If a Patient States I Will Never Come to the Hospital Again Are They Anxious
Breathe (Sheff). 2017 Jun; 13(two): 129–135.
Top tips to deal with challenging situations: physician–patient interactions
Georgia Hardavella
1Dept of Respiratory Medicine, King'due south Higher Hospital, NHS Foundation Trust, London, UK
iiDept of Respiratory Medicine and Allergy, King'south College, London, UK
One Aamli-Gaagnat
iiiDept of Clinical Scientific discipline, University of Bergen, Bergen, Norway
Armin Frille
4Dept of Respiratory Medicine, University of Leipzig, Leipzig, Germany
Neil Saad
fiveNational Center and Lung Institute, Imperial Higher London, London, UK
Alexandra Niculescu
6European Respiratory Society, Lausanne, Switzerland
Pippa Powell
7European Lung Foundation, Sheffield, Great britain
Short abstract
When challenging situations arise in physician–patient interactions, how can we all-time manage them? http://ow.ly/J1GI30bD5wp
Raise your words, not your vocalism. It is rain that grows flowers, not thunder. Rumi
Interactions between patients and medical practitioners can sometimes be challenging. We have all had consultations where the interaction was not optimal, either as medical practitioners or equally a patient ourselves. Neither normally wishes to crusade a hard state of affairs simply mutual misunderstandings, by both groups, often result in such an occurrence. Communication and listening skills are essential for every consultation merely in particular, for situations where the interaction may become difficult.
In this commodity, we will discuss what may brand a consultation hard and what outcomes this could lead to, and provide some suggestions to assistance both y'all and your patient.
What is a challenging interaction and how might information technology exist perceived?
Many different challenging interactions occur daily. These challenging interactions may arise due to discrepancies in expectation, perception and/or advice betwixt the patient and medical practitioner, and could exist acquired by the doctor, past the patient or past both. We accept outlined a list of potential scenarios in tabular array ane and discuss how these might be perceived from both a healthcare professional person and patient perspective.
Table 1
Most common real-life scenarios where an interaction with a patient can be challenging
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Examples of scenarios include when a doctor:
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informs the patient of bad news without ensuring that this is washed in an advisable setting (east.g. breaking bad news in a busy corridor at the blow and emergency department in the presence of medical students and other patients that are observing);
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delivers difficult news (e.m. a life-changing diagnosis) without showing empathy or ensuring there is appropriate support available for the patient (e.g. counselling services or caregivers/family unit members around);
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during a consultation, uses poor nonverbal communication (e.g. no eye contact with the patient, instead focussing solely on the computer screen or notes; opinion; gestures; or tone of voice); or
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speaks ambiguously, non explaining, in plain language, long-term management plans, or the importance or implications of diagnosis.
Alternatively, these scenarios may arise when a patient:
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has done research online almost their ailments and is convinced by their findings of a conclusion, and demands certain investigations/treatments;
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feels that they are not being listened to and might become frustrated, or threaten legal activeness or social media interest;
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does not accept the doctor'due south diagnosis or examination results and demands a second opinion;
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has symptoms affecting their quality of life but no diagnosis despite thorough work-ups by diverse medical teams, which can pb to frustration or a lack of trust in medical professionals;
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will not follow the suggested handling merely continues to attend consultations with deteriorating health (east.g. a heavy smoker with severe asthma who does non cease smoking and believes that their inhalers do non work); or
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volition focus on what went wrong rather than what is the all-time fashion to progress things.
Factors contributing to a challenging interaction
To preclude and resolve challenging interactions, one needs to consider factors that might contribute to these situations. Two important factors are the local healthcare setting in which the interactions take identify, and the variation in clinical practice between regions and countries. In particular, the majority of healthcare settings are overworked and overstretched to run into demand, and this continuously affects interactions. Insufficient fourth dimension for consultation or interaction with patients plays an important role, every bit healthcare system pressures are increasing patient numbers and expectations, against a background of cost-cutting. Foremost, it is important to bear in listen that both patients and healthcare practitioners want a positive interaction to ensure the best possible health outcome, as time spent in consultations is valuable for both parties. Figure one summarises several other important contributing factors.
