 This morning I want to talk about, you know, dealing with those difficult patients and how we can kind of keep our cool so that things don't get worse. So what is a difficult patient? What would you call a difficult patient? Complications? Here, well, it's okay, I've got answers for us. So somebody that's got many symptoms, severe, I guess that could be complications. Some underlying mental disorders, they're less functional, hard to satisfy. Doesn't matter what you do, somebody that's rude or angry, complains a lot, non-compliant, ungrateful, abrasive personality, they're overly dependent, you know, like lots of phone calls. Every time you turn around there's another telephone message from them, lots of appointments. Takes a lot of your clinic time, the Tejas, you've had these people before. So basically, according to the Journal of Internal Medicine, this is how they define it, which is basically what we were talking about, more symptoms, severe, underlying mental disorder, less functional. And a study by Hawn, I believe it was, they figured that about 15% of the patients, adult patients, are termed like the difficult patient, they're meeting this definition. But this is a statement from a difficult patient, somebody that knew that they were labeled a difficult patient. And I thought this was great because their ophthalmologist is the doctor that they've identified as the one that they really trust. And I'll let you read this, but what I love about this is the very end. I don't want to be a difficult patient, but I don't know any other way to be, but I love this. Here's another quote from a patient. The best doctor is going to listen to my complex history and be a partner with me, trusting that I can understand what's going on and be well-informed. And then as far as the non-compliant patient, well, resistance only happens if you push back, you can get them all the medicines in the world, but if they're not going to take it, that's still their choice, right? So it's the pushing back that creates the problem. And I love this, over half of the prescriptions that are written are either not taken or not taken correctly. So what are some of the reasons why patients are non-compliant? What do they give you when you talk to them? Exactly. Some of the reasons that I've heard, they forgot, I can't remember to take it. They're worried about side effects. They're worried about what's going to come from that, the cost. Sometimes they don't realize when they say, yeah, sure, give me the prescription. When they get to the pharmacy, even with their co-pay, sometimes they're expensive or if they don't have prescription coverage, they didn't believe it was going to really help. They had difficulty getting to the pharmacy, especially with our patients a lot of times. I worked with one guy that was in extreme pain, but he couldn't get to the pharmacy. So he didn't take his medication. This was not for an eye condition, it was for, he went into the ER with what they thought was gout, and you know how painful that can be. And he couldn't get to the pharmacy to get the pain medication filled, and so he had to live with this for like three days before he could get there. Because he didn't have anybody to go for him. Adverse reactions? It stings. I hear that all the time. Well, I didn't like to take it because it really stung. Or you know, they're maybe they're in denial. They really don't think it's going to be that bad. Or depression where they can't, they don't have the energy to do something for themselves. And then, you know, what prevents a patient from following the treatment plan that you've set out for them? Things that you believe that are going to help them in their condition? Well, maybe it's not their plan. Is it a physical issue? And they physically do it. We had one patient who was prescribed drops, but he also had a neurological condition where he didn't have the strength to actually get the drops in his eyes. And he was also a kind of a tactic, and he was having difficulty. So it was a physical issue. Is it a cognitive issue? Are they remembering? Are they able to remember? Again, the financial issue is that they can't afford the recommendations. And then we also had one patient that I was called down to do a mini-status exam on because the doc didn't believe that the patient was remembering. He thought they had some memory issues. And even though the patient insists that he was taking the drops just like they were prescribed, he didn't think that he was really remembering correctly. Well, the patient was sharp as a tack. And I believe that he really was. I just think they weren't working for him. So agreeing on the treatment plan with the patient so that your agenda and their agenda kind of are in alignment. One of the great things that help kind of also cut down on clinic time is that what else technique? You know, just when they're listing their complaints or their reasons why they're not sure if the plan's going to work or questions, asking, what else? So then they're kind of searching their memories. Is there anything else? Is there anything else? So that, you know, after they leave your office and they think, oh yeah, well I know why I can't do that. They don't come up with it then, right? So it just kind