How to deal with Difficult Patient Non Sowanna. Family Medicine of CFOM Department Naresuan Hospital

Definition ? The prevalence is estimate to be 15 percent of patients The presence of depressive or anxiety disorder, somatic symptoms and greater symptom severity

Four Principles of Family Medicine in Canada,CFPC Doctor-Patient Relationship 2. Skillful Clinician 3. Community-Based Practice 4. Resource Person to a Defined Population

แพทย์เวชศาสตร์ครอบครัว “ ไม่ใช่ (แค่) หมอทั่วไป ” “ หมอประจำตัวคนไข้และครอบครัว ” An expert to explore the complex interaction of physical, psychological and social problem

Doctor’s Agenda Patient’s Agenda Patient-centered Doctor-centered Information gathering Fact collection Doctor’s Agenda Beliefs Hopes Fears Expectation Patient’s Agenda

‘Nobody goes to a doctor with just a symptom ‘Nobody goes to a doctor with just a symptom. They go with ideas about the symptom, with concerns about the symptom and with expectations relate to the symptom ‘

Angry, defensive, frightened or resistant patient

Nobody likes a confrontation with an anger person Do we have the right to return the anger? Do the choice dealing with anger patient

Sign of anger Clenched fists Furrowed brows Wringing from hands Restricted breathing patterns Warning from office staff

Type of responses Factual responses The aggressive/hostile response The judgmental response The reassuring response( the pacifier ) The empathic response Silence

Management Try to uncover the source of anger Emotions related to the medical issues Reflective response

Reflection The act of listening Show you have heard and have interpreted what the patient said

Fearful about a diagnosis or Treatment Assess the patient’s fear Talk about context If you sense a potential for harm to you or your staff Ask for assistance

Manipulative patients Play on the guilt of others Threatening rage Legal action Suicide

Management Aware of your own emotions Attempt to understand the patient’s expectations Realistic and reasonable Say no

Somatizing patients The patients present with a chronic course of multiple vague or exaggerated symptoms Suffer from comorbid anxiety, depression and personality disorder Doctor shopped

Warning signs of Illness มาตรวจบ่อยด้วยอาการเล็กๆน้อยๆ อาการเดิมๆ, หลายๆอาการ อาการที่เป็นมานาน, ไม่เคยหาย, ไม่เปลี่ยนแปลง ดูทุกข์ทรมานเกินจริงกับอาการเล็กๆ ไม่หายเมื่อถึงเวลาที่ควรจะหาย

Warning signs of Illness พยายามให้ความมั่นใจกับผู้ป่วยแต่ไม่สำเร็จ พ่อแม่ที่ชอบพาลูกมาหาหมอตลอดเวลาด้วยเรื่องเล็กๆน้อยๆ ผู้ป่วยผู้ใหญ่ที่มีญาติมาเป็นเพื่อนด้วยเสมอ ไม่สามารถบ่งชี้ได้ว่าป่วยเป็นอะไรกันแน่

The patient is as frightened as you are. The patient think it is more serious than you do. Illness is frightening, but understanding what is going on help. This applies both to the patient and to you. Taking a history is a method of controlling what the patient says

Diagnosis testing and refer Management Describing diagnosis with compassion and emphasizing Regularly scheduled visits Reframe idea that “ it’s all in you hand” Avoid the vicious cycle Diagnosis testing and refer

Grieving patient Normal stage of grief Look for sign of depression and maladaptive behaviors Vary degree of time for different people

Management Encourage open communication Avoid inappropriate medication Caution against major lifestyle change

Frequent visit patients Patient with rational questions Misinformed patients Patients who are ashamed or embarrassed Patients with mental disorder Drug seekers Lonely, dependent patients The worried well Patients who don’t want to get well

Management Clear picture of the patient’s situation People assimilate information at different rates and that some may not Etiology-base approach Regular schedule Empathic response Acceptance and validation of the patient’s feelings Ask patient’s idea if you are unsure about diagnosis Take and document a careful history

Frequency visit patients require more than black and white science or professional advice The first step in treating them should be trying to identify the underlying reasons for their frequent visits

Personal Iceberg Metaphor

Coping (stances) Feelings Behavior Coping (stances) Feelings Feelings about feelings Perceptions Expectations Yearnings Self: I am, life energy

Components of difficult Physician Characteristics Patient Characteristics Situational issues

Physician factor Anger or defensive physicians Fatigued or harried patients Dogmatic or arrogant patients

Situational factor Language and literacy issues Multiple people in the exam room Breaking bad news Environmental issues

How to Break Bad News

A Six-Step Protocol Step 1. Getting the physical context right Step 2. Finding out how much the patient knows Step 3. Finding out how much the patient wants to know

A Six-Step Protocol Step 4. Sharing the information Step 5. Responding to the patient’s feeling Step 6. Planning and follow through

Step 1. Getting start ไม่ควรบอกข่าวร้ายทางโทรศัพท์ เตรียมตัวเราให้พร้อมก่อน Where? Who should be there? Starting off

Step 2. Finding out how much the patient knows Patient’s Idea How serious he/she thinks it is How much it will affect the future Gap between patient’s comprehension and medical reality Style of patient’s statement Emotional content

Step 3. Finding out how much the patient wants to know

“ถ้ามันเป็นอะไรร้ายแรงขึ้นมาจริงๆ หมอไม่ต้องบอกฉันหรอกนะ หมอจะรักษาอย่างไรก็สั่งมาเถอะ” “หมอถ้าเป็นอะไรให้บอกมาตรงๆนะ จะได้เตรียมตัวถูกว่าจะดูแลตัวเองยังไง อย่ามาทำกำกวมมันหงุดหงิด ไม่รู้ว่าเป็นอะไรสักที” “หมออย่าบอกลูกนะว่าผมเป็นมะเร็ง ผมแอบไปตรวจมาแล้ว เดี๋ยวลูกมันจะไม่สบายใจ”

Step 4. Sharing the information Start from the patient’s starting point Give information in small chunks Avoid medspeak Check reception frequently Repeat important points Listen to the patient’s concern Listen for the buried question

Step 5. Response to Patient’s Reaction Humor Denial Anger Crying Fear Guilt Bargaining Shock Anxiety Hope Fulfilling an ambition

Step 6. Planning and Follow Through Demonstrate an understanding of patient’s problem Distinguish fixable from non-fixable Make a plan and explain it Identify other source of support Making a contract

Communication with care Basic communication skills Active listening Respond Aware of your own emotional baggage in the room Do you have any questions about what we discuss today? Attending to your own physical and mental process as you see patients

No physician can avoid the difficult clinical encounter but having the tools to deal with these situations when they arise can make for batter experience for both you and your patient

รักษาให้หาย ทำได้บางคราว ช่วยให้ทุเลา ทำได้บ่อยกว่า แต่การปลอบใจให้สบายใจขึ้นนั้น ทำได้ตลอดเวลา ศ.นพ.ฝน แสงสินแก้ว บิดาแห่งจิตเวชศาสตร์ไทย

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