What are the doctor & patient barriers to effective consultation ?
Examples of doctor factors
•Lack of time (real or perceived)
•Inadequate clinical information (lost notes, computer meltdown).
•Inadequate clinical skills.
•Inadequate communication skills: eg. talking too much, using too many closed questions, not responding to patient’s agenda, inability to understand and communicate with people from different cultures and backgrounds.
•Attitudinal problems: boredom, lack of interest in psycho-social aspects of illness, burn-out, stress, fatigue, mental illness, prejudice and discrimination, difficulty handling strong emotions or accepting failure: difficulty coping with threats to competence.
•Poor recovery from previous stressful consultation or life events.
•Artificial stimulants.
Examples of patient factors
•Lack of time (real or perceived)
•Fear (of doctors, pain and dying)
•Lack of understanding of basic biology and probability.
•Unscientific health beliefs.
•Unrealistic expectations of the health service.
•Unrealistic expectations of medical science.
•Inadequate communication skills (over/under assertiveness, inability to speak English).
•Aggressive attitude.
•Mental illness.
•Artificial stimulants.
---------------------------------------------------------------------------------------------------------------------------------
Patient dependency...or is it doctor dependency?
How and why do patients become dependent?
Consider
•The patient's role
◦Why are patients reliant on their doctor? Consider positive and negative aspects to this.
◦Emotional attachment to the doctor
•The doctor's role
◦Why do doctors "need" patients? Where does this need come from?#
◦Emotional attachment to the patient
•The role of family and friends
•Societal influences
Other issues to consider
•"Doctor shopping"
•Dependency on medication eg analgesics
•The "analgesic headache"
•The "quiet prescription"
•The role of complementary therapy
•Making the wrong diagnosis (or even a very clever diagnosis)
•Trust
Responding to dependency
•Recognising that it is happening
◦Regular appointments for minor illness or minor trauma
◦Regular appointments with little content or repeated content. So why is the patient here?
◦The patient won't see another doctor, or presents with problems more logically dealt with by the nurse
◦Refusal to terminate treatment
◦Gifts
◦Inappropriate positive feedback
◦Collusion (see Balint)
◦No faith in external advice eg specialist advice
◦Genuine symptoms without any identifiable pathology or aetiology despite extensive examination and investigations.
Addressing the issue
◦Self awareness for the doctor
◾Where are your feelings coming from? Are you stuck in the comfort zone? In denial? "Why do I look forward to seeing this patient?" "Why do I dread seeing Mr X?" "Why do I mind if this patient likes me?" "Why do I feel good after seeing this patient?"
◾ Emotional intelligence
◾ Mindfulness
◾Support – mentoring/co-mentoring
◾Parent-child transactions - transactional analysis
◦Flagging up the problem
◾Defining the observed behaviour in a factual, non-judgmental way - "I have noticed that..."
◾Exploring the reasons behind the behaviour
◾Negotiating - "I wonder if..." "perhaps..."
◦Moving forward◾Sharing responsibility with the patient for the problem (this may have to start with the doctor accepting some responsibility first)
◾Ideas, concerns and expectations
◾Psychodynamic thinking
◾Motivational interviewing
◾Narrative based medicine
◾Spotting sabotage attempts
◾Patient-centred feelings-based communication, moving from passive, doctor-centred care to active patient-centred care
•Preventing dependency
Planning and agreeing specific goals and if possible a timeframe
◦Identifying what is possible and what is unrealistic
◦Keeping adult-adult, avoiding parent child and the child hook
Manipulative patients?
Identifying manipulative patients
•Applying guilt / transference
•Being anxious / chaotic
•Urgent important
•Threat of harm to patient
•A story that doesn't fit together
•Analgesic use
•Variable behaviour
•Dysinformation / non-information
Behavioural strategies that manipulative patients use
Manipulative patients?
The term "manipulative" is highly charged and in some cases quite pejorative. Of course, there are patients who truly fit the description of manipulative: i.e., they intentionally exploit the position, needs, unconscious fears or weaknesses of others in a calculated attempt to gratify their own needs or wishes, usually without concern for the social consequences or the feelings of others.
The problem is that this description may apply to anyone from a successful CEO to a patient with borderline personality disorder to a "street person" in a third-world country, trying to survive starvation. What we call manipulative, in other words, may have more to do with our own feelings of being "used" than to any specific diagnostic designation. For example, one study (Lewis & Appleby, British Journal of Psychiatry, July 1988; see comment in Feb. 1989 issue) found that when psychiatrists were asked to read a case vignette and indicate their attitudes toward the patient, the patients given a previous diagnosis of personality disorder were seen as less deserving of care than patients with similar vignettes who had not been so labelled. This often happens as soon as the term "borderline" is used to describe a patient.
