If a Patient States I Will Never Come to the Hospital Again Are They Anxious
Breathe (Sheff). 2017 Jun; 13(ii): 129–135.
Top tips to deal with challenging situations: doctor–patient interactions
Georgia Hardavella
1Dept of Respiratory Medicine, King's College Hospital, NHS Foundation Trust, London, Great britain
iiDept of Respiratory Medicine and Allergy, Male monarch's College, London, UK
I Aamli-Gaagnat
3Dept of Clinical Scientific discipline, University of Bergen, Bergen, Norway
Armin Frille
4Dept of Respiratory Medicine, Academy of Leipzig, Leipzig, Germany
Neil Saad
vNational Center and Lung Establish, Regal College London, London, Britain
Alexandra Niculescu
6European Respiratory Order, Lausanne, Switzerland
Pippa Powell
7European Lung Foundation, Sheffield, UK
Short abstract
When challenging situations ascend in doctor–patient interactions, how tin can nosotros best manage them? http://ow.ly/J1GI30bD5wp
Raise your words, non your phonation. It is rain that grows flowers, non 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 as a patient ourselves. Neither commonly wishes to cause a difficult situation but common misunderstandings, by both groups, often event in such an occurrence. Communication and listening skills are essential for every consultation but in particular, for situations where the interaction may become difficult.
In this article, we will discuss what may make a consultation difficult and what outcomes this could atomic number 82 to, and provide some suggestions to help both you 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 communication between the patient and medical practitioner, and could be acquired past the doc, by the patient or by both. We accept outlined a list of potential scenarios in tabular array 1 and discuss how these might be perceived from both a healthcare professional and patient perspective.
Table 1
Nearly mutual 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 done in an appropriate 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.k. a life-changing diagnosis) without showing empathy or ensuring in that location is appropriate support available for the patient (eastward.g. counselling services or caregivers/family unit members around);
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during a consultation, uses poor nonverbal communication (due east.g. no eye contact with the patient, instead focussing solely on the figurer screen or notes; stance; gestures; or tone of phonation); or
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speaks ambiguously, not explaining, in manifestly language, long-term direction plans, or the importance or implications of diagnosis.
Alternatively, these scenarios may ascend when a patient:
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has done research online most their ailments and is convinced past their findings of a conclusion, and demands sure 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 take the doctor's 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 piece of work-ups past various medical teams, which tin can lead to frustration or a lack of trust in medical professionals;
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will not follow the suggested treatment but continues to attend consultations with deteriorating health (e.grand. a heavy smoker with severe asthma who does not stop smoking and believes that their inhalers exercise not work); or
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will focus on what went wrong rather than what is the all-time mode 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 place, and the variation in clinical practise between regions and countries. In detail, the majority of healthcare settings are overworked and overstretched to meet demand, and this continuously affects interactions. Insufficient fourth dimension for consultation or interaction with patients plays an important role, as healthcare system pressures are increasing patient numbers and expectations, against a background of cost-cutting. Foremost, information technology is important to bear in mind that both patients and healthcare practitioners want a positive interaction to ensure the best possible health outcome, equally time spent in consultations is valuable for both parties. Effigy ane 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 clinic with a set of beliefs 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 inside the healthcare arrangement that may be challenging to overcome and may generate some mistrust. They may feel that their illness is across their personal command, which tin can brand them dependent on others' help, particularly their healthcare professional. Such circumstances can, understandably, make a patient feel anxious, worried, hopeless and uncertain about their health, which can be displayed as tension and negative reactions towards the healthcare professional person.
With increasing advances in medical research, expectations of the healthcare system and in healthcare practitioners have besides increased. Patients can take very high expectations and trust in the arrangement, and when it appears that their status is a medical "dead end" or that their prognosis cannot be adamant with precision due to the nature of the illness, it can be very upsetting. Language barriers, cultural diversity and their previous interactions with professionals or authority figures tin can also contribute to and impact interactions, and lead to misunderstandings. Moreover, patients may also accept other considerations to make, for example, if their diagnosis may impact on other commitments (professional person, caring responsibilities, etc.). Patients often work, may care for children or parents, or have other commitments that may be impacted past the diagnosis or may accept 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 as "a patient" is not, and should non be, the only affair in their lives.
