Managing different types of challenging patients

Dr Emma Davies offers some tips on managing challenging situations with patients

The majority of patients are likely to be appreciative and have realistic expectations. However, there will always be a small number of patients who take up a disproportionate of time and energy for reasons outside disease management.

Whether it is frequent complaints, misuse of the system, unrealistic expectations leading to inappropriate demands, unwanted attention/stalking or even aggressive or violent behaviour, these situations can have significant impact on you and your team’s patience, morale, ability to focus, and sometimes you and your team’s wellbeing and safety.

Below is some guidance to doctors and staff on navigating these tricky situations.

When you receive a complaint

Getting it right first time can be helpful in closing down a complaint early on. We urge you to contact your medical defence organisation for advice in identifying the elements of the complaint and assisting with wording comprehensive responses. Many complaints can be resolved at a local level, with careful handling by the practice or hospital and good complaints procedures, as well as an offer to meet with the complainant to discuss the issues further and offer an apology,
where appropriate can prevent matters from escalating.

The Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners advises doctors that patients are entitled to honest, open, and prompt communication about any adverse events that have caused them harm and outlines that doctors should:

• Acknowledge that the event happened;

• Explain how it happened;

• Apologise, if appropriate; and

• Assure patients… that the cause of the event will be investigated and efforts made to reduce the chance of it happening again.

However, sometimes a complaint can become repetitive or vexatious. A patient may even decide to make a complaint directly to the Medical Council, and they may also choose to take this course of action should they remain dissatisfied with the practice or hospital’s response to a complaint. It is therefore important to get any complaint response right, first time, if this is possible.  

1) Patients who have unrealistic expectations

It is not uncommon to meet the patient with the ‘shopping list’ of issues that they want to explore in a single consultation.

We would caution against a blanket ‘one concern per consultation’ approach and advise doctors from the outset to explore a patient’s expectations and concerns so that they can then best manage these early on in the consultation. Asking “is there anything else you want to discuss”? after the opening conversation can be a simple, but useful tool.

If a patient comes with a shopping list, after consideration of any issues that require urgent attention (such as chest pain), asking “which of these is the most important one to look into today” and then gently suggesting that a further appointment is made for the other concerns can help. This way they feel heard and accept that you are in a position of wanting to help within the timeframes given. 

2) Patients with unacceptable behaviour

Everyone has a different threshold for what they personally deem to be unacceptable; for example, some people may be more tolerant than others when patients swear or become angry – but what matters is how a patient’s behaviour impacts the staff member. Remember, the safety of you and your staff should be paramount.

When faced with unacceptable behaviour from a patient or their relative, and if your personal safety allows, ask yourself if their behaviour is a manifestation of an illness or stress.

Being sworn at or threatened by a person who is obviously responding to external auditory hallucinations may also be very distressing and, depending on the physical power of the patient presenting these symptoms, may be a real threat to your safety. In both situations there may be a different level of risk to the practitioner, but also a need to ultimately ensure the patient gets the right treatment. The bottom line is your and your staff safety comes first.

If you feel that your personal or staff wellbeing is at risk, consider calling the gardaí. The care and treatment of the patient then takes priority once it is safe to do so.

There will be patients we encounter who display unacceptable behaviour that is not a manifestation of a treatable physical or mental health illness.

If it is deemed that the unacceptable behaviour is not the manifestation of an illness the following options are open to you:

• Ignore it – this is a personal choice and different practitioners will have different thresholds for what they feel is tolerable.

• Try to de-escalate the situation – unacceptable behaviour is often a result of unmet needs. If we can ascertain what these needs are, and we can realistically meet them, that may defuse the situation. Sometimes explaining the effect of their behaviour on your own wellbeing can assist, as patients may genuinely not have appreciated the effect of their behaviour.

• Write a warning letter – they should clearly describe the behaviour that was unacceptable and the impact it had on the staff member(s) concerned. For example, rather than saying “you were very rude on the phone and it is not acceptable” a description may be: “You raised your voice and talked over the member of staff who was trying to explain the situation to you and used language which the staff member found offensive. This led to the staff member feeling intimidated.”

• Consider a behavioural agreement that outlines what the patient can expect from the practice and vice versa.

• As a last resort, you may wish to consider removal of the patient from the practice list – however, this action may well trigger a complaint or an allegation of discrimination, so it would be important that other options are fully explored first.

It is therefore important to get any complaint response right,
first time, if this is possible

3) Patients who are stalking

Some doctors are subject to unprompted and unwanted attention, either in the form of negative attention or inappropriate declarations of feelings from patients. This is a very particular type of behaviour that warrants a robust approach. Again it is important to consider if the behaviour is a manifestation of an illness and consider if the patient needs referral to mental health services.

The Royal College of Psychiatrists in the UK has produced some helpful guidance on how to deal with stalking (www.rcpsych.ac.uk/members/workforce-wellbeing-hub/psychiatrists-support-service/helpsheets?searchTerms=stalking). The principles are equally applicable in Ireland. In essence, this involves telling the patient clearly what behaviour they have demonstrated; that this is unacceptable; describing the effect this has had on the recipient; and a statement that if the behaviour does not stop, there will be consequences, such as removal from the practice or even referral to the gardai, depending on the severity of the behaviour.

If you are struggling to manage a challenging patient, please contact your medico-legal defence organisation for further advice.