On the other hand, there is no question that some patients with antisocial, narcissistic or borderline personality disorder are manipulative in extremely destructive ways. For example, BPD patients may use the threat of suicide to control, paralyze, or punish others, often related to transference reactions toward staff. For guidelines on how to deal with this, see the article by M.H. Stone, American Journal of Psychotherapy, Spring 1993. You may also want to see the paper on counter-transference hate by Maltsberger & Buie (Archives of General Psychiatry, May 1974) and on a more practical note, the book Treating Difficult Personality Disorders by M. Rosenbluth and I. Yalom.
In short, you won't need to learn how to detect the manipulative patient - he or she will detect you! The real issue is how to deal with your own reaction once you realise you are being manipulated.
Some manipulative behavioural strategies
1. [The Most Famous]
"There's only one pain medicine that works for me; begins with a "D", Duh . .Dem . . .Demerol!"
2. ["You're So Great!"]
"---I remember you! You took care of me before . . . You're the BEST nurse . . .---Not like that other one that was so MEAN and made me wait hours for some pain medicine!"
3. [Any Drug Allergies?]
"I'm allergic to ALL pain medicines EXCEPT Dilaudid."
4. ["I really have disease"]
"I'm here from out of town (thousands of miles away). And, I've just gotten an attack of {chest pain, kidney stones, my rare disease], I'm having terrible pain. I just happen to have a copy of my {chart, X-rays, doctor's letter} with me . . . No, I don't have a copy of the cath report . . . ---I forget where that was done!"
5. [Allergies to Alternative Agents]
"My allergies are Codeine, Toradol™, Darvon™, Aspirin and NSAIDs, ALL psych meds; ---Percodan™'s OK! {Five days after the release to market of Toradol™ occured the first probably spurious claim to me of "allergy" to the new drug.}
6. [Uniquely Tolerant]
"I have a 'high tolerance to pain medicines' ---That's NOT enough; I'm going to need at least 150 mgms of Demerol™ and 75mgms of Vistaril™! {Last reported episode of pain six months ago
7. ["Your Golden Opportunity"]
"Why, yes, I am the Executive Producer for The Rolling Stones, a really big Hollywood Movie Director, International Financier, Grand Vizier for Ali Pasha, etc., and I know all those other famous people, and can get you a fabulous travelling job as personal Nurse to so-and-so. Here's my card. I want you to come see me after the end of the month when I get back to Monaco and I'll take you all around in my personal 150' yacht . . . Oh, yes, you can bring a couple of friends, too. I'm just so grateful to you for helping me out."
8. ["The Stone Soup Method:"]
"Oh, good, that's beginning to feel a little better, Thank You! . . . Say, do you think you could get me a couple of extra pillows, ---and, ---and, some warm blankets? This bed is so hard. I know that it's not your fault. That's great. Thank You. Gee, I really haven't eaten . . . Do you think that you could find a little something to eat. That would be great. Maybe, some turkey and some nice soup . . . Yes, thank you so much. And, could you just turn off the light as you go? Do you have a TV here or anything? Say, by the way, . . .
9. [Contentious]
"Say, WHO does that doctor think he is? ---Saying that he can't give me any pain medicine unless he can diagnose a treatable disease! He's a Quack! He's no REAL doctor . . . ---I've been to all the best doctors there are! You can't get away with this! I want a phone to call my lawyer RIGHT NOW! I'm gonna sue Your Ass! You're never gonna work again! I want your NAMES! ---And I want your Supervisor, RIGHT NOW!
10. ["The 'Rush' Act":]
"You don't have to give it that slow! ---Just push it right in!"
11. ["Sarah Bernhard:"]
When surreptitiously observed, patient appears comfortable or resting, yet when patient knows himself to be watched there is a histrionic display of writhing and moaning and grimmacing; effort is put forth only when secondary benefits may be gained.
12. ["The Dying Swan":]
The patient who has somehow gotten in the car that has brought him {usually with "excruciating" back pain} now professes to be entirely incapable of self-movement to extricate himself to the awaiting gurney. Often compounded with a "flop act" when trying to undress the patient for monitoring and examination which appears without evidence for recognizable neuromuscular disease. Seemingly without gumption to resist or overcome the influence of any actual disease.
13. ["Pseudo-Collapse":]
For a dramatic entrance, or to forestall unwanted discharge, the malingerer goes to a public area (with witnesses) and ostentatiously crumples to the floor and begs for help. No injury has occurred in the "Hollywood Fall".
14. [The False Swoon & "The Drop Test':]
The malingered loss of consciousness has inconsistent or self-beneficial findings to the exam, such as the "victim's" hand and arm, seemingly flaccid, when elevated and dropped over the face defies gravity and cannot fall upon the victim in injurious fashion, but falls gracefully aside. Resistance to eye-opening, lack of Lash reflexes, and breath-holding during administration of Aromatic Spirits of Ammonia, are not normal responses.
