Dealing with Difficut Physicians..

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Permalink Reply by beka on May 14, 2009 at 1:34pm

Let's begin - ( I am going to write a lot..)
When you find yourself dealing with a difficult physician, there are ways to improve your patient relationship that don't involve childish pranks. Patient friction is best dealt with before it grates away at productivity. Here are some practical tips to help you deal with a difficult physician.

It may sound like something out of a fortune cookie, but it's true: The first step toward resolving conflict begins with you. You have to change your own attitude before you can tackle everybody else's problems including your own. Everybody has off days. Understanding your own attitude when feeling stressed or helplessness grants you sympathy from your physician when they're also having a bad day. WE ALL HAVE BAD DAYS.

The same is true when you relate with physicians. According to Jennifer King, a psychologist and director of Bristol, United Kingdom-based Edgecumbe Consulting Group, "If we take the view that many difficult doctors are really doctors in difficulty, we are likely to approach the problem more constructively and with a better chance of success." The goal is not to prove who is right and who is wrong; the goal is to reorganize theoffice appointment to create less friction.

Another necessary survival skill is professionalism. "Professionalism" is more than just a two-bit word thrown around at resume-writing classes. It is essential to smoothing out pateint-doc friction. Professionals believe they're not just doing their job – they're changing the world, one life at a time. THIS APPLIES TO EVERYONE..

Proactive thinking is key to professionalism. Anticipating problems and making changes should be a priority anytime you're working with the difficult physician. WRITE OUT YOUR QUESTIONS.

This could be a range of simple acts, from not chewing gum when talking to the physician to conducting research on a your condition before approaching the physician with questions about treatment. Radiologists require concentration to make diagnoses that can drastically alter a patient's life. If you're going to break their concentration, do it for a good reason and have your facts straight first.

Next, listen up. Listening for the meaning behind what people say is like a puzzle game. For example, when the physician says, "All of these exams look terrible," if you only listen to the words, you are liable to respond defensively. But, if you pay attention to the level of the physician's feelings, you might hear "I am stressed out and frustrated by these test results." Then, if you take the listening to the next level and put together the puzzle pieces of meaning, you might hear "I am having a difficult time making a diagnosis from these images and results." Responding to the physician on this level of meaning allows you to escape defensive behavior – and even anger – and helps you sympathize with the physician and respond by asking, "What can we do to help reach a diagnosis for me?"

You should also be assertive. Assertiveness is the fine art of confronting a problem without appearing confrontational. The first rule of assertiveness is to use your words, not your tone of voice, to express your message. In other words, do not sound angry or annoyed as you assert your point. Say it in the same flat tone of voice you might say, "Will you pass the butter?"

Use "I" language to assert yourself in your message. For example, "I feel nervous when you raise your voice." This message forces the receiver to realize that you're a person with dignity and deserving of the physician's respect. It also puts the focus on the behavior and symtoms, not the person, which is crucial to encouraging change.

Your message must make it clear that you believe the physician is capable of changing. So, if you are put in an aggressive situation, respond by attacking the physician's behavior, not his or her character. KEY, KEY, KEY..


But sometimes a friendly office environment just isn't enough. In this case, it may be necessary to have a formal discussion, or even an intervention, with the difficult physician. If intervention is necessary, consult with a social worker or behavioral health specialist about ways to approach a problem without making the guilty party go on the defensive. And remember, compromise is imperative.

Resolving grudges is not an easy task and may require innovative thinking. Don't be afraid to experiment with solutions, but keep in mind the basic tenets of diagnostic medicine: An imaging department is a team working to aid the patient. A neurologist often works by him-herself.

But if the difficult physician still continues to complain about you or your symptoms, try to view his complaints as places for improvement. Set goals, try to fix the problems and track your changes. Then be prepared to say, "Last month, we were told this medication protocol was sub-par. So, we made some changes and here are the results." JOURNAL

( Also, learning about digital photography and computer photo editing is rewarding, especially when you are pasting a picture of the physician's face on a bathing beauty. But, it may be best to save that suggestion for April Fools' Day.. )

During my 5 years without a diagnosis, and after getting one - youdont want to do what I did , send a photo from 1896 with 4 family members with cervical dystonia. That just allieanated them ... BUT DID IT anyway...

beka
More...
Thanks to Brian in Utah in PT !

