Helping physicians manage challenging patient encounters.

O26 In today's rapidly changing and challenging health care environment, where physicians have limited time with patients who have become more knowledgeable and demanding, the relationship between physician and patient has extra stresses placed on it. Medical malpractice litigation has increased as the physician-patient relationship has become more complex because of those stresses. In this article, some of the problems and effects of poor physician-patient interaction are explored, and a program designed to develop existing physician skills for successfully interacting with challenging patient encounters is described. in the January-February 1991 issue of Physician Executive, the author will describe the method of implementing the program in an organization.

There is a growing need to provide physicians with opportunities for developing and refining the skills necessary to achieve mutually satisfying outcomes for themselves, their patients, and the organizations in which they work. That need is being driven not only by physicians who want to optimize their quality of work life, but also by today's environment of closer scrutiny of the quality and cost of health care.

Any physician can provide examples of particularly difficult or challenging interactions with patients. The definition used here refers to a challenging patient encounter: the interpersonal relationship between physician and patient that requires something extra from the physician to enhance both physician and patient outcomes. It does not solely or specifically refer to a technically challenging patient, although there can be a close correlation between a technically challenging patient and a challenging patient encounter. For whatever reason, when the interaction is not handled well, a challenging patient encounter can lead to a poor physician-patient relationship and, at times, costly consequences.

Some examples of challenging patients include controlling patients, hostile patients, patients abandoned by another member of the medical staff (or by another department), patients who come in for specified medical reasons but have other agendas, and patients who have negative interactions with ancillary staff prior to seeing their physicians. A patient may also be challenging because of the patient's idiosyncracies, the attitudes of the physician, an organization or system difficulty, or some combination of these factors. One of the ironies of dealing with challenging patient encounters is that, everything else being equal, a patient is more likely to pursue litigation against a technically "superior" physician for technical malpractice compared with a physician who possesses merely "adequate" skills if the technically superior physician fails to develop good rapport and a trusting relationship with the patient, and the "adequate" physician does.(11)

Problems and impacts When a challenging patient encounter is not handled well, there are negative consequences for the patient, the physician, and the physician executive.(1-11) For example, patients are more likely to become aggressive and hostile; they may refuse to see a particular physician again; and there is generally lower compliance or a rejection of advice. In addition, patients are much more inclined to write letters of complaint; they contribute to negative word-of-mouth publicity about physicians and the organization; they are less likely to obtain adequate or correct information from physicians; and they are more likely to pursue malpractice litigation. Physicians are also the recipients of increased patient complaints and litigation, and there is greater likelihood of missed or incorrect diagnoses. They experience increased stress and frustration and lowered quality of work life, and they are more apt to miss opportunities to relieve anxiety and depression, which are often the cause of physical illness. Unsuccessful interactions with patients are also likely to contribute to negative impacts on relationships with department chiefs of service, medical directors, colleagues, nursing staff, and other patients, as well as bad reputations both for the individual physician and the organization. In an HMO setting, there is an increase in the number of follow-up telephone calls and patient visits, which clogs the system. In a fee-for-service environment, the patient is less likely to continue with the physician, resulting in a direct loss of revenue. Physicians also report negative impacts on family/personal life.(12)

Physician executives experience extra work, stress, and the frustration of dealing with colleagues who are complained about by patients. They must contend with increased patient complaints and litigation, as well as a resultant loss of revenue. In addition, greater physician stress and frustration may lead to bum out and/or physicians leaving the organization, resulting in replacement issues and costs with which the physician executive must directly contend.

A Management Program

There is generally a continuum or mixture of physician skill levels for successfully interacting with patients. Some physicians seem to always do an excellent job.

Others do so most of the time (unless there is an unusual amount of personal or departmental work pressure), and some have a difficult time successfully interacting with patients in a large number of their patient encounters. A successful approach to these problems has been a dynamic and interactive program that helps physicians learn how to more successfully deal with challenging patient encounters. A primary goal of such a program is to improve the skill levels of those with the lowest abilities, to help ensure that those who do a good job most of the time cope successfully more regularly and easily, and to provide an environment where those who almost always do a great job can hone dieir skills and share them with their colleagues. Program Approach In setting up such a program, experience has shown the importance of building four concepts into the overall approach.

* There is no single "right way" in all

circumstances for interacting with a

patient.

* There is no outside expert who has all

the answers specific to the circumstances

of unique departments and organizational

settings. Rather, effective

and useful learning takes place through a mutually supportive learning process and an open sharing of ideas among the unique group of individuals at each specific program. Hence emphasis is put on expert guidance and facilitation to enhance a co-discovery/ learning process that is most effective in groups of 10 to 15 participants. Readings from professional medical and related journals are used to complement discussion, role-playing, videotapes, and feedback.) * While the program is concerned with a serious and important aspect of the practice of medicine, appropriate use of humor in role-playing and discussions can contribute to a more enjoyable and worthwhile program for all participants. * The use of a skilled facilitator who is objective and apolitical and who doesn't carry departmental "baggage" will contribute significantly to the development of existing physician skills for attaining mutually satisfying outcomes with patients.

The facilitator plays a key role in helping to create an open and mutually supportive environment for physicians to talk about themselves and each other. A good facilitator will work closely with you in the design, implementation, and follow-up plans of a program. A few interviews should be conducted with physicians prior to the start of a program. The facilitator should have the ability and the willingness to change tactics or approach if necessary to meet your organization's needs, to help maintain enthusiasm among participants, and, where appropriate, to use humor to deal with an otherwise very serious topic. For a complete list of skills needed by a facilitator, see box on page 28.)