Factors contributing to a challenging interaction.
The patient
Each patient has their ain medical and psychosocial history that understandably will affect their behaviour. Patients will walk into your dispensary with a set of behavior and expectations affected by their personality and the severity of their symptoms, and the implications of this for their quality of life. They may as well have had negative experiences and previous disappointments within the healthcare arrangement that may exist challenging to overcome and may generate some mistrust. They may feel that their illness is beyond their personal command, which can make them dependent on others' help, particularly their healthcare professional person. Such circumstances can, understandably, brand a patient feel broken-hearted, worried, hopeless and uncertain about their health, which tin be displayed as tension and negative reactions towards the healthcare professional person.
With increasing advances in medical inquiry, expectations of the healthcare system and in healthcare practitioners have also increased. Patients tin have very high expectations and trust in the system, and when it appears that their condition is a medical "dead stop" or that their prognosis cannot be adamant with precision due to the nature of the affliction, it tin be very upsetting. Language barriers, cultural variety and their previous interactions with professionals or authorisation figures can too contribute to and touch interactions, and pb to misunderstandings. Moreover, patients may also have other considerations to make, for example, if their diagnosis may affect on other commitments (professional, caring responsibilities, etc.). Patients often work, may care for children or parents, or have other commitments that may be impacted by the diagnosis or may have impacted on the timeframe in which they seek help, all of which will be going through their heed. Being defined by their diagnosis and labelled equally "a patient" is not, and should non be, the only thing in their lives.
The healthcare practitioner
There is a wide variability in the development of appropriate communication skills among European healthcare practitioners and this has been a claiming. Advice skills courses or training are not included in the specialist curriculum in all European Union (EU) countries, nor are they included in the essential qualifications for specialist mail service applications.
A lack of communication skills training can result in:
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inappropriate selection of words and phrases, perchance due to assumptions existence made virtually the patient's level of health literacy or understanding of human biology;
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lack of planned construction in delivering difficult news (e.thousand. scattered data disruptive patients or no clear plan at all);
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inappropriate pick of setting to deliver difficult news;
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lack of options offered to the patient;
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not involving the patient in the conclusion-making process (e.one thousand. handling decisions taken without involving them and without addressing their needs and wishes);
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rushing the patient to hold to a proposed handling plan;
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rushing the consultation due to other pressures; or
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non referring the patient to advisable support services/resources (e.g. counselling, palliative intendance, support groups and quality trusted data).
Bad news may be cleaved in a nonempathetic way, letters may exist given to the nurses over the patient's head while interrupting the consultation, difficult words may exist used that the patient does not understand, and the patient may feel excluded from conversations with near no concern showed for their feelings and emotions. Often, what is everyday routine clinical data to the healthcare practitioner may be completely unfamiliar to the patient, giving the impression that the clinician is cold and unsympathetic to the individual'south emotions as they endeavor to come to terms with the diagnosis and its implications.
Overstretched clinic time may result in doctors not having fourth dimension to actually heed to the patient's concerns. What is the patient really afraid of? What practice they want to know? What are their experiences? These are questions that will be overlooked due to lack of time. Bereft time farther impacts the consultation as in that location is not time for the patient to verbalise, and for the doc to capeesh, the valuable contribution that the patient brings in having the lived experience of the condition, particularly if this is a rare disease.
In a complex clinical case, doctors may seem and so preoccupied with finding the solution to the clinical trouble that it is sometimes easy to forget that the patient might be overwhelmed by anxiety, frustration and negative emotions, and crave re-balls to feel safe, at ease and trust in the dr..
Healthcare setting (either outpatient dispensary or wards) is a familiar setting for doctors to take difficult conversations, whereas for patients, it tin can be uncomfortable and sometimes awkward, particularly if they are at the point of receiving their diagnosis.
