Navigating "Difficult" Pt Interactions

Katherine Termini and Jonathan Smith

Background¶

Between 15-60% of pt-physician interactions are considered “difficult” by the physician. Pts in these interactions also often report dissatisfaction, feeling unheardor uncared for.
Pts want to feel their unique perspective is understood by their team, even if that perspective differs from the team. Reaching this understanding can often resolve conflict.
Difficult pt interactions increase the risk for physician burnout.
It is important to note that most difficult interactions are not due to psychiatric illness.

When a pt has very strong affect towards you, try not to take this personally as it is rarely related to you specifically.
Remain calm and unflappable while in the room, even if the pt is upset. Focus on breathing deeply and pause before speaking.
Attempt to identify and verbally reflect the pt’s emotional state.
Understand that you cannot reason someone out of something he/she was not reasoned into
Minimize blaming and “you” statements
Acknowledge that being in the hospital is hard work for the pt, and the team wants to work with the pt toward a common goal.
Acknowledge that the interaction/relationship is less than ideal and how that may be impacting their care.
Assist a pt in revising unrealistic expectations by providing education, but always keep the reason for their expectations at the center (refusing a procedure due to fear of death or feeling out of control).
Indicate the pt’s own role and responsibilities in their care—highlight the things that they have direct control over.

Acknowledge the problem and pt’s anger
Allow the pt to vent uninterrupted
Agree on what the root problem is
Affirm what can be done to address this problem
Assure follow-through
That said, prioritize safety of pts and staff. If the pt is escalating to physical agitation, defer negotiations to a later time. Do not stay in the room if you feel that your physical safety is in danger or if the pt is being verbally assaultive. You never need the pt’s permission to leave the room.

A coping mechanism by which a pt views others as either good or bad without middle ground
This often manifests as different team members having different types of interactions with the pt or hearing different things from the pt. The pt may idealize some team members and villainize others.
If possible, have all team members (primary, consultants, bedside nurse) meet with the pt at the same time.
Alternatively, have all treatment plans be delivered by one central person (primary resident) with bedside nurse present
Provide pt a written summary of this plan.
Find ways to make small, reasonable concessions that give the pt more control over their care and day-to-day experience (e.g. shifting the timing of medications).
Set clear expectations and boundaries (e.g. team will terminate discussion and leave the room if the pt begins cursing at them) and follow-through on them
When feeling stuck, consulting the psychiatry consultation liason service can help address psychiatric factors that may be contributing or can play a mediating role