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Permalink Reply by beka on May 14, 2009 at 2:06pm

The following has to with Difficult Patients - Both sides of the Fence
DEALING WITH DIFFICULT PATIENTS

By Genji-kun
Email to: makoto_sipuden@yahoo.com





DEALING WITH DIFFICULT PATIENTS


From time to time every physician AND NURSE is going to have to deal with difficult patients. Depending on the degree of difficulty, this can create an arena in which a malpractice claim can flourish. Difficult patients fall into certain categories, and each requires careful handling. Each also requires the physician to become more than a healer. The categories of difficult patients include:
The drug seeker
The referral seeker
The malingerer
The self-destructive patient
The non-paying patient
The non-compliant patient
The anxious patient
The narcissistic patient
The “general”

THE DRUG SEEKER: This is a patient who simply wants drugs–narcotics, hypnotics, tranquilizers, or any drug that has abuse potential. Like any addicted person, the drug seeker will lie, cheat, or steal to get what he/she wants. He will use flattery, or will report false symptoms or non-existent chronic pains. This patient has a pattern of switching physicians frequently, and using as his reason that the doctor was incompetent, or not giving him proper treatment. If you suspect that a patient is a drug seeker, document every aspect of his treatment, including all conversations. If you do not give him the drugs he wants, he will probably move on quickly, but in case something goes wrong while he's in your care, it is crucial to have complete documentation.

THE REFERRAL SEEKER: The referral seeker always wants to be referred to a specialist, or wants care or treatment that is neither indicated nor covered by her insurance. She needs her primary care physician to make those referrals. In this age of managed care, the referral seeker has increased potential for malpractice litigation because many consumers believe that primary care physicians withhold care in order to increase their earnings. It is therefore very important to handle the referral seeker with care. Explain exactly–in non-medical, simple language–why you are not making the referrals that she is seeking. Then document every detail of her care, and why you have made the decisions you have regarding her case.

THE MALINGERER: The malingerer might be someone who simply wants to get medical excuses for repeated absences at work, or repeated tardiness, or perhaps even extended disability or leave with pay. The malingerer might also be someone who is planning a lawsuit as a result of an accident, like a car wreck or a work-related mishap. Often this is a person with minimal trauma who simply fails to get better, even though the prescribed treatment should be working. It can also be a patient whose improvement rate is rapid, then slows down for no apparent reason. The best approach with a patient who is not getting well and you suspect of possible malingering is to confront him directly, but tactfully. Explore with the patient their intentions regarding litigation, not returning to work, or other areas of possible secondary gain. If the patient is seeking some secondary gain, explain–again tactfully–that your job as his doctor is to help him get well. Make a record of your conversation in the patient's file. You should continue to treat the patient, but make certain that your documentation of treatment and your conversation is thorough. Quite often a patient who is planning to use his physician to achieve secondary gain, and therefore not being totally honest about his recovery, will change doctors if he knows that the doctor is aware of what he is doing.

THE SELF-DESTRUCTIVE PATIENT: Self-destructive patients range from those who simply don’t take very good care of themselves, to those who seem to be purposely inviting disaster. They include:
The asthmatic who continues to keep household pets
The heart patient who won’t quit smoking
The woman who has multiple pregnancies and abortions, but will not use contraception
The tension headache sufferer who refuses to try and reduce stress or alter a tension-filled lifestyle
The patient who “forgets” to take medication on purpose

THE NON-PAYING PATIENT: This might be a patient who is insured but refuses to pay his co-pay or deductible. It can also be an uninsured patient who cannot afford or will not pay for medical care.

Whatever the cause, your front office staff can help by determining how care will be paid for in advance. They can also note outstanding balances and how long they have gone unpaid.

An accurate assessment of the payment problem by front office personnel can improve collections and avoid misunderstandings.

