Mitigating Challenging Patient Situations

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By Michelle J. Hall, CPO, MS, FAAOP, and Ellen B. Snoxell, PhD, ABPP

Do you ever feel your heart sink when you look at your schedule for the day and see the name of a particular patient that you'd rather avoid? Do you ever get behind because a patient has brought in far too many concerns-many of which you cannot address-for you to finish in the time allotted? Do you ever feel like you should have worn armor and a helmet into the examination room? Positive interactions between the patient and clinician lead to a healthy therapeutic relationship, but negative interactions can prevent us from providing optimal patient care. This article describes several common problematic situations and offers suggestions that will improve patient care.

In addition to having a multitude of psychosocial crises and chronic stressors, patients may lack a strong support system or attentive and listening adults in their lives. Overwhelmed by the pressure of whatever crisis is most urgent, it is understandable that the patient vents to an understanding and empathetic clinician. Unfortunately, the time spent discussing problems you cannot resolve subtracts from the time available for addressing the orthotics or prosthetics issues that you can resolve.

We need to be mindful of our resources and boundaries to effectively help the patient who has a welter of psychosocial issues. Allow the patient to vent for only a few minutes, and then acknowledge that he or she must feel overwhelmed. Next, you can ask what you can do to address his or her O&P concerns; your patient needs you to target your time and energy on your area of expertise. Together, you can prioritize a list of the O&P tasks to be addressed during the appointment. You will likely need to remind the patient to focus on these issues during the session. At the end of the visit, review what the two of you accomplished by focusing on the right problem at the right time. This simple reflection can facilitate goal-directedness in future sessions. After the appointment, you can certainly link the patient with social services or another professional who knows available and applicable resources.

Some clinical visits feel like a debate match, with the patient arguing every point and not following through on instructions or recommendations. Instead of a therapeutic alliance, these relationships are contentious, argumentative, and replete with "yes, but" qualifiers. We are apt to characterize argumentative patients as "control freaks" or "noncompliant," and although this may be true, these patients still desire and need our assistance even if they seem to fight us every step of the way.

Forming an alliance with every patient is vital. One effective nonverbal strategy to help form this alliance is to sit next to rather than opposite the patient and to look in the same direction, possibly at a mutually developed goal list. Develop a list of options together, and ask the patient to prioritize them. Outlining a mutual strategy undercuts potential power struggles. Of course, there will always be the person who is spoiling for a fight, but even these individuals will take their battles elsewhere when you don't rise to the bait.

Like the patient described in the first scenario, this patient also arrives with a lengthy list of problems, except in this case, the problems fall within our scope of expertise. We may not identify patients who fit this pattern at the beginning of the first visit since they generally save the "bombshell" for the end of the allotted time. However, once we have correctly identified them, we can plan accordingly for future sessions.

At the outset of the appointment, prioritize and limit the scope of the visit to what can be accomplished in the time allotted. As long as no patient harm would result, stick with the priority on the list and finish the visit on time. By giving in to the impulse to take the extra time to accommodate the patient's request to cover multiple issues within one visit, we run behind on our schedules, which makes other patients wait. Just as nobody would expect a dentist to form a crown when the appointment was allotted for a routine checkup, the patient can reasonably be asked to schedule another visit to finish addressing his or her list of concerns.

Occasionally, we see patients who may be angry and threatening. These patients often have succeeded in getting what they want through bullying or intimidation, and they bring these tactics into the clinic. Such patients may seek to intimidate you by insulting your knowledge and experience or insulting a personal quality, such as your gender or race. They may attempt to bully you by invading your personal space, shouting, swearing, threatening legal action, or even making physical threats. In rare cases, some people intimidate by intentionally behaving in an unbalanced manner-hyperventilating, losing contact with reality, or appearing to have a panic attack.

Obviously, maintaining a safe environment for ourselves and all patients is the first and foremost concern. Every provider needs to be highly familiar with the site's safety plan in order to efficiently implement it in emergencies, and to be aware of your coworkers so that you can step in and offer assistance or alert authorities if needed. Unless you believe the patient (or accompanying family member or friend) is armed or is behaving in a way that imminently threatens you or others, de-escalation techniques are your first-line interventions. Position yourself at about a 45 degree angle from the patient, not directly across or next to the patient, with sufficient distance so that his or her threat response is not intensified. Say that you can see he or she is upset and you want to help. Allow time for venting, and assist the patient in identifying the concerns you can address. Often, anger camouflages feelings of helplessness or depression; having tissues handy can signal permission to cry and de-escalate strong emotions. Maintaining an empathetic but firm presence and remaining calm can go a long way in reducing the emotional charge in the room. However, if the patient continues to escalate, you will need to implement the safety plan.

Unlike the other patient scenarios described, this patient is generally pleasant and may even praise you. He or she will comply with many, if not most, of your recommendations but somehow never seems to "graduate" from treatment. This type of patient often has limited social support and seeks substitute friendships with healthcare providers. Sessions feel more like social calls, and the clinician might feel a little resentful when he or she recognizes that the patient is using the appointments to fill a need that has little to do with O&P care.

Although we can have special and trusting bonds with our patients, these relationships are not mutual. Every healthcare profession is governed by ethics codes, and we recognize that our duty toward our patients goes beyond friendship. We owe it to our patients to not satisfy their hunger for friendship so that they may seek and develop true friendships in their communities.

As orthotists and prosthetists, we have received training in O&P care but few, if any, of us have received conflict resolution training. In our particular clinic, we are fortunate that our treatment team includes a psychologist. The opportunity to discuss challenging situations in advance of a patient's return visit, and include behavioral strategies in our toolkit, allows us to maximize the time we spend doing what we do best. We hope that you have learned from these remarks and use these ideas in your practice the next time you have that unsettling feeling when looking at your schedule.

Michelle J. Hall, CPO, MS, FAAOP, is a prosthetics residency director at Gillette Children's Specialty Healthcare, St. Paul, Minnesota.

Ellen B. Snoxell, PhD, ABPP, is a rehabilitation psychologist at Gillette Children's Specialty Healthcare. They work together at the Gillette Lifetime Specialty Healthcare St. Paul - Phalen Clinic.