of saves a little bit of time, what else? So the components of a difficult encounter, you know, we talked about the difficult patient. There's one part of this whole, you know, triangle. There's also the situational issues that make it a difficult encounter and also the physician characteristics that make it a difficult encounter. So as far as situational, maybe it's language and literacy or the understanding. Having multiple people in the exam room, it gets confusing. Being able to, you know, attend both the patient and you when there's other things going on in the room is kind of difficult. Breaking the bad news, that makes it a bad difficult situation. And just having them, by the time they get into the exam room, if it's been a long way to the backed up clinic, that can also make it a difficult situation. Physician characteristics, if you're overly tired or already harried, are angry and defensive. Not from that particular patient, but just coming from somebody else, maybe, or whatever. And of course, this does happen. We do have physicians that are dogmatic or a little arrogant. So changing the way that we see the difficult patients will also help us to interact with them differently. And once you interact with somebody differently, it has to change the way that they return the interactions. So just being aware that sometimes the patient's angry or their anger, their angry behavior, underline that is really fear. Fear is the primary emotion there. Anger is a secondary emotion. Having lots of appointments or calls, you know, the person that's a little bit anxious, seeing them instead as being more actively engaged in their own treatment and their own health care, a different way of looking at it, having many complaints, lots of severe symptoms, seeing that patient as maybe your challenge, you know, that's going to really test your skills. You know, this is going to be the one that might be a little bit more interesting because it's going to take a little bit of research. And then, you know, the people that come in with chronic pain or they're having to have painful procedures, asking about their chronic pain or history or asking about, you know, if they do have a lower pain threshold, kind of it tells the patient that you are aware and caring. It also, you know, lets you know that you may have to really prepare this patient if this is something that's a little bit painful or if there's any numbing drops or something like that that you could use. Chronic pain, they're taking lots of pain medications. It's lowering their production of endorphins. They're not dealing with pain as well. So using distraction, being extra solicitous, are you doing OK? How are you doing now? Breathing. Having the patient match your breathing patterns, slowing it down will keep them from getting super anxious during super painful procedures and then using a little humor where appropriate helps a lot. Working with the fearful patient, again, that distraction, very helpful. You know, talk about the patient's hobbies or things that might, you know, interest the patient, kind of break that fear, give them out of that. They can't hold two things in their mind at once, right? How are you doing? How are you feeling? Talking through what's happening step by step. Breathe again, auto-blase, slowly so that the patient can match that. Again, that extra solicitousness that you need to have there. And again, a humor. Humor works with so many things. Working with the angry patient. We'll look for the signs, so they might not be cussing at you, but you get the facial expression or the short, curt answers, things like that. Things that might tip you off that this is kind of a person that's kind of angry first of all, showing empathy, keeping your cool, remembering that don't take it personally. You know, even saying, you know, you look angry. Because there's something that we can do to that, keeping your cool, even though you're faced with a confronting kind of person. Again, I cannot emphasize breathing enough. During the day, just start to breathe so shallowly. We need to take that deep breath every now and then. It gives us that extra beat to kind of pull ourselves together. Make your voice calm. Soften your tone a little bit. Be a little bit quieter than the patient's tone. Brings it down. Validate them. It doesn't mean you have to agree, but just saying, I see that you're angry. I hear that you're angry. I can understand why you were very upset about long wait times or whatever it is. Don't ignore or belittle their emotions. That only makes it worse. Explore their values. So, for example, if they're angry about something, that's something that they really care about. You know, help, a big thing, right? I'm asking, what do you want? How can I, what are you wanting from this encounter? Tone is everything. If you're going to ask, what do you want? You can say, what do you want? Totally wrong tone. What is it that you want? What do you want from this? Different meaning entirely. Avoid the blaming or what even might feel like blame. Avoid threatening postures. Take a step back from them. If they're seated, sit down. Don't stand with somebody seated. Even if they're standing, if you sit down, it's a less threatening thing. All of a sudden, they