THE NON-COMPLIANT PATIENT: When dealing with a non-compliant patient, a suggested approach is to:
Document the patient’s failure to comply
Document the patient’s reasons for non-compliance
Document your recommendations
Schedule follow-up in a timely manner
Look for negotiable moments

“Negotiable moments” are those times when there is an opportunity to suggest a healthy change to the patient, like when a smoker wants to start birth control pills, or when certain preventive tests are recommended per the Guide to Clinical Preventive Services. Since smoking can exacerbate the possible side effects of the pill, a smoker should be advised to use some other form of birth control. However, because of the high rate of effectiveness and convenience of taking the pill, this could be a good time to encourage the patient to quit smoking so she can use an oral contraceptive. And when a preventive test is being recommended to a patient, the opportunity is at hand to recommend certain self-preserving behaviors. Remember, you can suggest, but you cannot coerce a patient to follow the guidelines. It is his or her decision and as the primary care physician you must continue to treat the patient whether he or she follows the guidelines or not.

THE ANXIOUS PATIENT: Patients who appear to be very anxious might simply be going through a particularly stressful period in their lives. However, they might also suffer from anxiety-related illnesses. In the past few years great strides have been made in diagnosing and treating a variety of anxietyrelated illnesses, and we have learned that there are certain symptoms to look for. These include:
The patient whose anxiety is out of proportion to medical problems
The patient who is prone to hysteria
The patient who suffers panic or anxiety attacks
The depressed patient who never seems to be feeling or getting any better and worries incessantly

It is important to take care when dealing with patients who might suffer from anxiety-related illnesses. Ruling out organic disorders is the first step. This may include referring him/her to a specialist. Reassurance is the second step. The use of anti-anxiety medications is the third step.

THE NARCISSISTIC PATIENT: This is a patient who just likes to talk about himself. He wants an audience, not health care. This is another patient with whom great care should be taken to document all treatment, conversations, instances of non-compliance, etc.

THE "GENERAL": This is a patient who comes to your office and orders your staff to do a certain lab test without consulting you. Often a mother, she feels she knows best how to evaluate her teenage son’s problems– with a test she heard about from a relative, health food store employee, or chiropractor.

Techniques for dealing with difficult patients
Additional techniques for dealing with problem patients include:
Discuss the behavior openly with the patient;
Try to get the patient to enter into an “agreement” which demands that the patient alter the negative behavior and in return the doctor will continue to treat him.
When all else fails, consider termination of the patient-physician relationship.

Discharging a Patient
Discharging a patient is never an easy thing to do, but sometimes it is necessary in order to avoid being placed in a position of compromising professional ethics. Or if it makes you vulnerable to an unwarranted malpractice claim by a patient who isn’t getting what he or she wants from you. Make sure you follow certain procedures when you discharge a patient so that charges of abandonment cannot be brought against you. These include:
As soon as you become aware that there is a problem dealing with a patient, document this fact in the patient’s file. But remember a patient has a right to see all her records, so be tactful in your remarks.
If the patient is non-compliant, or misses appointments, document that in the record.
Discuss the problem directly and tactfully with the patient, and avoid appearing to be angry or judgmental. Make sure the patient understands that you are concerned about her and her health and well being.
If you decide that you must discharge the patient, do so in person. Again, do not appear angry or judgmental. Make sure you make the point that you are doing so because you feel perhaps the patient will be more compliant with another physician.
Give the patient a reasonable amount of time to find a new doctor, and agree to provide emergency services during that time. However, make sure the patient knows that after that time you will not provide any services.
As soon as you’ve told the patient, follow-up in writing. Completely document in that letter all the reasons for the discharge, then mail it via registered mail, and keep a copy of the receipt along with a copy of the letter in the patient’s permanent file. (See Exhibit C in the appendix.)

Anyone who practices medicine in a group has to be able to recognize a difficult or disruptive doctor. This doctor can not only increase the chances of a malpractice claim being filed, but can create the atmosphere for all sorts of litigation from disgruntled employees, suppliers, etc. Unfortunately, as the stress of coping with the constantly changing face of medical care has increased, so has the number of disruptive doctors. No one is immune to the effects of stress. Therefore it is very important that you protect yourself by putting in place certain guidelines that all health care providers in your practice must meet.

