One in seven consultations are described as difficult by the doctors doing them. Why this happens can be grouped into several categories: patient, doctor, disease and system. More than one factor may contribute in any consultation.
Patients can come across as uncooperative, hostile, demanding, disruptive and unpleasant. Of course the patient may think exactly the same thing about the doctor! Patients may have unrealistic expectations or be unwilling to take responsibility for their health.
Doctors may be in sub-optimal states even before the consultation has started. They can be hungry, angry, late or tired. Their personal lives may be a mess. Their personality may clash with the patients. They may have pre-conceived ideas about the patient which handicaps the consultation before the patient even opens their mouth.
Some conditions are particularly challenging to deal with. These include chronic pain, ill -defined diagnoses and those with little prospect of improvement. Straightforward conditions where there is a recognised pathway of management broadly understood by both doctor and patient are much easier to deal with.
Limited resources, finances, support, interruptions and particularly time pressures all contribute to the difficulties experienced by doctors.
Difficult interactions with patients can take up a disproportionate amount of the doctor’s time, resources and emotional energy. They can cause the doctor to feel stress, anxiety, anger and helplessness and can lead to a dislike of the patient and the use of avoidance strategies. All this compromises the doctor’s ability to provide good care and can lead to increased mistakes which are bad for both doctor and patient alike.
A difficult interaction makes both parties feel frustrated and dissatisfied and may result in a breakdown of trust. The patient is then likely to seek another doctor in the practice or at the hospital and this uses up more precious health care resources.
A doctor who stops listening to patients, argues, talks over them and interrupts them does nothing to get out of the downward spiral that occurs in these consultations. Instead, these other suggestions, which may be made by either doctor or patient can help set things right again.
The first thing to do is to recognise when these difficult consultations arise and instead of getting sucked into the “I’m right and you’re wrong” game, take a step back and try to say what the problem is.
A doctor may say, “ We both have very different view about how your symptoms should be investigated and that is causing some difficulty between us. Do you agree?” A patient may say, “We both seem to have very different views about the optimal number of blood sugar tests that a diabetic needs to do. Do you agree?”
This approach names the elephant in the room and avoids casting blame, fun though that sometimes is. It externalises the problem from both the patient and the doctor and creates a sense of shared ownership. Verbalising the difficulty is the gateway to working towards a solution.
Sometimes a person who is coming across as angry and abusive may be highly anxious about for example a terminally ill partner. A doctor can say, “You seem to me to be very angry about this. Tell me more about this.” It is important to listen to what the patient says, because if the patient really feels that they have been heard they are likely to calm down.
Sometimes what the patient wants really is unreasonable. A doctor may have to be clear about what is and is not acceptable sometimes. It is useful for all members of the practice to have consistent rules regarding such things as prescribing or late appointments. The way to explain this could be, our practice has a policy about this matter and the policy is…..
Doctors and patients will often have different ideas on issues such as diagnosis, investigations, and management options. Sometimes there seems to be no common ground which is often the result of unrealistic expectations. Dr Google and The Daily Mail may have something to do with this. If both can strive to achieve some common ground difficulties usually diminish.
A solution focused process helps the patient feel included and that they are not being abandoned. Asking them to come up with different options can take some of the burden off of the doctor.
Adapted from article by Marika Davies, medico legal adviser, Medical Protection Society, London.
Published in BMJ 3 August 2013
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