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Managing the Difficult Patient

In the era of the “empowered patient,” what are the best ways to handle those difficult patients who challenge your judgment, tax your time, and test your patience?

Exclusively on QuantiaMD, Dr. Richard Roberts and his expert faculty address the findings from the eye-opening survey on the Five Faces of the Difficult Patient and share their advice, cautions, and strategies for preserving a strong relationship with even the most difficult of patients.

Moderated By:
Richard G. Roberts, MD, JD, FAAFP, FCLM
President, World Organization of Family Doctors
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Expert Practice Series Presentations
Richard G. Roberts, MD, JD, FAAFP, FCLM
President, World Organization of Family Doctors, Professor, Past Chair of Family Medicine, University of Wisconsin, School of Medicine & Public Health
(3,081)
930 Comments
Leonard J. Haas, PhD, ABPP
Clinical Psychologist and Health Behavior Coordinator, VA Healthcare Center, Salt Lake City, Utah
Gerald B. Hickson, MD
Director of the Center for Patient Professional Advocacy, Vanderbilt University School of Medicine
Joseph E. Scherger, MD, MPH
Vice President for Primary Care, Eisenhower Medical Center, Rancho Mirage, California
(2,182)
828 Comments
Leonard J. Haas, PhD, ABPP
Clinical Psychologist and Health Behavior Coordinator, VA Healthcare Center, Salt Lake City, Utah
Gerald B. Hickson, MD
Director of the Center for Patient Professional Advocacy, Vanderbilt University School of Medicine
Joseph E. Scherger, MD, MPH
Vice President for Primary Care, Eisenhower Medical Center in Rancho Mirage, California
(1,576)
449 Comments
Leonard J. Haas, PhD, ABPP
Clinical Psychologist and Health Behavior Coordinator, VA Healthcare Center, Salt Lake City, Utah
Gerald B. Hickson, MD
Director of the Center for Patient Professional Advocacy, Vanderbilt University School of Medicine
Joseph E. Scherger, MD, MPH
Vice President for Primary Care, Eisenhower Medical Center, Rancho Mirage, California
(1,864)
615 Comments
Leonard J. Haas, PhD, ABPP
Clinical Psychologist and Health Behavior Coordinator, VA Healthcare Center, Salt Lake City, Utah
Gerald B. Hickson, MD
Director of the Center for Patient Professional Advocacy, Vanderbilt University School of Medicine
Joseph E. Scherger, MD, MPH
Vice President for Primary Care, Eisenhower Medical Center, Rancho Mirage California
(2,097)
665 Comments
Leonard J. Haas, PhD, ABPP
Clinical Psychologist and Health Behavior Coordinator, VA Healthcare Center, Salt Lake City, Utah
Gerald B. Hickson, MD
Director of the Center for Patient Professional Advocacy, Vanderbilt University School of Medicine
Joseph E. Scherger, MD, MPH
Vice President for Primary Care, Eisenhower Medical Center, Rancho Mirage California
(1,892)
556 Comments
Richard G. Roberts, MD, JD, FAAFP, FCLM
President, World Organization of Family Doctors, Professor, Past Chair of Family Medicine, University of Wisconsin, School of Medicine & Public Health
(2,016)
587 Comments
Latest Comments
"The cyberchondriac type of patient can cause much frustration, especially when they present and expect immediate feedback on multiple Internet pages about their S/S during an OV.  Since it does take time to review data, I ask my pts to forward e-mail attachments on information they want me to cover during their next appointment.

The big danger in having numerous complaints is that the clinician may follows the route of premature conclusion determining that the patient’s problems are all related to some type of anxiety syndrome.  This may result in failure to consider an alternative hypothesis which may result in failure to efficiently and effectively recognize a true significant medical problem in a timely manner.

Interesting research statistics regarding the reasons parent sue.  Yes, I agree that many times a pt may present with only a portion of the facts and a faulty history concerning the reason they are switching providers.  Many times these patients are revolving door, doctor shopping or drug seekers.