In his article, “Managing the Unmanageable: The Disruptive Physician” in the November/December 1997 issue of Family Practice Management, John- Henry Pfifferling, Ph.D. offered a model for creating a practice agreement. This is an excellent model because it deals not only with what he refers to as “Reasonable expectations,” but with “Unreasonable behavior.” By being this direct you avoid all sorts of inferred or implied violations of the agreement. Everything is spelled out. Pfifferling’s model is listed as followed:

REASONABLE EXPECTATIONS:
Complies with practice standards
Uses conflict resolution skills in managing disagreements
Addresses concerns about clinical judgments with associates directly and privately
Addresses dissatisfaction with policies through appropriate grievance channels
Communicates with others clearly and directly, displaying respect for their dignity
Participates in regular behavioral feedback
Supports policies promoting cooperation and teamwork
Is open to constructive criticism

UNREASONABLE BEHAVIOR:
Fails to comply with practice standards
Shames others for negative outcomes
Uses foul, abusive language
Arbitrarily sidesteps policies
Acts in ways that could be perceived as sexual harassment
Threatens associates with retribution, litigation or violence
Criticizes staff in front of others
Is disrespectful or discourteous a majority of the time
Relies on intimidation to get his or her way
Communicates indirectly about clinical decision making

This model is offered as just that–a model. It is up to each practice's members to create their own agreement, but it is a necessary tool in risk management.

There might also be times in your career when you have to deal with a doctor who is either incompetent or unethical. In those situations proceed cautiously. Document each instance that creates the suspicion. Do not discuss the matter with others in general, but use the channels already in place for making your concerns known. Do not make disparaging remarks about the doctor, or attempt to launch an “investigation” on your own. Remember that if you are wrong you will not only do grievous injury to his or her career, but to your own as well. However, you must protect yourself from malpractice claims that might arise as a result of his/her actions, so if the occasion arises you must take action.

The Final Word

It is impossible to completely eliminate errors by human beings, or equipment, or systems. All are fallible. It is possible however to lower the incidence of error, and to lessen the penalties whenever an error occurs. Learning the lessons of this course, sharing them with members of your staff, and putting them into immediate action can help accomplish this. Remembering that all members of a health care team owe a duty and responsibility to each other is also key, because it will help raise the level of communication, and as we have seen strong communication skills–with patients and with colleagues and co-workers–is a critical element in preventing malpractice claims.

If a mistake is made, do not try to cover it up. Deal with it in a direct, calm manner. Avoid placing blame, or directing it toward others. And if it appears that a claim might be filed, contact your liability carrier immediately. If a claim is filed let your attorney handle the matter. Do not discuss the case without the advice and consent of your attorney, and don’t seek opinions from other physicians on your own.

Hopefully, you will always be free of malpractice claims. But if you are not, the stronger the risk management skills you develop, the stronger the defense you will be able to provide.
MORE...

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Permalink Reply by beka on May 14, 2009 at 2:16pm

If Your MD Does Not :
Commandment I: Do the right thing. "It's so much easier to do the right thing than think of a legalistic way to handle the situation," he said. Physicians should always stop and think about what they are doing, and approach the problem with compassion and empathy. The physician and the patient need to find a mutually satisfying solution.

* Commandment II: Be sure that the patient has decision-making capacity. "Otherwise you'll be in big trouble," Dr. Lubin said. "Allowing a patient to leave when he's a danger to himself and others is not the right thing to do." If a patient is waiting for care and suddenly wants to leave, the physician should find out why For example, a patient with breast pain may want to leave because she has seen people die from the disease in recent months and is alarmed about the possible diagnosis.

* Commandment III: Do not discharge a patient from your care without the best possible treatment you can give, and always follow up with the patient, "You can't abandon the patient," Dr. Lubin said. If a physician explains why leaving is inadvisable but the patient leaves anyway, the next commandment is especially vital.

* Commandment IV: Meticulously document what happened. "This includes what you told the patient about the consequences [of the patient's actions] and the treatment and follow-up that you have arranged," he said. He also suggested that physicians get documentation from others about what happened.

* Commandment V: Never lose your temper. If physicians feel the urge to vent, there's always the supply closet, Dr. Lubin said. Losing your temper with colleagues and ancillary staff also isn't allowed.

* Commandment VI: Do not feel obligated to put yourself in danger of physical assault. Keeping tabs on your own temper doesn't mean that you should accept foul language or violent behavior from a patient. The physician has the prerogative to ask the patient to leave--or get out of harm's way.

Even more frustrating than foul-mouthed patients are insistent ones, Dr. Lubin continued. In one hypothetical case, he described a 45-year-old man in good health who presents to a physician with frontal headaches that have become more frequent in the past 6 months. The patient mentions that he is going through a difficult divorce from his wife. He insists that he needs a CT scan of his head, even though there is no evidence of an intracranial problem on his physical exam or in the routine lab data.