Program Objectives

The success or failure of an interactional program of this type is often determined by how well key objectives are defined. They must be broad enough to encourage participation by generalists and specialists who, while having some common ground, can often be quite diverse in their needs and approaches. While broad, these objectives must also be focused and specific to the unique characteristics of the overall organization. Finally, in order to generate a feeling of accomplishment in participants, not to mention justifying the cost of such a program, objectives must be measurable. Some of the generic objectives that should be included in this type of program are to: * Understand the physician's and the patient's

perspective in the physician patient

relationship to enhance awareness

of both the physician's role in

quality of service and the changing

values and expectations of today's

patients. * Understand what patient characteristics

"push physicians' buttons." * Understand how the physician's values,

attitudes, and behavior affect the

relationship with patients. * Demonstrate strategies in challenging

patient encounters that promote a mu - tually satisfying relationship with the

patient. * Be able to successfully respond to patients

who experience organization systems problems

(for example, long waits

on the telephone, difficult time getting

an appointment, negative interaction

with receptionist/ancillary staff.) * Understand the key components of the

physician-patient interaction and how

they affect rapport between the MD

and patient. That is, to understand

how "power ... .. control ... .. influence,"

trust," and "cooperation" are affected

by the:

- Role of language use, style, tone.

- Impact of body language/nonverbal

communication" (especially important

in culturally diverse situations"').

- Sensitivities and issues associated

with particular specialties. Program Content Rapport is an essential theme that runs throughout the physician-patient relationship. Unless good rapport is established in the first 30 seconds or so, and then maintained for the duration of the interaction, the chances of a mutually satisfying relationship are markedly reduced. Consequently, it is a good idea to discuss at the beginning of a program verbal and nonverbal ways to establish and maintain rapport, as well as why and how rapport sometimes breaks down.

Closely related and of equal importance to rapport are the values, hopes, and expectations of patients, which are often sources of stress in the physician-patient relationship. Some of the most common sources of patient stress are fear of a painful procedure, fear of the illness or of a more serious illness, anger and frustration in making an appointment or dealing with receptionist/ ancillary staff, loss of privacy, fear of wasting the doctor's time with a "trivial" problem, and concern about being accepted and cared for (and not rejected) by the doctor. Thus it is essential for physicians to more effectively empathize with patients and be provided an opportunity to step into the shoes of their patients. Another area of focus is the issues that affect the physician-patient relationship as seen from the physician's perspective. Physicians generally characterize their challenges" as angry/hostile patients, patients who wait until the end of their visits to get to the main reason for the visits, noncooperative family members and/ or colleagues, noncompliant patients, patients who have no knowledge or apparent interest in their own bodies, patients who fail to give pertinent information, and conflicting patients' life-styles (values, prejudices, etc.). Reflection by physicians on their behavior and internal attitudes before and during interactions with patients can be both revealing and beneficial in that it encourages physicians to identify and prioritize the personal challenges to be addressed.

It is essential to ensure an opportunity for physicians to share their views and understand the subtleties, interconnectedness and impacts of power," "control," "influence," trust," and "cooperation" in their interactions with patients. Physicians greatly benefit from a better understanding of their preconceptions about each of these key ingredients and how they might change their attitudes and behavior about them with patients. For example, a group discussion on what kind of power a physician has, how that power differs from control or influence, and how physician power affects patient trust and cooperation can be very valuable. This discussion provides an opportunity to share reactions and ideas for effectively dealing with patients' criticisms.

Another focal point for discussion is physicians' ability to deal with anger, criticism, and stress. Physicians experience criticism from patients, staff, and colleagues that, if not handled well, can contribute to poor interactions with patients. One way to address this issue is to identify the various types of criticism that are especially difficult, challenging, and painful for individual physicians and then to discuss as a group appropriate responses.

Physicians can now discuss and analyze specific challenging patient interactions that are drawn from their own prioritized challenge list. It is useful to structure the discussion so that they define the nature of an actual problem or issue, suggest possible reasons for the problem, and consider different approaches for successful interaction.

"Physician" and "patient" role-playing for one or more possible approaches to a challenging patient encounter provides an opportunity for physicians to learn from their interventions and have the effectiveness of their approach evaluated. The goal here is to get one or more approaches out on the table for discussion so physicians can see firsthand possible additions and refinements to their patient interaction skills. Skillful facilitation during the videotaped role-plays and the group discussions that follow can ensure everyone's participation and enhance opportunities for learning.

Program Outcomes

A successfully implemented program can benefit the patient, the physician, and the organization in a number of important ways. For example, patients generally have greater satisfaction with the quality of service and care they receive. In addition, there is a greater likelihood that their actual medical outcomes will be better because of improved physician-patient communication and compliance.

Outcomes for physicians are positive in a number of important areas as well. For instance, there is generally an increase in their sense of personal control; increased satisfaction from greater patient compliance; and enhanced camaraderie, mutual understanding, and respect among colleagues. Overall, there is a decrease in physician stress and frustration, which contributes to a better quality of work life and enhanced morale.

Finally, the organization also benefits from a successful program. The day-to-day running of a facility, as well as its overall reputation, benefits from increased physician and patient satisfaction and retention of members/patients. A contribution to better physician-nursing staff relations is another outcome of an effectively implemented program.

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