How Respected Family Physicians Manage Difficult Patient Encounters
How Respected Family Physicians Manage Difficult Patient Encounters
Background: Nearly all family physicians have patients that engender a sense of frustration or dislike, often described as "difficult." Most research in this area focuses on describing these patients and their physicians, not management or coping.
Objective: To describe how respected family physicians identify, manage, and cope with difficult patient encounters.
Methods: Qualitative semi-structured interview study. Participant physicians described as "excellent" were recommended by medical school family medicine faculty around the county. Interview questions included "describe the patient you least like seeing," and "how do you keep sane but still assure adequate care for the patient?" Interviews were analyzed using the editing method, looking for common categories and themes.
Results: 102 physicians were interviewed. Physicians described both patient behaviors (stay sick and demanding) as well as medical problems (multiple, chronic pain, drug seeking, psychiatric) that they found frustrating. Difficult encounters occurred when these patient behaviors and medical problems clashed with physicians' personal and practice traits. Their management strategies to return the encounter to success incorporated collaboration, appropriate use of power and empathy.
Conclusions: We propose a model where clashes between patient behaviors and physicians' traits turn a successful encounter of collaboration, appropriate use of power and empathy into a difficult encounter of opposition, misuse of power and compassion fatigue. Management strategies used by our participants aim to return success to the encounter and may serve as a guide for practicing physicians and for future research.
For a quarter of a century, the medical literature has acknowledged that there are patients in whom a "heartsink" feeling occurs when their names show up on a physicians' schedule. Both anecdotal reports, and studies of physicians and these patients have been published. Common to the definition of these patients is "the distress they cause their doctor and the practice."
A number of studies have attempted to discover why these patients cause such distress to physicians. A complex and daunting literature has arisen, looking at physician variables such as workload, job satisfaction, and psychosocial attitudes, Freudian countertransference, patients' medical problems, and patient demographics. From these, causation models have been developed that generally contain three or four interacting components: patient characteristics, physician characteristics, the environment and relationship skills.
Studies examining physician characteristics have found that physicians with lower job satisfaction, less experience, and poorer psychosocial attitudes describe more difficult patient encounters. Fewer studies have studied how physicians actually manage difficult patients. Instead, management advice is given anecdotally or from an educational or psychological perspective.
Despite all this advice, practicing physicians lack a "best practices" method of managing difficult patient encounters. A first step in developing a "best practice" is to develop a conceptual model, based on input from stakeholders, such as physicians. Often, input from "expert" or "excellent" physicians serves as a starting place to begin this research. Respected family physicians can certainly serve as these stakeholders, and by sharing their expertise and experience, help clarify approaches to these difficult encounters.
We elected to choose practicing physicians who serve as volunteer preceptors for medical students in family medicine and described as excellent by predoctoral directors of family medicine. These physicians elect to be under constant scrutiny by students and fellow physicians. Predoctoral directors of family medicine and other faculty members receive constant feedback not just on these physicians' ability to teach, but on the quality of their medical care, as well. These preceptors are visited and observed by faculty members on an ongoing basis. The purpose of this paper is to elicit descriptions of difficult patients and their management from these respected family physicians and to develop a model to first, assist physicians in understanding and improving their difficult patient encounters and second, serve as a basis for future research to confirm the best practices for caring for such patients.
Background: Nearly all family physicians have patients that engender a sense of frustration or dislike, often described as "difficult." Most research in this area focuses on describing these patients and their physicians, not management or coping.
Objective: To describe how respected family physicians identify, manage, and cope with difficult patient encounters.
Methods: Qualitative semi-structured interview study. Participant physicians described as "excellent" were recommended by medical school family medicine faculty around the county. Interview questions included "describe the patient you least like seeing," and "how do you keep sane but still assure adequate care for the patient?" Interviews were analyzed using the editing method, looking for common categories and themes.
Results: 102 physicians were interviewed. Physicians described both patient behaviors (stay sick and demanding) as well as medical problems (multiple, chronic pain, drug seeking, psychiatric) that they found frustrating. Difficult encounters occurred when these patient behaviors and medical problems clashed with physicians' personal and practice traits. Their management strategies to return the encounter to success incorporated collaboration, appropriate use of power and empathy.
Conclusions: We propose a model where clashes between patient behaviors and physicians' traits turn a successful encounter of collaboration, appropriate use of power and empathy into a difficult encounter of opposition, misuse of power and compassion fatigue. Management strategies used by our participants aim to return success to the encounter and may serve as a guide for practicing physicians and for future research.
For a quarter of a century, the medical literature has acknowledged that there are patients in whom a "heartsink" feeling occurs when their names show up on a physicians' schedule. Both anecdotal reports, and studies of physicians and these patients have been published. Common to the definition of these patients is "the distress they cause their doctor and the practice."
A number of studies have attempted to discover why these patients cause such distress to physicians. A complex and daunting literature has arisen, looking at physician variables such as workload, job satisfaction, and psychosocial attitudes, Freudian countertransference, patients' medical problems, and patient demographics. From these, causation models have been developed that generally contain three or four interacting components: patient characteristics, physician characteristics, the environment and relationship skills.
Studies examining physician characteristics have found that physicians with lower job satisfaction, less experience, and poorer psychosocial attitudes describe more difficult patient encounters. Fewer studies have studied how physicians actually manage difficult patients. Instead, management advice is given anecdotally or from an educational or psychological perspective.
Despite all this advice, practicing physicians lack a "best practices" method of managing difficult patient encounters. A first step in developing a "best practice" is to develop a conceptual model, based on input from stakeholders, such as physicians. Often, input from "expert" or "excellent" physicians serves as a starting place to begin this research. Respected family physicians can certainly serve as these stakeholders, and by sharing their expertise and experience, help clarify approaches to these difficult encounters.
We elected to choose practicing physicians who serve as volunteer preceptors for medical students in family medicine and described as excellent by predoctoral directors of family medicine. These physicians elect to be under constant scrutiny by students and fellow physicians. Predoctoral directors of family medicine and other faculty members receive constant feedback not just on these physicians' ability to teach, but on the quality of their medical care, as well. These preceptors are visited and observed by faculty members on an ongoing basis. The purpose of this paper is to elicit descriptions of difficult patients and their management from these respected family physicians and to develop a model to first, assist physicians in understanding and improving their difficult patient encounters and second, serve as a basis for future research to confirm the best practices for caring for such patients.