It's tempting in such cases to ask the patient where he got his medical degree or to tell him that the CT scan is a silly idea--but there's a better alternative:

* Commandment VII: Never be distressed by insistent patients. Sometimes, a patient comes into the office with a list of problems, a list of doctors whose treatment efforts haven't succeeded, and a list of medications that don't work. These patients often have an even longer list of procedures, tests, and medications that they want. The physician should tell the patient that the test is not needed--and explain why.

* Commandment VIII: When a patient has a lot of new nondescript complaints, be sure to explore the possibility of depression. Somatization usually appears before the age of 30 and commonly occurs in females. The problems are not life threatening, and "you will be unlikely to cure them," Dr. Lubin said. Providing lots of medications or procedures isn't the answer. "These patients usually do better if they deal with doctors who give them respect."

* Commandment IX: You have an obligation to care for your share of these difficult patients.

* Commandment X: Do not act as if your ego or your wellbeing is adversely affected by the patient's nonadherence. It's important to find out why the patient isn't taking the medication.

"Just because they're difficult patients doesn't mean they don't have real concerns," Dr. Lubin concluded.

COPYRIGHT 2003 International Medical News Group
COPYRIGHT 2008 Gale, Cengage Learning

IF YOU DONT SEE CHANGE IN YOUR CARE, FIRE THE PHYSICIAN. There is always somehere online who can help you find another movement disorder specialist. To let the disorder just go with a diagosis or treatment, is simply foolish. Think about it- there are plenty of people who NEED and WANT you, regardless of the state you are in or how you look...YOU MATTER
beka
phew...

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Permalink Reply by beka on May 14, 2009 at 1:42pm

MORE ...
Just like some patients can be "difficult", so can some doctors ( though this is not something most doctors would acknowledge - at least not about themselves !) Doctors can be rude; inconsiderate; hurtful and insulting.
A good example would be the doctor who answers a patient's queries by saying - "Are you the doctor or am I ?" These doctors have an inflated sense of self-worth, and enjoy putting patients in their place.
Patients need to remember that no doctor can survive without patients, and there is no need for you to put up with such behaviour. Medicine is a service profession and any doctor who is not willing to serve his/her patients is not a good doctor.Sometimes patients get intimidated by a doctor's reputation or his entourage of assistants, but you cannot afford to leave your brains or your self-respect at home when you visit your doctor !
If you are fortunate enough to be paying your doctor ( fee for service), your best option would be to walk out. But even if you are in an HMO, you still have options, so don't feel helpless ...

Thanks to Dr. A. Malpani for blogging about this topic..

More....Told ya , I would write a lot !!
beka

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Permalink Reply by beka on May 18, 2009 at 4:03am

I have added this info to help patients and docs relate.. so we all can get better care...of course, that still remains an issue...in ICU, in every hospital, in every office, clinic etc...
beka

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Permalink Reply by RevWagner on May 28, 2009 at 6:22am

Beka I am fired up right now. I am not sure this is the place for this post, but I did not see a better one. My insurance company is insisting that I go back to the U of M one more time. These "Docs" wrote that I was making things up, because I am nurvious around people. Despite the fact that I have been a Pastor for 14 years. They ticked my neurologist off, and he had his secretary call me to drop me as a patient. The truth is as we get closer to socialized medicine we have less choice. I can get care as long as they want me to get care. I must give a big shout out for my family doc. He has been my biggest advocate though this whole thing. His hands are tied by Priority Health. I am not one to make a scean, but everything in me wants to take the Psyc. report with me. I want to tell them that if they are not competent enough to help than get out of the way so I can get help. Do I have a right to ask to see the department head, or do I have to settle for another green student who is still learning. I do not want to get thrown out; so what can I say without saying too much. How can I remain professional, but still get my point across. Anyone have any advice. I am just so tired of dealing with all this. My platelet count is back down to 25-30, and the last thing I want to do is deal with the U of M right now.