The healthcare practitioner
There is a wide variability in the evolution of appropriate communication skills among European healthcare practitioners and this has been a challenge. Communication skills courses or training are not included in the specialist curriculum in all European Matrimony (Eu) countries, nor are they included in the essential qualifications for specialist post applications.
A lack of advice skills preparation tin upshot in:
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inappropriate choice of words and phrases, perhaps due to assumptions being made about the patient's level of wellness literacy or understanding of human biology;
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lack of planned structure in delivering difficult news (e.m. scattered data confusing patients or no clear program at all);
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inappropriate choice of setting to deliver difficult news;
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lack of options offered to the patient;
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non involving the patient in the controlling procedure (e.g. treatment decisions taken without involving them and without addressing their needs and wishes);
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rushing the patient to agree to a proposed treatment plan;
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rushing the consultation due to other pressures; or
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not referring the patient to advisable support services/resources (e.g. counselling, palliative intendance, support groups and quality trusted information).
Bad news may exist broken in a nonempathetic way, letters may exist given to the nurses over the patient'due south caput while interrupting the consultation, difficult words may be used that the patient does not understand, and the patient may feel excluded from conversations with almost 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 up to terms with the diagnosis and its implications.
Overstretched clinic time may result in doctors non having time to actually listen to the patient'south concerns. What is the patient really agape of? What do they want to know? What are their experiences? These are questions that will be overlooked due to lack of time. Insufficient fourth dimension further impacts the consultation as at that place is not time for the patient to verbalise, and for the physician to appreciate, the valuable contribution that the patient brings in having the lived feel of the condition, especially if this is a rare affliction.
In a complex clinical instance, doctors may seem so preoccupied with finding the solution to the clinical problem that it is sometimes easy to forget that the patient might be overwhelmed by anxiety, frustration and negative emotions, and require re-assurance to experience safe, at ease and trust in the doctor.
Healthcare setting (either outpatient dispensary or wards) is a familiar setting for doctors to have difficult conversations, whereas for patients, it can be uncomfortable and sometimes awkward, peculiarly if they are at the point of receiving their diagnosis.
In addition, a physician's emotions may become the better of them or their behaviour might exist affected past a lack of slumber, hunger, their ain health status, lack of job satisfaction or other concerns. Finally, the doctor's approach and advice style volition influence their interactions and could have serious adverse furnishings on the patient (eastward.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 explain the condition in terms the patient could empathize).
Information technology's important for doctors to recognise that some patients may be intimidated and perceive inequality in the physician–patient relationship, which tin can exist exacerbated past doctors acting in a style that is perceived past the patient equally condescending or patronising. All this can be remedied with appropriate training and relevant professional development.
The system
Dysfunctional healthcare systems can only add together to the tension between patients and doctors. Uncomplicated things like long waiting times in the clinic, consecutive unjustified cancellations, or delays to previous appointments or investigations; essentially, anything that may have gone incorrect in the patient pathway tin potentially pb to a challenging interaction between patients and doctors. Doctors are probably the first person patients will spend some time with afterward something has gone wrong and therefore they will hear the patient'southward immediate frustrations offset paw.
Lack of resources in terms of staffing levels or of maintaining patient privacy and dignity during consultation is another contributing cistron; for case, during a consultation there may be several doctors or nurses moving in and out of the room that distract attention and may affect dignity and privacy.
A lack of centralised documentation systems tin sometimes lead to asking the patient to repeat the same information over and over once more, and consequently dedicating less time to actually managing the clinical case and addressing the patient'south needs. Abiding repetition for every new doctor may cause the patient frustration, while information technology is difficult for the dr. to know what the patient already understands.
Potential effects of a challenging interaction
Above all, it should exist acknowledged that patients want a positive interaction with their physician. In reality, a challenging interaction between patients and doctors should be considered within the healthcare organization in which it occurs. Patients seek professional help because they are in hurting or are concerned.
When the 3 factors of the patient, the dr. and the organization interact, a particularly difficult situation can ascend. Figure 1 summarises the near important contributing factors, which are outlined below. We all respond differently when in a challenging situation but our behaviour or response could have serious detrimental effects (table 2).
