Communicate, set boundaries, and extricate yourself carefully

When it comes to dealing with difficult patients, you’re not alone. Every office has them. You dread seeing their names on your schedule. Your staff puts off returning their calls. Clearly, something needs to be done to improve relationships with these patients, but what?

Difficult patients are dependent, clingy, and entitled at best; they may also be manipulative, self-destructive, noncompliant, litigious, and even hostile. They all, however, demand excessive amounts of time and attention from you and your staff. And despite your efforts, you frequently find yourself frustrated and exhausted after interactions with them and sense that they have similar feelings.

The following tips may help salvage a relationship before it’s too late.

Sharpen your communication skills
Before you take the easy way out and blame the patient for the fractured relationship, take a good look in the mirror. Are you doing everything you can to understand and address the patient’s underlying needs or expectations? In other words, are you effectively communicating with this patient?

I call this the “Maxine” rule. Whenever my mother, Maxine, visits the doctor, she calls me afterward. As the only healthcare professional in our family, I get all her unanswered questions and complaints, as well as a critique of her most recent medical visit and advice on how to interact with patients. Now when dealing with a difficult patient, I remember that advice: “slow down, listen, and don’t be arrogant.”

When you are working with a challenging patient, ask yourself, “Would my family member, who has no medical background or experience, be satisfied with this interaction?” If the answer is “no” or “maybe,” you may need to think about how to improve your communication skills. If you can honestly reply “yes,” then the reason for your communication problem most likely lies elsewhere.

Often poor communication and the resulting difficult relationship are by-products of the time constraints many of us face. Simply recognizing that you need more time with certain patients, and scheduling your day accordingly, can go a long way in addressing the problem. This tactic, however, will not help with the patient who is never content with the time you provide.

Create boundaries
Standardized approaches can help lessen the emotions involved in dealing with difficult patients. Reasoned, consistent processes that provide clear boundaries from the start can not only avoid problems down the road, but also help defuse situations before they escalate.

A uniform narcotic medication refill protocol is an easy place to begin. Our office has a policy of no medication refills on weekends or after hours on weekdays. This policy is widely publicized in our office, including signs in every exam room. Now, instead of arguing with a patient on the issue, we simply refer to our written policy.

A standardized approach can be expanded to other difficult patient issues as well. Deanna R. Willis, MD, MBA, and Ann Zerr, MD, outlined a three-tiered approach to challenging patient management (Fig. 1). Outlining your practice’s approach to difficult patients beforehand removes the emotion of the moment and reduces the possibility of defensive reactions.

The last resort
When efforts to salvage the relationship with a difficult patient are not successful, what are your options? Can you terminate your relationship with a patient?

The American Medical Association (AMA), in an opinion on termination of a physician-patient relationship, stated, “Physicians have an obligation to support continuity of care for their patients. Physicians do have the option of withdrawing from a case, but they cannot do so without giving notice to the patient, the relatives, or responsible friends, which allows the patient sufficient time to secure further care.”

In general, the AMA suggests giving 30 days notice. This suggestion is discretionary, depending on your individual circumstances; however, if you do not provide proper notice, you can be accused of patient abandonment. Because the definition of abandonment varies from state to state, it’s wise to consult your medical liability provider before terminating your relationship with a patient. It’s also a good idea to contact the patient’s third party payor, who may be able to provide a patient advocate to act as liaison between you and the patient and possibly help salvage the relationship.

If, despite all your best efforts, the relationship fails, you’ll need to take the following steps:

• Send a written confirmation of termination via certified mail with return receipt requested.
• Outline a specific period during which you will provide continued care.
• Remind the patient that his or her medical condition requires care. Advise the patient to find another physician immediately.
• Provide the patient with contact information for other physicians in your specialty or for a medical referral service.
• Inform the patient on how to obtain a copy of his or her medical records from your office. Never withhold medical records even if the patient still owes your office money.
• Personally sign the termination letter and keep a copy in your records.

Dealing with the difficult patient can be a challenge, but it’s a challenge that physicians can overcome. Improving communication skills, managing your time, and planning ahead are key.

In addition, formulating standard approaches and establishing office policies will help you handle difficult patients with empathy, fairness, and timeliness.

For more information and advice on practice management issues, visit the AAOS online Practice Management Center at www.aaos.org/pracman

The AAOS also sponsors private blogs where members can ask questions, share ideas and approaches, and post comments on issues. Simply click on the “Private Blogs” link (on the online Practice Management Center) to see a list of current discussions.

Robert H. Blotter, MD, is a member of the AAOS Practice Management Committee. He can be reached at rblotman@hotmail.com