Consultation Skills

Dysfunctional Consultations

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Consider...

Difficult patients can be exhausting and can trigger off some powerful emotions in the doctor dealing with them (see below).  Difficult patients are often regarded as ‘heart-sinks’ – that is, they make your heart sink when they come through the consulting door.   The four pure emotions are (i) Sad (ii) Mad (iii) Glad and (iv) Fear.

BUT… consider where are your feeling is coming from?    Is it :

  • the patient
  • the doctor (are they your own internal scripts)
  • or the doctor-patient relationship      

Focus on the problem not the person.

Groves classification of Difficult Patients

Groves’ Classification (1951).   Groves classified difficult patients (those that we as doctors often dislike seeing) into four categories:

  1. The dependent clinger
    These patients have frequent attendances for often simple problems.  After the consultation, they are often ingratiating to the doctor.  Flatter you in excess and gives excessive ‘praise’.
  2. the entitled demander
    These patients are demanding or manipulative.  They always want something and they want it now!    May demand Investigation, Treatment or even referral!  Get their way by instilling a sense of fear, intimidation, guilt or by devaluing the doctor (unlike the dependant clinger who uses flattery to get his/her way).    Might  threaten the doctor with legal action if their request is not honoured.  Often see the doctor as a barrier to what they are asking for…hence the animosity.   Watch out…..they can become aggressive…..always think of your personal safety too.
  3. The manipulative help-rejecter
    These patients keep coming back to tell you that the treatment you gave was rubbish.  But despite rubbishing your therapy, they still keep coming back to you.  They are doctor dependant. Every time they come….it’s the same old story…you can even guess before they’ve sat down!  They have preconceived ideas (and need the Dr on their side.)  They aim to seek an indissoluble relations with the doctor…….hence being often ingratiating.    Do they get something out of feeling sick all the time???  Secondary gain can often be the attention they get from third parties like friends and relatives.  Even if a symptom/ailment has been successfully resolved, it will only be replaced by another! 
  4. The self-destructive denier 

    These patients usually feel that although they can’t control their own life, the doctor can!   They often do have an illness like COPD, but in addition, they have bad habits that worsen their condition and are not prepared to give them up…..they want a miracle pill from the doctor instead. 

A general approach to handling all of Grove's categories of difficult patients

  1. Build Rapport.  They are people at the end of the day – your fellow human beings.   Listen attentively, empathy, make eye contact (careful in aggressors).  Get a shared understanding of the problem. 
  2. Avoid being critical.   Avoid confrontation.  You are after an adult-adult conversation.   Don’t make them feel small.  Don’t get into a verbal fight – it’s no good for anyone – you all leave with a bad feelings when you get back home.
  3. Encourage patients to take more responsibility for their own health.  Get them to come up with solutions or coping strategies than you doing all the work for them.  Ask rather than tell.  Try and develop a shared management plan.  Use patient diaries and other method to help patients gain an insight into linking illness with psycho-social events.
  4. Firm structured approach with consistency.  Communicate with other doctors to try and avoid them Doctor Shopping (ie consulting different doctors for different opinions and different referrals!).   Be courageous and see them again and again rather than passing them over to others.
  5. Recognise own feelings.  Keep control of  a) yourself  b) the consultation  c) the situation.  Sometimes it can be helpful to verbalise your feelings to show the effect the patient has on you and others.  This can be therapeutic.
  6. Options for the frequent attenders
      • lay down boundaries/limits : frequency of attendance, hierarchical problem list
      • share the work load : delegate to practice nurse, self help groups, counsellors, psychologists
      • consider delayed response to encourage ownership of the problem  (e.g. not going on a home visit just because the patient wants one.   you decide on clinical grounds).
  7. Housekeep yourself.  Always remember “Whose problem is it?”.  Avoid difficult situations.  Don’t give out your personal phone number or “special access” to you.

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