Problem Patients?

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Problem Patient? Use the Three "P'S"You can win cooperation on the spot by following these simple steps.By Harrington PrestonSenior EditorYou know those patients: The one with a sheaf of Web printouts and a list ofbrand-name drugs who wants to argue over treatment. The brusque one whosnarls at receptionists when appointments run late. The one who demands asecond opinion as if you're trying to cheat her out of an expensivetreatment.They're the patients from hell. But you can deal with them by mastering afew techniques for persuasion. The key is finding out what the patientreally wants-and providing it, but in a way that's okay by you. Best of all,you needn't take more than a few additional minutes to get yourself and thepatient on the same side. It's no more time than you'd spend alienating thatpatient with an argument.We've summarized the steps as pause, probe, and persuade.Pause: Get your emotions under control"When I was a young doctor and thought I knew everything, a patient askingfor a second opinion was an affront," says internist Park McGehee ofOpelika, AL. "The patient would see my reaction and would get resentful andsay something like 'Well, maybe I'll go somewhere else.'"Orthopedist Barry C. Dorn was even more impatient: "I'd tell them, 'If yougo to a chiropractor, don't come back.' " Dorn, who practices in Winchester,MA, has mellowed since; he now teaches negotiation in the continuingprofessional education program at the Harvard School of Public Health. (Andhe says he likes chiropractors.)Even if your ego isn't quite as well developed as the young McGehee's andDorn's were, you may well react angrily when a patient comes in withsuspicion on his face and a chip on his shoulder. Having read something witha title like "What your doctor won't tell you," he thinks you're out towreck his life.Indignation smacks of identity conflict, says Rajamalliga N. "Lee" Sharma,an ob/gyn who runs a conflict-resolution consultancy. Competence andautonomy are at the core of doctors' professional identity, she says, so achallenge to either is apt to provoke anger.In fact, though, a patient may have no clue that he is challenging you."Often the patient wants the opinion of someone he or she respects," saysSharma, who, like McGehee, practices in Opelika, AL. "It has nothing to dowith a perceived lack of confidence in the physician's body of knowledge."McGehee's patients were simply following a requirement imposed by insurancecompanies. "Every elective surgery had to have a second opinion," he says.You don't know what your patient is thinking. When your hackles rise, then,step aside emotionally. Pause.Probe: Find out what the patient really wantsSay a patient wants to go to an herbalist, try an inappropriate drug, orhave an irrelevant test. What you need to know is why. In negotiation lingo,you need to stop talking about positions and start talking about interests,so you don't waste time and temper butting heads over incompatible plans.To put it another way, you and the patient share the goal of making him ashealthy as possible, but you're arguing about which bridge to take from hereto there. For instance, the patient with old news from the Internet issimply pointing out some bridges that are new to him, if not to you. Unlikeyou, of course, he may not know that a bridge is weak, out-of-the-way, ordangerous.By asking the patient why he wants what he's asking for, you map thelandscape he pictures on the other side of the bridge. Often, you'll need toask several questions. But once you understand where the patient wants togo, you can point out how your route will get him there faster and moresafely than the one he thinks he wants. At least, you can help him travelsafely across the bridge he prefers. Either way, he crosses the river, youboth stay on good terms, and neither of you loses any sleep.The process has become second nature to Barry Dorn. "I get a lot of patientswith back pain," he says. "I ask them, 'How are things going for you thesedays?' or 'What would you like to have happen?' The answer may be, 'I wantto go to a chiropractor because my best friend went to one and he feltcompletely better.' Then you have to go forward and say, 'Tell me about yourbest friend and what happened.' You have to pull the story out of thepatient."You ask, 'What do you like to do in the course of your day?'" Dorncontinues. "The patient may answer, 'I like to go running, I like to swim.'Whatever. And I'll say, 'Does this condition affect your activities?' andthey say 'No, not