[Another Tip-Off Phrase:] "None of the Doctors has ever been able to give me a diagnosis or to fix it. I've been to Doctor after Doctor; it's always the same. I want you to tell me what's wrong."
Strategies for tackling the issue
•Being proactive - preparation
•Listening
•Sticking to the agreed agenda
• Assertiveness
•Negotiation
•Creating a (written) contract
•Sharing responsibility
•Giving responsibility back
•Clear records and plan
•Adult-adult - feeding back behaviour
•Stop transference
•Non-judgmental
•Motivation cycle
•Explanation
•Active follow-up
-------------------------------------------------------------------------------------------------------------------------------------
Problem patients in general practice:
the "loader"
This sort of patient has a thick record file, often detailing numerous negative investigations, but may have many past physical health problems which are time-served. She has been to many other doctors in the past, but no-one has been able to "help" her. She spends 30 minutes or more pouring out her story to you (she has rehearsed this many times before with others) and then says "I defy you to sort that lot out, doctor".
Listening
You probably have to listen to this patient's story right through, so that she feels understood. Watch for non-verbal minimal cues and keywords during her story, which may give clues to the most important issues for her. If you start hearing the same story repeated, you have probably had it all: politely interrupt by a non-verbal movement and an empathic comment, perhaps.
Feelings
While you are listening to the story, how do YOU feel? It is likely that these feelings are reflected from the patient. Note them mentally, as they will be useful later.
The agenda
You need to define a common agenda with the patient. What are her aims? Are they realistic? Match up your agenda with the patient's - and make this agenda explicit. Set out a contract with the patient, detailing what you plan to do together to achieve these aims. The contract must include the use of time, and the fact that the patient is going to solve her problems, not you - you are just a catalyst. Then empower the patient to take the control within this framework.
Prioritise problems
Get the patient to list the problems - this can be done as homework - then determine with her which is the most important for her, so that you can tackle that problem first. It may not be the most important problem as far as you are concerned, but let the patient have the control: She may want to test you out with a secondary problem first. It is sometimes helpful to use a graphical symbolic representation, eg: Draw a flower, and put a problem in each of the flower's petals. Then pick the petals off, one at a time, in the order the patient chooses.
Tackling the problem
Summarise the patient's chosen problem, using words which she has used, to check out that you are talking about the same thing. Empathise, using those feelings which you noticed while she was telling her story. Allow her to express her own feelings, then explore these feelings to allow the patient to define the possible solutions to the problem. Keep in your mind these questions:
•What's the problem?
•Why is it a problem?
Avoid being sidetracked, unless the new topic becomes more important (but don't forget to go back to the other topic later). Remember that jumping to another topic may be the patient's conscious or subconscious way of avoiding a difficult or painful issue. Give the patient time to devise her own realistic solutions (homework again), in conjunction with other people who are involved, if appropriate. She can then put the plan which she has devised into action, and you can then tackle the next problem together.
The problems
There are three sorts of problem:
1.The problem which is solvable by some specific action.
2.The problem which will solve itself with the passage of time.
3.The insoluble problem, which the patient must accept and come to terms with.
Which category does the problem fit into? This will determine the most appropriate course of action.
When it gets stuck
...Which does happen, remember those keywords, and feed them back to the patient. What about those minimal cues - "You looked very sad when you were talking about your father..." - and the use of silence? It could be that you and the patient are on different wavelengths, so check this out by summarising.
Transactional analysis
The patient feels helpless like a Child, and you are the Parent who will solve all her problems. Instead of responding in this way, speak to her as an Adult to an Adult: She will find this difficult at first, but persevere, allowing her to take control of the consultation in an Adult way.
Don't rush it
Go at the patient's pace, not yours. Let the patient do the work, don't give her your answers to her problems. A satisfactory outcome may take several sessions, or sometimes even years, but you can achieve this during ordinary 10-minute consultations. She would be coming to see you anyway, so using this model you are at least using the time constructively. And don't give up! You will find that often everything suddenly all seems to fall into place!
Remember
Let the patient do the talking. Listening is an active process - use your eyes and your feelings as well as your ears. Don't be afraid of silence: Watch for those eye movements which show internal dialogue, and don't interrupt it! Those eyes will move before the patient starts speaking again, so turn your ears back on - she may well talk very quietly, and what she says may well be very important. Spot those keywords - "angry", "depressed" - remember them and feed them back for clarification - "you said that you felt very angry about...". The patient is most likely to do "homework" if you give her a piece of paper with the headings on which you have agreed with her - "advantages of.../disadvantages of..." - headed practice paper seems to work best.
Take a walk
After these consultations you will feel shattered. If you do not come to terms with the feelings which are still in your head, they will affect the next consultation, so the next patient might get a bad deal. So, even if you are running late, put the kettle on, unload your feelings onto the practice manager, or take a breath of fresh air. The rest of your surgery will run much more smoothly as a result.