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Permalink Reply by beka on May 29, 2009 at 5:21am

You have every right to see the Dept head... so why is the neurologist dropping you ? Is this the same one that asked for names of other docs last week that I sent you ??
Can your Primary Care Internist refer you to one of these other docs on the list I sent you ??? Once you have a psych report it just follows you around... Sometimes YOU HAVE TO MAKE A SCENE about your own care.
Whose body is it ? The docs , the University or YOURS ??
beka

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Permalink Reply by RevWagner on May 29, 2009 at 7:08am

The neurologist dropped me months ago when the U of M said I had Psychogenic Dystonia after an one hour appointment. They questioned his treatment of me, and he was worried about treating me for PNKD when a university said it was psychogenic. My primary care is the only doc I see for dystonia. I have not seen a neurologist for about a year. No one else would see me because the first neurologist I saw in 30 minutes diagnosed me as malingering. The psych report is positive for me, because it states that I do not have Psychogenic Dystonia, and am not malingering. I wonder if these neurologist realize how much they mess up a patient when they label them as "faking". I am sure that I have not seen the end of it all. My greatest fear is that I will die from this ITP thing before someone takes me serious. I have a mother, aunt, and brother with PNKD, and they have told me that probably two of my kids will have PNKD. The more they fool around with me the less time they have to find something that might help my kids.

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Permalink Reply by beka on May 29, 2009 at 11:41am

I want you to first see your hematologist ( I hope that you have been referred one ) to increase that low platelet count.No bumps or bruises.No,the more complex a patient is,the more likely it is for any physician to treat the complex patient. Many forget the Do NO HARM oath when they graduated from medical school.

beka

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Permalink Reply by kdorff on June 1, 2009 at 8:29pm

My vision of the world, indubitably seen through rose colored glasses, but for what it is worth...

It seems like a good set of non confrontational responses to the doctors at U of M, if you really are forced by your insurance company to go there, and they still seemed convinced you have psychogenic dystonia, is:
1) I appreciate that you tried to help me last time by sending me to a psychologist, but the psychologist hasn't been able to help me and moreover sees no evidence that I have psychogenic dystonia. Do you have any ideas about how I should seek help for a mental health disease that mental health professionals see no evidence of?
2) Given what I know about the diagnosis of psychogenic dystonia and especially given my psych report, I have a hard time accepting that I really have psychogenic dystonia. Can you explain to me what symptoms I had that caused you to diagnose psychogenic dystonia? Is there anything that you noticed during the short period that you spent with me that was convincing enough to warrant my continued diagnosis of psychogenic dystonia, even in the absence of corroborating evidence from a psychologist?
3) There seems to be a lot of differing opinions about the process of diagnosing psychogenic dystonia, but multiple sources seem to suggest that the best way of diagnosing it is by combining the expertise of a neurologist and a psychiatrist over a long period of time. If you continue to believe strongly that I have psychogenic dystonia, would you consider working with my psychiatrist to confirm my diagnosis?
4) I've done a lot of things since I started showing symptoms of dystonia to try to treat the symptoms of this illness. I appreciate that in a few cases, psychiatric help can alleviate or at least improve symptoms, but so far it doesn't seem to be making any difference in my illness. Is there some other treatments for dystonia that are worth trying next?

I know that you believe that you don't have psychogenic dystonia, and it sounds like with many good reasons. Please don't take the questions above the wrong way...I don't mean to suggest in any way that you have psychogenic dystonia or consider it a sensible diagnosis, and I wish you luck shaking such a label. Neurologists are being really irresponsible in my humble opinion, as well as in several medical studies' opinions, to diagnose psychogenic dystonia rather than sending patients to a psychologist to evaluate the possibility. Unfortunately you are now stuck trying to advocate for yourself that you do not have a mental illness, a difficult thing for anyone to do. The more you can use your psychologist or his report to advocate for you, the better. Although showing up and making a scene about your diagnosis would undoubtedly be satisfying, an outward acceptance that psychogenic dystonia was a reasonable, but incorrect, thing to consider might make the neurologists feel less like they are trying to defend their previous conclusion and more like they are working with you to help you, a patient who is fundamentally in pain. Best of luck!

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Permalink Reply by TWISTEDJAM on May 29, 2009 at 11:54am

Beka ... "Dealing With Difficult Physicians" makes an excellent discussion !

Thanks so much for posting ! ! !




Grace

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Permalink Reply by beka on May 31, 2009 at 6:20am

I posted this info to teach you all how to talk to docs- they are not Gods and DO make mistakes.
We all are human.
beka

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