Groves (1951)Groves (1951)

Defined 4 categories of Defined 4 categories of difficult patientdifficult patient

1. Dependent clinger1. Dependent clinger

Express excessive gratitude for doctor’s actions

Seek regular reassurance over minor problems

2. Entitled demander2. Entitled demander

Frequently complains about imagined shortcomings in service

3. Manipulative help rejector3. Manipulative help rejector

Presents a series of symptoms doctor is powerless to improve

4. Self destructive denier4. Self destructive denier

Patient refuses to accept his behaviour affecting his disease

Will not modify self-harming habit

An approach to theAn approach to theDifficult relationshipDifficult relationship

AcknowledgeAcknowledge

1. Engagement

Review Whether you ‘engaged’ properly with the patient at the beginning of consultation

AcknowledgeAcknowledge

2. Empathy

Make sure the patient knows he or she has been seen, heard and understood

AcknowledgeAcknowledge

3. Education

Provide patient with enough information to understand what you are advising

AcknowledgeAcknowledge

4. Enlisted

Motivate patient to accept your advice

Rebuild relationshipRebuild relationship

1. Shave the relationship difficulty by verbalising it

e.g. “ I’m finding it difficult to help you

because…….”

Rebuild relationshipRebuild relationship

2. Build a partnership

e.g. “ How do you feel about that? Can you

think of ways you can help me help

you? Is there something I can do to

help us work together better? ”

BoundariesBoundaries

1. Define you boundaries and seek patient’s acknowledgement and agreement to them

e.g. “ Mrs. Smith, I’ve made a list of the eight things.

You’re asked me to deal with today, but you did

not book a long consultation. I think we can deal

with three today in the time we have, would you

like to say which three you’d like me to deal with

today and which can be deferred to tomorrow? “

BoundariesBoundaries

2. Temporal

How much time you are prepared to give.

CompassionCompassion

1. Empathy

Acknowledge the patient’s education and make sure he or she knows you see

Determine the meaningDetermine the meaning

People do things for a reasonEvery patient comes with a pre-set belief

about what could be the problem and what might be the solution

Find out what they are thinking

1. Miss Wong, aged 20, is living with her son

(4 years old). She has no remarkable past

medical history. She works in a karaoke bar. She requests some tests on her liver as her ex-boyfriend died of “liver disease” recently.

How would you conduct this consultation?

2. Mrs. Chan is now aged 49. She divorced his husband 4 years ago. She recently

heard about hormonal replacement therapy in the media and requested this treatment from you. After physical examination and investigation, you found she was fit for HRT. Six months later, Mrs. Chan was admitted into hospital with myocardial infarction. Shortly afterwards her son Paul came to see you. He alleged that the HRT caused her mother’s heart attack.

How would you interview with him.

3. Mr. Wong, aged 45 and a construction site labourer, complained of persistent low back pain for 2 months. He alleged this to a fall at work 3 months ago when he was hit by a pile of stacked timber. He was pursuing compensation for negligence against his employers. He had no abnormal physical signs and X-rays of his lumber spine have been normal. He denied any unhappiness and worries apart from the unbearable pain at work. He has consulted other doctors without relief. He then requested a sick leave certificate for a month as he did not think he can work, and no treatment other than rest could help him.

3. What would you do?

Knowing that you are not going to give him a long sick leave, Mr. Wong bursts into foul languages and wares his arm in front of you while demanding his request again.

What do you do next?

X..Y.#..@..%!-X..Y.#..@..%!-Z..@>>>?!!Z..@>>>?!!

What is angerWhat is anger

A person’s emotional response to provocation of to a threat to his or her equilibrium

Manifestation of a deeper fear and hidden insecurity

Guidelines for handling angry patientGuidelines for handling angry patient

Do Listen Be calm : keep still and establish eye contact Ask patient to sit down Address patient Be comfortable Show interest and concern Use clear and firm language Be sincere Allow patient to ventilate feelings Arrange follow up

Guidelines for handling angry patientGuidelines for handling angry patient

Don’tTouch the patientMeet anger with angerReject the patientBe over familiarTalk too muchBe judgmental

Questions in the interviewQuestions in the interview

Rapport building

‘ I can appreciate how you feel ‘‘ it concerns me that you feel so strongly

about this ‘‘ tell me how I can make it easier for you ‘

Questions in the interviewQuestions in the interview

Confrontation

‘ you seem very angry ‘‘ it’s unlike you to be like this ‘‘ I get the feeling that you are upset with

…’‘ what is it that is upsetting you? ‘

Questions in the interviewQuestions in the interview

Facilitation , Clarification

‘ so you feel that………. ‘‘ you seem to be telling me…….. ‘‘ if I understand you correctly……….. ‘‘ tell me more about this…………. ‘

Questions in the interviewQuestions in the interview

Searching

‘ do you have any special concerns about

your health? ‘‘ do you relate to anyone who has a proble

m

like yours? ‘