really,' or 'Yes, I can't drive my car to work.'"It does take a few minutes," Dorn concedes. "However, if you get into anadversarial relationship, you probably spend just as long in subliminalsparring. Drawing the patient out is a lot more rewarding, and the patientperceives that you're interested in him as a human being."As a physician, you're the patient's advocate," he notes. "Half of thisbusiness is really the emotional response to illness. You have to be able todeal with that."Persuade: Show the patient how your plan meets his goalsLee Sharma tells of one patient, already in labor, who came to the hospitalfor some medicine and insisted on going back home to deliver her baby. Withdifficulty, the staff persuaded her to stay until Sharma came.When Sharma arrived, she'd had time to prepare herself emotionally fordealing with a stubborn patient-the "pause" step. Her first action was toprobe for reasons why the woman would be so adamant about going home fordelivery. "I spent about a half-hour talking with her," Sharma says. Themother wanted to recover quickly so she could return to her work as amissionary. A prior delivery had ended with a cesarean and a long recovery.This time, the mother was determined to control the process. The patient's"bridge" was a rickety one: Deliver at home.Next, Sharma pitched her treatment recommendation. Both Sharma and themother wanted a healthy baby and a quick recovery. Sharma agreed to try fora vaginal delivery. However, using plain language that made sense to thepatient, she pointed out the risk of uterine rupture. To be prepared in casethat happened, Sharma needed to monitor the baby's heartbeat and start anIV. Was that okay with the mother? It was. Her non-negotiable demand for ahome delivery evaporated when she saw that her position wouldn't serve herinterests.Here are some tips for making the three-step process work:. Restate your common goals. This assures the patient that you know herconcerns and share them. It also lets you check that you've understood her;she can tell you if you're wrong. In addition, it helps to get your patientinto a Yes frame of mind. It sounds hokey, but salespeople and negotiatorswill tell you it works.. Link the plan to the goals. Sharma picked a plan she and her patient couldboth live with-a trial of vaginal delivery-and told the patient the stepsshe'd have to take to avoid problems.. Stick to the positive. Sharma didn't argue over the patient's wish todeliver at home, let alone disparage the idea. The treatment plan made itobvious that home delivery wasn't feasible, so Sharma didn't mention it atall. Similarly, when a patient confronts McGehee with a pile of Webprintouts, he doesn't scold the patient about trusting the Internet foradvice. Instead, he suggests a couple of reliable Web sites and says, "Ifyou see something I need to know, print a copy for me." When the patientbrings in an article, McGehee takes it and thanks him.. Be prepared to parley. If your first explanation of a treatment plan iscompatible with what the patient wants, fine. If you need to do a littlehorse trading, however, offer options that don't go head-to-head with whatthe patient says she wants. For instance, besides agreeing to try a vaginaldelivery, Sharma also told the patient she could wear clothes from homeinstead of a hospital gown. If the patient still equivocated, Sharma mighthave sought out a labor and delivery room with homelike furnishings.. Accept the patient's decision gracefully. If the patient is set on doingthings his way, help him do them safely. When someone is determined to see achiropractor, for example, make sure he goes to a reputable one. McGeheeeven makes a point of suggesting a second opinion if the patient seemsunsure. "I say, 'Why don't we send you over to Dr. So-and-So and see what hethinks? And let me put copies of your pertinent records in a folder to takewith you.' That way, I've empowered the patient," McGehee explains."Everybody's comfortable and happy, and the patient trusts me. It's awin-win scenario."Want to learn more?Our sources suggested these books:Getting Past No: Negotiating Your Way From Confrontation to ation,by Ury (Bantam, 1993).Getting to Yes: Negotiating Agreement Without Giving In,by Roger Fisher et al (Penguin, 1999).Difficult Conversations: How to Discuss What Matters Most,by Stone et al (Viking, 1999).Renegotiating Health Care: Resolving Conflict to Build Collaboration,by Leonard J. Marcus et al (Jossey-Bass, 1995).Resolving Conflicts at Work: A Complete Guide for Everyone on the Job,by Cloke et al (Jossey-Bass, 2000).