Establish Boundaries With Difficult Patients Early, Before the Relationship Descends Into Crazy Town

Be forewarned, this is an “elephant in the room” post about dealing with difficult patients. It’s a common situation and a sensitive topic. And if you’re uncomfortable confronting the problem, or dealing with challenging, dependent, manipulative, noncompliant, upset and/or time-sucking patients…then read no further.

The nearly daily reality is that every hospital and healthcare provider has “difficult” patients. “[We] don’t always like the patients that we take care of. It sounds harsh, but let’s be honest,” Lanette Anderson writes in a NurseTogether.com post. “The caveat to that statement is that we don’t have to like them. We do, however, have to provide the best possible patient care that we can, while maintaining an appropriate level of professionalism and compassion.”

Human nature is fascinating, and this “elephant in the room” is not to be ignored. Among the many models of human behavior, here’s one based on my observations about relationships. We’re talking about patients here, but the same principles apply to staff, doctors, executives, friends and family. We see three common groups:

• Most patient relationships are great, or at the least, qualify as acceptable.

• A small percentage of the time there will be no pleasing a patient, no matter what you do. And if you can't overcome the issue, it may be best to ethically help them to find care elsewhere.

• There's a third category. Those people who seem to be wired to be aggressive and push the boundaries. “Difficult” may be an understatement; they are more like bullies.

Maybe it’s genetic or something in their past that drives people in this third group. Regardless, it seems the more you give, the more they want. (In World War II, Chamberlain, and the rest of the world, discovered the hard way that appeasement is not a good strategy with bullies.)

Here's the thing I have discovered from meeting with thousands of doctors, executives and staff over the years. It is often possible to achieve a turnaround with this third type. You can enjoy great relationships IF you set appropriate boundaries early on.

If you politely—but firmly—establish what is, and what is not, acceptable, these people will usually "get it." "Oh, if that's the case, fine." And they'll respect you for it. (They may need to be reminded from time to time.)

Early intervention is key. If you do not set boundaries, relationships can (and often will) spiral into what I call "crazy town." After that, there will be no pleasing them whatever you do (see category #2 above).

And here's the hard part: How do you do that in the real world?

First, you need a unified approach in creating boundaries. Dr. Robert Blotter backs me up on this: “Standardized approaches can help lessen the emotions involved in dealing with difficult patients. Reasoned, consistent processes that provide clear boundaries from the start can not only avoid problems down the road, but also help defuse situations before they escalate,” he advises in Tips for Dealing with the Difficult Patient. (American Academy of Orthopaedic Surgeons)

You and/or your staff need to be able to objectively read the situation for what it is. Is the patient really "difficult" or are they (a) going through a lot of emotional distress, perhaps due to their illness, or worse, (b) someone on your team screwed up.

These are entirely different issues and subjects for deeper discussion another day. But here are some quick tips about problem situations.

• Put your best player or players right up front. Some staff members are really gifted at interpersonal relationships, while others are not.  Some are assertive while others are not. Management personnel at hospitals and practices also have varied skill sets at this sort of thing. Identify which people have the ability and experience to handle potentially caustic situations and involve them early in the encounter.

• Be caring and helpful, but not a doormat. Answering upset with anger pours fuel on the fire and makes things worse. It requires skill, but staff members can be tolerant, express understanding and concern and still guide a patient’s expectations in a positive direction.

• Effective communications are a cornerstone. Staff training in communications skills, including active listening and role-playing, is a fundamental element to empathy, understanding, coping with and ultimately helping difficult patients.

• Allow for “disruption” in your schedule. You can’t ignore the inevitable. Some patient encounters will be disruptive today…probably every day. By some estimates, there’s one in every six encounters. The best practice course is to be prepared. As impossible as this sounds, your office schedule and operations needs to expect the inevitable distraction.

• Remember that most problem relationships are solvable. Early action is the key to disarming, redirecting and properly channeling the concerns of a patient before they accelerate to the level of “difficult” or beyond.

It's not easy being a patient.

We recommend that you discuss these issues openly with your team and come up with an action plan that includes a process to identify difficult patients early. The patient, the staff and the provider will all benefit.

“Being a patient is an emotional roller coaster,” Dr. Brian Secemsky reminds us. “It is therefore paramount as practitioners to step back and recognize the immense amount of emotional stress exacted on your patients throughout the course of their hospital stay. This is an especially important concept to recognize when caring for the patients on your service who truly test your nerves and ability to empathize.” [Huffington Post Healthy Living]