In addition, a md's emotions may become the meliorate of them or their behaviour might be affected by a lack of slumber, hunger, their own wellness status, lack of job satisfaction or other concerns. Finally, the doctor's approach and communication style will influence their interactions and could have serious agin effects on the patient (due east.g. if the healthcare practitioner is arrogant or impatient and believes they don't have a responsibility to discuss the situation with the patient or explicate the condition in terms the patient could empathise).
It'southward important for doctors to recognise that some patients may exist intimidated and perceive inequality in the doctor–patient human relationship, which can be exacerbated by doctors acting in a way that is perceived by the patient every bit condescending or patronising. All this can be remedied with appropriate training and relevant professional development.
The organization
Dysfunctional healthcare systems can only add to the tension between patients and doctors. Simple things like long waiting times in the clinic, consecutive unjustified cancellations, or delays to previous appointments or investigations; essentially, anything that may have gone wrong in the patient pathway tin potentially atomic number 82 to a challenging interaction between patients and doctors. Doctors are probably the first person patients will spend some time with later something has gone wrong and therefore they will hear the patient's immediate frustrations showtime paw.
Lack of resources in terms of staffing levels or of maintaining patient privacy and nobility during consultation is some other contributing cistron; for example, during a consultation at that place may exist several doctors or nurses moving in and out of the room that distract attention and may affect nobility and privacy.
A lack of centralised documentation systems can sometimes atomic number 82 to asking the patient to repeat the same information over and over once again, and consequently dedicating less time to actually managing the clinical example and addressing the patient'southward needs. Constant repetition for every new doc may cause the patient frustration, while it is difficult for the doctor to know what the patient already understands.
Potential effects of a challenging interaction
Above all, it should be best-selling that patients want a positive interaction with their doctor. In reality, a challenging interaction between patients and doctors should be considered within the healthcare system in which it occurs. Patients seek professional help because they are in hurting or are concerned.
When the three factors of the patient, the md and the system collaborate, a peculiarly difficult state of affairs can ascend. Effigy 1 summarises the nigh important contributing factors, which are outlined below. We all answer differently when in a challenging state of affairs merely our behaviour or response could have serious detrimental effects (table 2).
Table 2
Potential implications of a challenging interaction
| Patient |
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| Doctor |
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| System |
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Patients
Patients tin can be overwhelmed by a multifariousness of beliefs and emotions: frustration, feeling they have piffling to no control over their diagnosis and health condition, uncertainty over the form of their treatment and prognosis, fright, worries, and overall dissatisfaction with the healthcare system. Communication betwixt the patient and medical professionals may then be prejudiced and upshot in the patient losing trust in the doctor. This can exist farther afflicted by the implications of the condition itself on the patient's psychology.
Due to the combination of all this, patients tin can feel they are not heard and consequently feel more vulnerable. They may have already arrived at the dispensary in a state of some anxiety after various tests, investigations or previous appointments. They may be anticipating bad news or may be reluctant to consider various treatment options, believing these may disrupt theirs or their loved ones' quality of life. They may have had had previous poor experiences of hospital or healthcare settings and may fright that raising concerns or asking questions could delay or otherwise impact on their treatment. Their culture or upbringing may have led them to believe they should not ever question somebody in authority even if they take lots of questions. A clinician rushing through an appointment may exist perceived as "harsh" or less considerate than one who takes the time to listen to the patient's concerns.
Healthcare practitioners
A challenging interaction for a medical professional already overstretched past the healthcare system may increment levels of stress, anxiety and anger, which in turn will impact on operation and communication.
Generally, physicians tend to experience helpless later on a challenging interaction with a patient, and may be unsure about how to take things forward or whom to consult for communication. As previously stated, in nigh EU countries, at that place is a lack of training in how to manage these cases and a possible response might exist to motility the patient to another colleague (i.due east. avoidance).