Table two
Potential implications of a challenging interaction
| Patient |
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| Doctor |
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| System |
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Patients
Patients tin exist overwhelmed by a variety of behavior and emotions: frustration, feeling they have little to no control over their diagnosis and wellness condition, uncertainty over the course of their treatment and prognosis, fear, worries, and overall dissatisfaction with the healthcare system. Advice between the patient and medical professionals may so be prejudiced and event in the patient losing trust in the doc. This can be further afflicted by the implications of the status itself on the patient's psychology.
Due to the combination of all this, patients can feel they are non heard and consequently feel more than vulnerable. They may have already arrived at the clinic 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 diverse handling options, assertive these may disrupt theirs or their loved ones' quality of life. They may have had had previous poor experiences of infirmary or healthcare settings and may fear that raising concerns or asking questions could delay or otherwise bear upon on their treatment. Their culture or upbringing may have led them to believe they should not always question somebody in authority even if they have lots of questions. A clinician rushing through an date may be perceived equally "harsh" or less considerate than 1 who takes the time to listen to the patient's concerns.
Healthcare practitioners
A challenging interaction for a medical professional already overstretched by the healthcare system may increase levels of stress, feet and acrimony, which in turn will impact on performance and communication.
Mostly, physicians tend to feel helpless afterwards a challenging interaction with a patient, and may be unsure about how to take things frontward or whom to consult for communication. As previously stated, in nearly EU countries, there is a lack of training in how to manage these cases and a possible response might be to move the patient to some other colleague (i.e. abstention).
Organization
The potential effects to the patient and medico will put more force per unit area on the system, every bit they may result in overuse of resources. This ways that the patient will either try the "medico shopping" approach, i.e. seeing several different doctors for the aforementioned event and trying to collect unlike opinions, or inappropriately attending the accident and emergency department frequently trying to discover a solution to a nonacute effect. 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 it. If that is not possible, so it is all-time to create the conditions for dealing with a difficult state of affairs in a manner that is open and safety for all, and to develop the skills of agile listening and constructive communication (table 3).
Tabular array three
Tips on managing hard interactions
| Plan your interaction in advance |
| Pay attention to nonverbal communication |
| Discuss with colleagues and exercise not hesitate to seek additional training should this be required |
| Look for signs of acrimony or distress |
| Ensure prophylactic and maintain control |
| Create bridges of communication and trust |
| Explain the difficulty and try to find mutual basis |
| Help your patient get emotional control |
| Focus on highlighting solutions and resolve areas of disagreement |
Programme your interaction in advance
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Recollect in advance how all-time to deliver that news to that particular patient, and structure your thoughts
Choose appropriate words that will not offend or be perceived negatively. It is important to break downward data into small pieces that are easy to understand and to ensure the patient has a clear agreement before progressing the conversation. Asking patients to reiterate and confirm halfway through the conversation, and summarise at the stop, is ever efficient, and ensures both parties share the same information and action plans.
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Do not under-communicate the difficulties that occur with the disease
Remember that it is far amend for patients to be prepared and to participate in the treatment decision-making process than to exist kept in the nighttime or, even worse, be undermined. Effort to create a positive "teamwork" with the patient.
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Consider the role of the patient's partner or carer during the consultation.
This may be the patient'southward spouse, parent or friend who can help support the patient during the consultation. They may also have their own questions or concerns about the status, which should be addressed. The inclusion of a partner or carer is essential, particularly in a "bad news" conversation. Two pairs of ears are better than i, peculiarly when the information being received is negative, unexpected and/or difficult to understand. In such situations, information technology can exist hard for the patient to accept in. For such conversations, discover out when the family member is available to be party to the chat
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Ensure y'all evangelize the news in an advisable setting, check they can hear you lot and ensure patient consent is obtained prior to having multiple people observing your consultation (eastward.g. students)
Pay attention to your nonverbal communication
Nonverbal communication is equally important as the actual words a clinician uses during their interaction with the patient. Body posture, gestures and eye contact can all combine with exact communication to facilitate a meaningful positive communication with your patient.
Provide ways to access further information and support
Some patients may not take in all of the information you provide up front, particularly if they take received a new diagnosis. Providing your contact details, such equally your e-mail service address and phone number, may allow them to ask yous questions in their own fourth dimension, after the consultation has finished. Avoid telling patients not to read anything on the cyberspace about their condition, but rather, consider ways in which you tin provide access to additional information and back up, including sign-posting to counselling, support services and patient support groups. Patient information resource published past your system are also encouraged.