I respect the pt’s right to use the Internet and strive to provide trusted medical resources for them to read.  I believe with this type of pt it is best to explore the foundation for their apprehension and propensity to believe the severity of their symptoms, go back and review their history, family etc.  Strive to promote a healthier lifestyle where the pt is moving more and engaged in other activities away from their computer.  Promote a balance in life ie diet, exercise etc. 

This was an excellent presentation offering in general, I truly enjoyed the entire series.

Thanks,

Valerie"
Valerie Ting, APRN-BC
Nurse Practitioner, Comprehensive Health Center
556 Comments
"This is especially challenging in the ER where you have revolving door type of patient sometimes (drug-seekers, hypochondriacs) who are constantly in and out of the hospital ED.  Since we expect the patient to be honest in explaining their symptoms it really makes it challenging when drug-seekers or hypochondriacs are actually ill.  Yes, I most definitely agree, even though they may have cried wolf many times before you don't want to fail to notice an actual problem when one arises.  Although, you don't want to waste money ordering unnecessary expensive tests on patients who are see on a weekly basis and have already had multiple radiological and laboratory testing already.  Many of these pts are constantly being radiated by yet another ERP just to find that the same test were already ordered by another provider and everything was normal.  So these types of patients truly present a big problem.

However, I don’t believe that this is the case with this 82 Y/O ♀.  It may be that financially the patient doesn’t have the means to afford her medications.  Her life values, economic difficulties, possibly a fix income as  many of our senior are dealing with and her inability to afford the of co-pays for both the office visit plus multiple prescriptions can be overwhelming.

 

She may have a lack of family or a support system living nearby to assist her meet her daily needs.  Additionally, at her age she may be forgetful or be starting dementia or she may be experiencing depression due to loneliness.  Sometime a patient may be noncompliant with their prescriptions because they don’t perceive the benefit the drug.  Once suggestion, If your pt is experiences S/E you may consider alternating day therapy to assist with ruling out the S/E from the drug.

I agree we must always be respectful of the pt and be tolerant of the pt’s cultural beliefs, that means even the revolving door type of drug-seeker.  This use to really bother my co-workers in the ED, I vividly remember some of them actually laughing at me telling me you know why they're here Valerie.  Even so, when a pt even one knows to be a drug seeker would present with yet another migraine complaint I would take their HX, onset accompanying S/S assess their V/S and place them in a dark, quiet room and provide an ice pack and emesis basin as indicated.  You'll never know when one of these types of pts could actually be having the worse H/A ever and maybe the beginning of a TIA, CVA 

 

As health care reform evolves, the vision is that clinicians will share medication management responsibilities following the patient-centered medical home model of care.  Using a combinations of approaches and supplementing the clinical intervention with compliance devices (prompts) ie medication organizers, labels (stickers), timers (alarm clocks), voice prompts on phone etc. may be necessary for the majority of older patients.  This is a problem even for some of my younger pts unless the prescription is a daily dose format. . So, even my younger pts in their hurried (rushed) lifestyle sometimes have a difficult time in managing their medications times especially if they aren’t use to taking medication.  For these individuals an assortment of approaches, and creative reminders to follow throughout their activities of daily living in order to remain compliant with prescription administration times is essential.  Today, with all of the electronic gadgets available pts and their support system should be able to assist the patient with prompts which or at their disposal.

The legal risks of caring for a patient where nothing you prescribe or recommend seems to work can be very frustrating to any provider.  However, this type of patient does challenge us and I have actually learned a lot about medicine just from caring for them.  Yes, I agree that a shared decision-making consent can help us minimize legal risk in caring for these patients.  I agree, we should never make assumptions about the patient’s non-compliance.

I thoroughly have enjoyed this program and the series in general.

Thanks,

Valerie"
Valerie Ting, APRN-BC
Nurse Practitioner, Comprehensive Health Center
665 Comments
 
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