Organization
The potential effects to the patient and dr. will put more pressure on the system, as they may result in overuse of resources. This means that the patient will either endeavour the "physician shopping" approach, i.eastward. seeing several different doctors for the aforementioned effect and trying to collect different opinions, or inappropriately attention the accident and emergency section frequently trying to find a solution to a nonacute issue. Sometimes, patients adopt both approaches, which can overstretch healthcare systems in terms of chapters and costs.
Managing a challenging interaction
The optimal approach in dealing with a challenging interaction is to prevent information technology. If that is not possible, then it is all-time to create the conditions for dealing with a difficult state of affairs in a manner that is open up and rubber for all, and to develop the skills of agile listening and effective communication (table 3).
Table three
Tips on managing difficult interactions
| Programme your interaction in advance |
| Pay attention to nonverbal advice |
| Discuss with colleagues and practise not hesitate to seek additional training should this be required |
| Look for signs of acrimony or distress |
| Ensure rubber and maintain control |
| Create bridges of advice and trust |
| Explain the difficulty and try to find mutual ground |
| Assistance your patient get emotional control |
| Focus on highlighting solutions and resolve areas of disagreement |
Plan your interaction in advance
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Think in accelerate how all-time to deliver that news to that item patient, and structure your thoughts
Choose appropriate words that volition not offend or exist perceived negatively. Information technology is of import to break down information into small pieces that are like shooting fish in a barrel to empathize and to ensure the patient has a articulate understanding earlier progressing the chat. Asking patients to reiterate and confirm halfway through the conversation, and summarise at the finish, is always efficient, and ensures both parties share the same information and action plans.
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Practice not under-communicate the difficulties that occur with the disease
Call back that it is far better for patients to be prepared and to participate in the treatment decision-making procedure than to be kept in the dark or, even worse, be undermined. Try to create a positive "teamwork" with the patient.
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Consider the part of the patient'south partner or carer during the consultation.
This may exist the patient'due south spouse, parent or friend who tin can assist support the patient during the consultation. They may also take their own questions or concerns about the condition, which should exist addressed. The inclusion of a partner or carer is essential, peculiarly in a "bad news" conversation. 2 pairs of ears are better than one, especially when the information being received is negative, unexpected and/or difficult to understand. In such situations, it can be hard for the patient to take in. For such conversations, find out when the family unit member is bachelor to exist party to the conversation
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Ensure you deliver the news in an advisable setting, cheque they tin hear yous and ensure patient consent is obtained prior to having multiple people observing your consultation (e.one thousand. students)
Pay attention to your nonverbal communication
Nonverbal communication is equally of import equally the actual words a clinician uses during their interaction with the patient. Trunk posture, gestures and eye contact can all combine with verbal communication to facilitate a meaningful positive communication with your patient.
Provide ways to access farther information and support
Some patients may not take in all of the data y'all provide upward front, especially if they have received a new diagnosis. Providing your contact details, such equally your electronic mail address and phone number, may allow them to enquire you lot questions in their own time, subsequently the consultation has finished. Avoid telling patients not to read anything on the internet virtually their condition, just rather, consider ways in which you can provide access to additional data and back up, including sign-posting to counselling, support services and patient back up groups. Patient data resources published by your system are also encouraged.
Keep the initial information simple and effort non to apply too avant-garde medical language
Reassure patients that it is a adept thought for them (or their carer/partner) to write things down, whether at the fourth dimension of a consultation or a list of questions in accelerate of a consultation.
Talk over with colleagues and exercise not hesitate to seek additional training should this be required
What may be a challenging interaction for one person may differ from someone else. The human factor significantly contributes to the different perceptions further complicated past unlike experiences and after different comfort levels in dealing with different personality types and situations. There is no "one size fits all" approach. You need to be open up to learning and developing your practice, and discuss with colleagues or your mentor as this will provide you with valuable advice. On a similar note, never hesitate to seek additional training to further develop your communication skills (either online, face up to face up or at a professional development workshop). In a scientific, evidence-based, clinical setting, it may seem unfamiliar to develop and then called "soft" or interpersonal skills merely the techniques learnt will be just as valuable when communicating with colleagues and patients, and building relationships generally.