Keep the initial information simple and try non to use besides advanced medical linguistic communication
Reassure patients that it is a good idea for them (or their carer/partner) to write things down, whether at the time of a consultation or a list of questions in advance of a consultation.
Discuss with colleagues and do not hesitate to seek additional training should this be required
What may be a challenging interaction for i person may differ from someone else. The human factor significantly contributes to the different perceptions further complicated by different experiences and subsequently different comfort levels in dealing with different personality types and situations. There is no "one size fits all" approach. Yous need to be open to learning and developing your practice, and discuss with colleagues or your mentor as this volition provide you with valuable communication. On a similar note, never hesitate to seek additional grooming to further develop your communication skills (either online, face to face or at a professional person development workshop). In a scientific, evidence-based, clinical setting, it may seem unfamiliar to develop so called "soft" or interpersonal skills but the techniques learnt volition be just every bit valuable when communicating with colleagues and patients, and edifice relationships generally.
Is this becoming a difficult situation?
Look for signs of anger or distress, an increment in speed of speech, or a change in behaviour or body language. This may point that the patient is uncomfortable with the chat or procedure. Steer the conversation away from the topic and address it when the patient is more comfortable discussing it or consider whether the procedure is immediately necessary.
Create bridges of communication and trust
Another cardinal requirement for a positive interaction to occur is ensuring that the patient's psychological safety is ensured. This is particularly relevant for taking small risks when interacting with the patient while, at the same time, facing uncertainty or ambiguity. The solution here is to focus on creating favourable atmospheric condition in which any interpersonal risks between you and the patient are kept to a minimum. For instance, reassure the patient that they tin feel safe and communicate openly with yous in order to establish trust and ensure there is sufficient time scheduled for the consultation, so that you are not rushed.
Explain the difficulty and try to notice common footing
Attempt to put the focus on the "elephant in the room", i.e. verbalise the problem in a kind yet clear manner and notice some common ground with the patient. Establishing common basis is a fundamental signal in reducing any tension that may have arisen. The patient needs to accept confidence and actually recognise that you are listening to them. For example, you lot can prove agreement towards the patient'south anxieties and worries, and reflect this understanding dorsum to the patient. This shows empathy, and may assist the patient feel more comfortable, let off some steam and voice any underlying problem or business that contributed to the challenging interaction. On some occasions during these "de-escalation" conversations you may realise that at that place is an alternative explanation to the patient'southward feelings and this may take increased their feet or fright.
Help your patient get emotional control
Feeling helpless and hopeless is a common claiming encountered by a patient facing a difficult wellness condition. Imagine existence a patient yourself. Non existence in command can trigger negative emotions and can make communication difficult. Empathy and effective listening tin help with this. As well, keeping the patient informed and involving them in the decision-making process is the ground for giving them a sense of control. Behave in mind the psychological touch on of your conversations with the patient and the possible symptoms it might cause, particularly in respiratory patients. For instance, many of our patients develop problems with feet, panic attacks and hyperventilation, which tin 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
Afterwards summarising the situation and hearing opinions from both sides, give the patient two or iii options with balanced information; this changes the focus from whatsoever miscommunication or statement to action, and helps to redirect the patient to a solution-focused path. Allow time for questions and discussion with the patient. The patient should feel valued and involved in the decision-making procedure.
Ask the patient how the consultation went.
We must admit that about of the states forget to practise this. Use open up questions along the lines of "How practice you lot think your consultation was today?". Accept fourth dimension to mind and, where necessary, clarify.
Go some time to reverberate
Afterward any challenging interaction, it is of import to reverberate on what happened and identify what could exist improved. How did your actions contribute to the state of affairs and what could you accept washed differently? Recall about difficult people and situations equally your teachers, not your enemies. How will you take that learning forward for side by side time?
This thought process will help you in future challenging situations and provide amend insight as to how to manage similar cases in the future. It is always useful to talk over this with peers/colleagues to get some feedback and update your supervisor or head of the section.
Regardless of the outcome, your personality, patient characteristics and challenges in the healthcare system, try to stay in line with your mission to deliver 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
Conflict of interest A. Niculescu is an employee of the European Respiratory Gild and P. Powell is an employee of the European Lung Foundation.
Suggested reading
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Articles from Breathe are provided here courtesy of European Respiratory Society
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467659/
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