Gerald Zarlengo, MD, Chairman & CEO, Copic Insurance Company

Difficult patient encounters are something all medical providers may face and patient factors such as strong emotions, somatization, unrealistic expectations, and mental health issues commonly contribute to these. Additionally, we need to take into account environmental or situational factors such as busy patient schedules, multiple people in the exam room, language or literacy issues, and provider issues such as fatigue/burnout, anecdotal previous patient experiences, and defensiveness. 

What is the first step in a difficult encounter?

Although it may sound obvious, it is important to first recognize that you are perceiving an encounter as difficult. This may occur as early as seeing a patient name on your schedule or may not occur until you are in the middle of a visit. No matter when the sense of difficulty is recognized, it is important to reflect on why the patient and/or encounter is evoking your strong emotions. 

Emotions are never wrong but can be detrimental to a provider-patient relationship depending upon how they are identified and managed. While a patient’s anger may be a frequently cited emotion in a difficult encounter, it is important to remember that anger is often the result of an underlying primary emotion such as fear or sadness.

Useful techniques

Acknowledge emotions: Acknowledge the patient’s and your emotions. Don’t be afraid to call out an emotion, such as, “I can see you are angry.” If the patient corrects you and says, “No, I am not angry just frustrated,” take that as a positive as you have already begun to deescalate the situation. Let the patient know you are having challenges as well, “I am having difficulty as I really want to help you, and I am frustrated we haven’t found a better solution for you.”

Reflective and active listening: Summarize what you are hearing from the patient, “I hear you saying you are frustrated as your pain has not improved and it is limiting you at your job.” Brief summary statements are an effective way of expressing empathy. Pay attention to your body language as nonverbal communication contributes more to interaction than the words you say—stay calm, lean in, and pay attention.

It’s okay to say I am sorry: While sorry statements are not necessarily a form of empathy, it may be appropriate to say things as, “I am sorry I kept you waiting so long,” and then follow it with an empathic statement, “I know you must be very frustrated.”

This is a partnership: You may discover that in your exploration that the patient has unrealistic expectations (i.e., “I want to be pain free.”) and you can work toward an agreement to work together on a reasonable goal. “I want to be transparent—I may not be able to relieve all of your pain, but we can work together to improve your symptoms such that you can return to work and enjoy your life outside of work.”

Recognize it will take time: Building a relationship and/or behavior modification takes time. Set reasonable goals on what may be accomplished in one visit.

Communication skills require practice: Remember that we all have differing skills and patient communication is a clinical skill that is developed with practice. There are plenty of wonderful workshops on communications skills. We encourage you to take an opportunity to be videotaped as it is a powerful way to understand nonverbal skills in particular.

When all else fails, take the appropriate steps: Despite your best efforts, not all relationships may be salvageable. You are never required to maintain a relationship that is potentially dangerous or abusive to you or your staff. You can set limits on patient behavior that is particularly disruptive. Remember there are important guidelines to follow when terminating a relationship. You should never terminate a relationship based on characteristics that may be considered discriminatory such as gender, race, ethnicity, age, or disability. Draft a termination letter that is succinct but spells out that you will provide emergency care and non-controlled refills for 30 days. Suggest resources for identifying a new provider and assure them that all records will be transferred. Avoid restating your side of the story in the letter and make sure your staff knows your plans. Finally, send the letter via certified mail.

The information provided herein does not, and is not intended to, constitute legal, medical, or other professional advice; instead, this information is for general informational purposes only. The specifics of each state’s laws and the specifics of each circumstance may impact its accuracy and applicability; therefore, the information should not be relied upon for medical, legal, or financial decisions and you should consult an appropriate professional for specific advice that pertains to your situation.