feel like, okay, I'm not being threatened here. And then sitting to the side rather than straight on, which is a confrontational kind of position. Creating that open space, you know, keeping no barriers in between you so it's not like a desk or something that would signify authority kind of thing. So, and then use your active listening skills. So there's two kinds of listening. There's mindful listening and there's active listening. And mindful listening, we're going to do a little exercise. So I want you to turn to the person next to you and the first person is going to talk for two minutes and it can be about anything, an issue that bothers you, something you're passionate about, just how you feel about having to get up at 7 a.m. in the morning and be here. And the other person is going to just listen, okay? After two minutes, I want the listener then to just reflect back what they've heard. That's all. If your mind, as the listener, if your mind wanders, just bring it back. But the whole point is to just really attend to what your speaker is saying. Okay, two minutes. Go ahead. So, wrap it up a little bit. Now for one minute, I want the listener to reflect back to the speaker what they've said. Go ahead. Okay, so just kind of wrap it up, okay? So now I want the listener to reflect back what they just heard. Go ahead. Okay. What was that like? Was it hard just to pay attention to listen? To find yourself kind of thinking about what you were going to talk about or did you find yourself wanting to get clarification or go more in depth and as a listener to try to ask questions or things like that? Exactly. Mindful listening is all about just listening. That's it, which is simple. Active listening is sometimes a little bit easier and especially, you know, because of your training. Because you're training to probe, right? Well, that's more of the active listening. You're still giving your full attention and you're still going to be summarizing what you've heard, but you're probing for deeper meaning. So as you're reflecting, you know, did I get that right? You know, did I miss anything, that kind of thing? So the difference? Let's just do one minute, okay? Let's just do one minute. Let's do it again, pick something new. And for one minute, speaker, talk about an issue, listener is going to be active listening this time. You're going to summarize, ask for clarification and then switch, and you know, did I get that right? Did I miss anything? Is there something more? And then just go ahead and switch when you're done. So speaker, go ahead. If you haven't switched, go ahead and switch. Go ahead and wrap it up. What did that feel to be the speaker? Did you feel heard? How did it feel to be the listener? Was it easier to be able to listen? How did that feel to be the speaker? Did you feel heard? How did it feel to be the listener? Was it easier to be able to get this feedback and clarify and all of those things that are much easier, isn't it? You know, mindfulness sounds so easy, but it's not necessarily. It does take practice. I guess that's why we call it a mindfulness practice, right? Active listening really will help for the patient also to feel heard. So one of the other things is, you know, our nonverbals, actually about 93% of the information that we receive are coming from nonverbals. This makes it difficult when you are a person with visual impairment or blindness, especially if, you know, the blindness has happened later in life, adventitiously, we're used to getting a lot of the information. So they become hyper-vigilant to the tone of your voice, to the meter of your voice, things like that. So just as an awareness, but keeping that open posture, you know, don't cross your arms, what are you telling them, lean forward, you know, making eye contact even though they might not be able to see you. You know you are. The feeling is there, they're picking up on the tone and everything else. So to do exactly what you would be doing to someone who is fully sighted, do that to the person who is blind, they pick up on the same cues, even though they're nonverbal, they're picking up on it. Empathize with people. This was really interesting. There was a study that was done and they were asking physicians about, you know, empathy and being able to empathize with their patient verbally and they said, well, you know, I don't have time to do that, you know, or I don't know how. But what they found was that patients, and I want to get this right so I'm going to read this, in this study by Levinson and his associates, when discussing life-threatening diagnosis, the patients were offering many opportunities for an empathetic response. The doctors only responded 10% of the time. And it didn't take a lot of time. When the empathy was not provided, the patient again offered another opportunity for the doctor to empathize. And they kept doing that, it's like, oh, he's not getting it. So they keep offering these opportunities for the empathy. So when the empathy was provided, the patients ranged responses, ranged from one to two words up to one sentence. They felt heard and they were done. Took less time. So that empathy. So offering reassurance to somebody, you know, even if you can't assure a good outcome, the reassurance