Dr Bronwyn Hartwig shares helpful skills for clinicians dealing with the difficult interactions that arise from patient expectations that are challenging or impossible to meet.
A hallmark of many difficult patient interactions are expectations from a patient that are challenging or impossible to meet. Being able to effectively handle these difficult interactions has many benefits, including:
- a better relationship with the patient
- lower risk of complaint or patient dissatisfaction
- enhanced professional satisfaction.
There has been an assumption that continuous quality improvement in healthcare translates into lower risk of patient dissatisfaction and complaint. However, it is challenging to consider that as risks of a particular treatment are significantly reduced over time because of rising quality, there can be a concurrent increase in dissatisfaction due to rising community expectation around that treatment.
Many patients have expectations around the care provided by a professional relating to two very different skill sets:
- The technical ability of the clinician – the patient comes to the interaction with the expectation that the clinician will apply his/her knowledge, skill and experience to their presenting problem.
- The care and compassion expressed by the clinician – the ability to deal with the emotional impact of illness on a patient and their family is seen by many patients as the hallmark of a good healthcare professional.
External factors such as media reporting can also influence patient expectations more strongly than an understanding of the latest technical or scientific research in a particular field. It is sobering to consider how pervasive the media’s effect on patient expectations has become, continually showing stories of good news around outcomes provided by health care professionals.
While this news makes great media, it also increases the expectations of those in the community who may access those services in the future. The lack of balance in the portrayal of the range of possible outcomes from medical treatment – particularly the lack of portrayal of disappointing but not devastating outcomes – has significantly raised community expectations.
Other factors that are in place when difficult interactions occur between patients and clinicians include:
- System factors – issues related to how care is delivered within a particular community can lead to difficulties that do not exist in similar communities because of different policies.
- Disease factors – no matter how well adjusted and insightful a patient may be when they are well, any disease that involves long-term pain, low chance of treatment success, significant disability or an overwhelming sense of loss has the potential to make interactions difficult, no matter the personality of the patient when they are well.
- Factors within ourselves – including our previous encounters with similar people, degree of training in handling difficult situations, our attitude to how we think patients should behave when they are sick, and our ideas about the degree of personable responsibility a patient should take.
In addition, it has been observed that many ‘difficult’ patients display many of the behaviours that one would associate with adolescents. In these patients a clinician may see someone who:
- fails to problem-solve
- is more interested in justifying their current position than trying to bring about resolution
- is more willing to blame others for their misfortune rather than accepting that personal choice, lifestyle factors or even luck and fate play a significant factor in peoples’ lives.
Difficult situations often lead patients to focus on arguments over issues that are unhelpful in their move to decision-making and problem-solving. The compassionate and caring professional who is able to avoid becoming involved in pointless or needless argument, but consistently and compassionately focuses on how they are able to assist the patient to problem-solve, is being truly therapeutic.
The ability to handle unrealistic expectations and the difficult interactions that can often follow is a key skill that all health care professionals should take an interest in developing – for the betterment of both their patients and society.
Three helpful skills for difficult patient interactions
- Active listening – active listening involves acknowledging emotions and feeding back short summaries to the patient eg, ‘You followed the instructions as you understood them and you have not achieved the outcome you were hoping for, this must be very frustrating for you.’
- Empathy – empathy is the experience of being heard and understood. It involves legitimising emotions that the patient is experiencing and offering support to address the patient’s needs.
- Reframing – research has suggested that labeling a patient as ‘difficult’ results in a subtle change in our behaviour towards them (less eye contact, less listening, less sharing of decisions). These changes are almost never helpful. Reframing our own perceptions of the patient ie, considering whether the patient’s behavior or expectations may result from fear, anxiety or personal experience can help us attend more closely to the patient’s needs.