Practice Tips

Effective communication is essential to the delivery of high quality, safe patient care. Communication failures can lead to adverse patient outcomes.

We communicate every day, yet often our communication efforts fail. The Joint Commission has identified communication failures as a root cause in many sentinel events. Breakdowns in communication between patients and providers, and between providers are key factors in adverse patient events that lead to malpractice claims.

Patient-centered care is at the heart of improving communications. The Institute of Medicine defines patient-centered care as “providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.” With this concept in mind, organizations should develop methods to improve the communication skills of their staff. There are several models outlined in healthcare literature that organizations can adopt to improve provider and staff skills.

Empathic listening is paramount to effective communication. Empathy has been described as attempting to temporarily walk in the shoes of another. One JAMA article states that empathy has become a critical component of today's physician-patient relationship. The article goes on to state that when patients are treated with empathy, they are more forthcoming with symptoms and concerns, participate more in their care and gain autonomy, which in turn yields more accurate diagnosis and better care.

According to an article published in American Family Physicians, “Empathy requires understanding the patient’s circumstances and perspective. Empathic listening skills and a non-judgmental, caring attitude are necessary to improve patient trust and adherence to treatment. This approach may decrease unnecessary diagnostic testing and reduce the risk of malpractice accusations.”¹

While communicating effectively leads to improved patient relations and improved patient outcomes, there are times when providers and staff encounter difficult conversations with patients. Studies have shown that providers rate as many as 15–30% of their patient encounters as "difficult.”

Factors such as personality disorders, multiple and poorly defined symptoms, non-adherence to medical advice, and self-destructive behaviors can lead to providers perceiving patients as difficult. Providers should consider screening these patients for underlying psychological conditions, such as depression, anxiety, and previous or current exposure to abuse, which may be contributing factors to the difficult encounters. 

Some studies have suggested that providers are more likely to misdiagnose “difficult patients,” in comparison with patients who engage in neutral or non-disruptive behaviors, regardless of the complexity of the care.

Patients frustrated with insurance coverage, high deductibles, long wait times, and other issues may choose to take out their frustrations on office staff. Staff not only need to know the technical aspects of their job but also how to approach patients in a manner that helps build a relationship where they can work together to address these issues. 

Strong communication skills are necessary to effectively deal with difficult patient encounters. Providers and staff members who feel increasing pressure to do more with fewer resources may wonder how they can find time in their busy schedules to improve their communication skills. Studies have shown that effective provider/patient communications increase patient treatment adherence, which can lead to improved outcomes and may reduce the time necessary to deal with these issues. 

Identifying how your attitudes and behaviors contribute to conflict in the workplace is a good first step in improving communication skills. Common factors such as negative bias towards specific health conditions, poor communication skills, and situational stressors may lead to communication breakdowns. Being aware of factors that affect your ability to communicate effectively is an important first step in overcoming these obstacles. 

Employing empathy can help to diffuse difficult patient encounters. Another article addressing difficult patient encounters notes that “empathetic lisening skills and a nonjudgmental, caring attitude are necessary to improve patient trust and adherence to treatment.”²

To employ empathy when interacting with patients:

• Actively listening to the patient with a posture signaling openness, good eye contact, and a non-threatening tone of voice will show the patient you are willing to listen to their concerns.
• Remember to accept the patient and not judge them.
• Acknowledge their feelings and thoughts and then reflect on your understanding of what they have presented to you.

Here are some expressions that can help signal to the patient that you heard their concerns and care about them:

• Let's see if I have this right.
• Sounds like you've reached your limit.
• That must have been very frustrating.
• I can understand why you might be feeling angry.
• I'm sorry that you had to go through that.

Once an organization identifies a communication model they want to use, it is important that staff be given the opportunity to practice the skills they have acquired. For example, staff can identify the top ten challenges they face when dealing with patients and then develop scripts staff can use to address these challenges. Role-playing is an important component of incorporating new skills into our behaviors. Listening to a presentation on how to improve communication skills can educate staff on available methods, but staff should be given the opportunity to practice these skills. Without this opportunity, they are unlikely to sustain the behavior change.

Medical Record Documentation

Thorough documentation of patient care is vital, especially with difficult encounters and a patient’s failure to follow treatment plans.

Include the following when documenting a patient’s failure to follow their treatment plans:

• Missed and canceled appointments including attempts to contact the patient to reschedule. See MMIC Practice Tip: Appointment Management: Missed and canceled appointments, referrals not completed.
• Missed diagnostic tests or referrals, including attempts to contact the patient to complete the tests or referrals. See MMIC Practice Tip: Results Management: Tracking Diagnostic Tests and Referrals.
• Each discussion of the recommended treatment plan with the patient, including the patient’s refusal and/or failure to comply with tests, consults, and office appointments.

Include the following when documenting difficult patient encounters:

• Describe the inappropriate behavior factually.
• Include, in quotation marks, the patient's or family member's rude, threatening, or inflammatory statements.
• If vulgar language is used, the following documentation may be made, "While using vulgar language, the patient complained about the office practice of ... The patient stated they would not put up with..."

Steps to take if the situation becomes out of control

If despite your best efforts, you perceive the situation is out of control:

• Locate yourself in a safe non-public section of the office. Alert your staff to assure they are nearby and on standby to offer you assistance. Never be the first in the room with the patient controlling the exit. Assure a staff member stays close to a phone and dials the police if requested.
• Set limits for the discussion if the patient's language and/or behavior is unacceptable. State that their language/behavior is unacceptable. "I realize you are angry, however, when you raise your voice, I find it difficult to assist you. If you lower your voice, we can work together to solve the issue." The goal is to gain control of the conversation while you investigate if there is a need and a way to meet the patient's voiced concerns.
• Write a simple document containing the behavior and the actions the patient has agreed upon and have the patient sign it. Ask the patient to verbally repeat the agreement. Place the agreement in the patient’s medical record and provide a copy to the patient.

If a patient’s behavior becomes dangerous to staff or other patients, it may be necessary to terminate the patient/physician relationship. See MMIC Practice Tip: Termination of Physician-Patient Relationship for steps to take in this situation.

Resources

^{1, 2.} Managing Difficult Encounters: Understanding Physician, Patient, and Situational Factors Rosemarie Cannarella Lorenzetti, MD, MPH; et al American Family Physician Web site March 15, 2013 Volume 87, Number 6

How can we better manage difficult patient encounters? Alan R. Teo, MD, MS et al, The Journal of Family Practice August 2013, Vol 62, No. 8

Managing Difficult Encounters: Understanding Physician, Patient and Situational Factors, Rosemarie Cannarella, MD, Ph.D., et al American Academy of Family Medicine.  2013

Difficult Patients More Likely to be Medically Misdiagnosed, Nancy A. Melville, www.Medscape.com March 16, 2016

Improving Communications-Improving Care American Medical Association, JAMA Article J Am Board of Fam. Med. 2006;19 (6) 533-541