that, you know, we're going to watch this very carefully. I'm here with you. We're going to get through this together. Those kind of reassurances that you're with them, you're available, you care. That goes a long way as well. In bringing down some of the fears and the anxiety about it. And then knowing yourself, recognizing your own warning signs when you feel like your buttons are being pushed. You know, we are human. We have buttons. Sometimes they get pushed. So the feelings are your first clue that your buttons are being pushed. So examining your pattern of response. Okay, what is it about this that's pushing my button? Why am I feeling this way? Most of the patients that you find frustrating to deal with have a great deal of adversity in their own lives. They've got so much going on. It's their stuff. It's not yours. So when you feel like your button is being pushed, think about it. Okay, who's is this anyway? Maybe it's theirs, not yours. What their expectations are of the visit. Where is that coming from? Being clear to set your own expectations, your own boundaries, and sticking to them. And being aware of that transference, that misplaced strong emotion that you might be feeling. So to avoid overreacting. You attend to the patient after you first attended to yourself. If you feel yourself coming up with some kind of an emotion. In that interaction, check in first. Then check with the patient. Identify the issue, the problem that's supposed to be addressed right there. Acknowledging again the patient's feelings. Allows them to know, okay, he gets it. They don't have to keep giving you those cues again. And then, you know, identifying, is there something in particular that you're angry about? Or are you just feeling really kind of angry in general? Sometimes they're just angry at the situation. Not you. And that kind of helps to also not take it personally when you feel like it's just a matter of help. I think it's very helpful to ask the patient, what is it that you're asking me to do? Sometimes when it's not very clear, sometimes it's like they'll talk in a circle. And then being able to say, this is what I will do. This is what I won't do. And those are the boundaries. And then also, you know, specifying who's going to do what. Okay, so this is what I'm going to do. And then in return, you're going to make sure that you take this three times a day or whatever it is, and you're going to return in the clinic in one week, those kind of things. So everybody is this, this is what I'm doing. This is what you're doing. This is what I will do. This is what I won't do. And why? Those are boundaries. And boundaries can be, you name what your limits are, and they can be given gently. They don't have to be, you know, there's no way I'm going to do that. It doesn't have to be confronted. It's like, I'm sorry, I won't do that. Or I can't do that. I won't do that. Whatever it is. Call it what it is. And, you know, most people have a hard time setting boundaries because they don't think that it's polite, you know? So that it can be delivered very politely. And you have to give yourself permission to have boundaries. It's a sign of a healthy relationship to have some boundaries. So in some of the communication, like we did in our active listening exercise, what I hear from you is, did I get that right? You know? A lot of times, you know, calling it what it is. How do you feel about the care you're getting from me? Sometimes I don't feel like we work well together. That's not a statement of blame on either part. It's this interaction. You know, in every relationship, there's really three people. You, the other person, and the relationship. So sometimes it's just that we don't work well together. Nobody's fault. This, it's difficult for me to listen to you when you use that kind of language. I was actually in clinic with one of our ophthalmologists. The patient was very upset. And using, you know, some pretty strong language. And he used this exact phrase, she calmed right down. So, and she was able to then express her anger, watching her language, which made it easier for him to listen to her about what was going on. Can you help me understand what's going on with you right now? And then asking for what their understanding is of what's going on. It could be totally different than what you think. And then sometimes, you know, when we just don't have anything, it's like, I wish I or a medical miracle could fix this for you. Goes a long way. And then again, self-care. We've been hearing a lot about this with the whole wellness initiative that's going on. It's not self-indulgent, it's not selfish. We can't nurture others if we don't have anything to nurture them with. We have to take care of ourselves. So making sure that we are getting what we need as well. That's also one of those boundary settings of, I need this, I need some self-care time. So, of course, my references. And thank you. Thank you for coming out early and listening. Is there any questions or anything else? Thank you. OK, you know, and I'm always here if you just kind of need to process a difficult interaction or, you know, something that came up that you weren't expecting, little feelings about that patient. I'm here. Thanks for coming out early.