Is this condign a difficult situation?
Wait for signs of anger or distress, an increase in speed of voice communication, or a change in behaviour or body language. This may indicate that the patient is uncomfortable with the conversation or procedure. Steer the chat abroad from the topic and address information technology when the patient is more comfortable discussing it or consider whether the procedure is immediately necessary.
Create bridges of advice and trust
Some other central requirement for a positive interaction to occur is ensuring that the patient'due south psychological safety is ensured. This is particularly relevant for taking small risks when interacting with the patient while, at the same time, facing incertitude or ambiguity. The solution hither is to focus on creating favourable conditions in which any interpersonal risks between you and the patient are kept to a minimum. For instance, reassure the patient that they can feel safe and communicate openly with you in order to plant trust and ensure there is sufficient time scheduled for the consultation, so that yous are not rushed.
Explain the difficulty and endeavour to discover common ground
Try to put the focus on the "elephant in the room", i.e. verbalise the problem in a kind however articulate manner and find some mutual ground with the patient. Establishing common ground is a key point in reducing any tension that may have arisen. The patient needs to take confidence and actually recognise that you lot are listening to them. For example, you can show understanding towards the patient'south anxieties and worries, and reflect this agreement back to the patient. This shows empathy, and may assist the patient feel more comfortable, permit off some steam and vocalisation any underlying problem or business concern that contributed to the challenging interaction. On some occasions during these "de-escalation" conversations you may realise that there is an alternative explanation to the patient'southward feelings and this may have increased their anxiety or fearfulness.
Assistance your patient get emotional command
Feeling helpless and hopeless is a mutual challenge encountered by a patient facing a difficult health condition. Imagine being a patient yourself. Not being in control can trigger negative emotions and can make communication difficult. Empathy and constructive listening tin help with this. Also, keeping the patient informed and involving them in the controlling process is the basis for giving them a sense of control. Comport in mind the psychological bear upon of your conversations with the patient and the possible symptoms it might cause, especially in respiratory patients. For example, many of our patients develop problems with feet, panic attacks and hyperventilation, which can evidence more debilitating than some of the other symptoms of their condition.
Focus on highlighting solutions if in that location are areas of disagreement
After summarising the state of affairs and hearing opinions from both sides, give the patient two or three options with balanced information; this changes the focus from any miscommunication or argument to action, and helps to redirect the patient to a solution-focused path. Allow fourth dimension for questions and discussion with the patient. The patient should feel valued and involved in the controlling procedure.
Enquire the patient how the consultation went.
We must admit that nigh of u.s. forget to do this. Use open questions along the lines of "How do y'all think your consultation was today?". Have time to listen and, where necessary, clarify.
Get some time to reflect
Later whatsoever challenging interaction, it is important to reflect on what happened and identify what could exist improved. How did your actions contribute to the situation and what could you have washed differently? Call up about difficult people and situations as your teachers, non your enemies. How will yous accept that learning forward for next fourth dimension?
This thought process will help you in future challenging situations and provide better insight as to how to manage like cases in the future. It is always useful to discuss this with peers/colleagues to get some feedback and update your supervisor or head of the section.
Regardless of the result, your personality, patient characteristics and challenges in the healthcare organisation, try to stay in line with your mission to evangelize optimal medical care to all your patients.
Acknowledgements
Many thanks to Gill Hollis, Lisbeth Høva and Janette Rowlinson, who kindly provided feedback and gave us patients' perspective on our manuscript.
Footnotes
Disharmonize of interest A. Niculescu is an employee of the European Respiratory Society and P. Powell is an employee of the European Lung Foundation.
Suggested reading
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Articles from Exhale are provided here courtesy of European Respiratory Guild
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467659/
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