
• provide the patient with an opportunity to explain by listening to their responses
• maintain eye contact
• keep a safe distance, positioning yourself between the patient and an exit
• get help or leave the room if you are feeling unsafe.

Manipulative behaviour

Patients may use manipulative behaviour, such as threats, cajoling, crying or using guilt, in an attempt to get their own way. Patients using these behaviours can be difficult to talk to. They may be entrenched in their version of events and will not budge from their beliefs. They may do all they can to convince you to do what they demand, for example, threatening to issue a complaint against you if you do not prescribe a particular drug or give them special treatment. Be careful not to compromise your care by giving in to unreasonable demands.

The key is how you react once you realise you are being manipulated. You need to:

• ensure he entire practice team know the practice rules and remain firm
• attempt to understand the patient’s expectations and try to separate those from their behaviour
• try to help the patient within appropriate boundaries
• realise that sometimes you need to say “no”
• seek help from a colleague or another practitioner.

Family members

Challenging encounters with your patient’s family and friends need to be carefully managed. These encounters can be the result of their stress or what they consider to be a previous lack of communication or mishandling of the patient’s care. Communication is essential to get to the heart of the issue. The appropriate approach is to engage with the family more and keep them updated. However, always remember your privacy obligations and remember to seek your patient’s consent before speaking to their family or friends. In an emergency you are able to convey information to the family without the patient’s consent.

Set boundaries

While empathy and understanding are imperative, it is also necessary to establish boundaries and be firm about these with your patient. Boundaries establish what behaviour you find acceptable or unacceptable within your practice or at the hospital. Seek your patient’s acknowledgment and agreement on these boundaries.

You may want to establish a treatment plan with the patient where they agree what is acceptable in terms of behaviour, such as “you will not telephone me after 8pm but rather call an ambulance if it is an emergency”, or “you agree not to use profanity when speaking to our practice team”, or “I do not prescribe drugs of addiction”. Offering the patient choices in treatment by using a shared decision-making model, may also improve the patient’s engagement with their care and your relationship.

It is important to have insight into your strengths and weaknesses when it comes to dealing with difficult interactions with patients or families.

Think about whether you have the right mix of personality and skills to effectively deal with a difficult situation or whether you may need to let someone else who is more familiar or sympathetic with the patient take over. Don’t forget to work as a team with other health practitioners at the hospital or your practice.

If it gets to a point where the patient becomes physically or verbally abusive, it’s time to step back. Tell them that they have overstepped the boundary and that their behaviour has become unacceptable, and then initiate your security protocol.

Accept that some doctor-patient relationships cannot continue

Consider whether you can continue working with the patient if the relationship has broken down and you believe the patient does not trust your clinical judgment. It may be in the patient’s or your best interests that you do not continue looking after them.

If necessary, seek advice from Avant on how to appropriately end the doctor-patient relationship. It is important this is done in the correct manner to avoid alienating the patient, which could lead to a possible complaint against you. Avant has further information at: How to end the doctor-patient relationship

Take particular care to document events involving confrontations and discussions in a difficult encounter with a patient or family member. Your summary of the interaction should be factual and objective. You may want to step back and calm down before you make an entry in the patient’s records.

Managing difficult interactions with patients and their families can be stressful and draining. Prioritise your well-being and the well-being of the practice team. You will be in the best position to manage stressful interactions with patients if you pay attention to your own work-life balance, engage in hobbies and exercise and take care of your relationships. It is also valuable to seek support and help from your colleagues.

If you have a challenging interaction with a patient, take some time to think about the events and your response, and reflect on the outcome and anything you may have learnt to help you with similar interactions in the future.

Avant also offers a range of doctor health and well-being resources which can be accessed via the following link Avant - Health and wellbeing.

For medico-legal advice, please contact us here, or call 1800 128 268, 24/7 in emergencies.