Managing difficult patients

Dr Krishna Prasad Venkiteswaran

MS (Sur) MCh (Uro) DNB (Uro) FRCS (Sur) FEBU (Uro)
Senior Consultant Urologist
Aswini Hospital and Gem Hospital & Research Centre, Thrissur.
“Difficult Patients”
• Every health care professional encounters “difficult” patients at
sometime in their career.

• Nurses and Doctors are more prone to encounter them.

• Dealing with them develops from personality of the HCP, experience

from peers and past.
 “Difficult Patients”
What exactly is a difficult patient?
1. Patient not taking our medical advice in spite of being under our care.
2. Un-cooperative patient.

3. Aggressive / upset / abusive patient & relatives.

• Patient upset about cost of treatment.
• Patient upset about inefficacy of treatment.
• Patient upset about lack of professional behaviour of doctor / staff.
• Patient relatives upset about morbidity and mortality in hospital.
“Difficult Patients”
What can be done for patient not taking our medical advice and Un-
cooperative patient.
• Cause of refusal / uncooperativeness needs to be found out
• Terminal illness known.
• Depression – Exogenous, Endogenous.
• Forced into treatment by well meaning relatives.
• Fear of medications, previous bad experiences with allergies.
• Lack of trust of the medical practitioner, or the allopathic system.
• Tailor the treatment accordingly
• Empathy.
How can we be prepared
Avoiding complaints
• Honesty is best policy when dealing with patients and relatives.
• Most complaints are because of unrealistic expectation of the patient.
• Don’t hesitate to refer the patient to a colleague who has better
expertise in a particular surgery.
• Do not exaggerate your results trying to win over a patient for surgery.
• Remember that our primary intention is to help patients, not to make
money. Unless indicated strongly use non-surgical methods to treat
patients.
How can we be prepared
Avoiding complaints
• When facing a problem with the management get help from other
doctors and staff whenever indicated.
• Call a colleague if indicated. 2 brains may work better than one.
• Complications should be discussed before hand and carefully written
down in consent forms.
• If complication occurs it should be informed to patient and relatives
with possible solutions.
• Document everything with date and time and get signatures.
How to tackle difficult patients
• Try to maintain calm during interaction (easier said than done).
• Try to use normal speech tones
• Avoid using unpleasant words or actions from our side in spite of provocation.
• Listen carefully to patient before framing a calculated reply.
• Try to record the conversation in voice recorders (easily available)

• Try to find out the cause (real cause) of the aggressiveness.

• Mostly cost of treatment in my experience
• They may blame inefficacy of treatment to reduce cost
Every doctor will encounter a difficult patient at some point.
How to tackle difficult aggressive patients
Upset patient may react in several ways
1. Verbal abuse
2. Physical abuse
3. Complaints to hospital authorities.
4. Legal action / Consumer court / Criminal court.
5. Social media, Written, Visual media and e-mail abuse
6. Complaints to medical bodies.
How can we be prepared
Verbal Abuse
• Develop communication skills
• Observe other doctors talking to patients. Inculcate their good points.
• Attend professionally conducted certified course in communication
skills
• Mock playing different clinical scenarios with video recording replays and critics.
• Conveying bad news skills.
• Improve our personality
• Yoga, breathing exercises, physical exercises, reading, listening to music.
 How can we be prepared
• Know to protect oneself from physical attack
• Talk to patient/relatives in closed consulting room, not in corridors.
• Always have nurse in room when talking to difficult patient.
• Use PRO help when suitable.
• Have security back up always. Know how to get them quickly to your room.
• Basic knowledge of defense skills is an advantage.
• Have a senior / local policeman and lawyer as a good friend in need.
• To have local people and political support is always an advantage.

• In case of physical attack try not to panic – try to think logically and act
• Keep deterrents like pepper spray, low voltage stun stick (available in Online shops) in
consulting rooms. Do Try not to use them unless physically threatened.
How can we be prepared
Legal action / Complaints to hospital / medical bodies
• Documentation is the most important factor when facing legal action.
• Date time and signature in documentation is vital.
• Having witnesses who can corroborate your claims is important.
• CCTV monitoring in consultation rooms (avoiding examination rooms)
• In case of potential complaint arising (for example after a
complications, explanation and documentation) witness signature,
name date time should be documented.
• Never answer written replies by oneself under emotional stress. Get
professional help to formulate replies.
How can we be prepared
Legal action / Complaints to hospital / medical bodies
• Become a life member of IMA. Utilize legal help from IMA by taking
Indemnity insurance. Other organizations like ASI, private organizations
also provide these types of help.
• Always take Indemnity insurance with sufficient coverage.
• Keep a good lawyer on hand and take his/her opinion in written replies
to complaints.
• Encourage your professional organisations (USI, UAK) to make
guidelines for procedures, conduct courses in communication and
provide legal assistance for a fee.
Social media / Written / Visual media abuse
• This is the latest and very effective method of abuse
• Character assassination that is done through these can cause irreparable
damage.
• Inter-doctor rivalry can be the core problem.
Actions possible
Always maintain cordial relations with colleagues.
Show respect for the opinion of colleagues to the patients who come for
2nd opinions.
Do not respond to social media accusations directly. Get lawyer help.
Carefully written answers using polite language, outlining the
circumstances can be used in replies to counter social media abuses.
Conveying bad news (Fatality)
• Mortality is terrible for the family. They will naturally feel aggrieved. Feel
for the patient and relatives with true heart.
• Always talk to maximum 2 or 3 people in a room. If there is a crowd waiting
make sure security assures them outside before discussing with close
relatives in closed room.
• Get other doctors and staff support (anesthesiologist, senior nurses) when
conveying bad news. Talk as a team.
• Explain what happened in detail and what was done to save the patient.
• Try not to respond to provocation from relatives. Try to maintain calm and
show empathy.
Conveying bad news
• In surgical mortality a post mortem if needed should be done so that
it may be helpful in case of potential legal action.

• Conduct Mortality Morbidity meetings including different specialties

and documentation of the committee meetings will be greatly
beneficial in prevention of such incidence as well as in cases of legal
action.

• Keep the hospital management in the loop all the time.

Mob Attacks
• Kolkata 2019: Mob violently attacks doctors at NRS Hospital after
Mohammed Sayeed’s death, police mute spectators, allege students.

• Mob Attacks Afghan Doctor and Female Patient. Kabul, Afghanistan

2013 — A mob attacked an Afghan medical doctor and his female
patient, stoning the doctor after the two were discovered in his
private examining room without a chaperone.

• Goa: Priest Led Mob Attacks Doctor And Family Over Activism Against
Illegal Activities. June 05, 2019
Mob Attacks
• Try to get away to safety if possible (Run into car or closed secure
room and lock the doors).
• Call local Security, Police, Management. Keep emergency numbers
handy in your phone.
• Get any help you can – don’t feel ashamed to shout or cry loudly -
Your life may be at stake.
Thank you for a listening.

Be careful. We live in difficult times…..

A friend in need is a friend indeed…