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Journal of Evaluation in Clinical Practice ISSN 1365-2753
Caring for patients during challenging clinical encounters James A. Marcum, PhD Professor, Department of Philosophy and Medical Humanities Program, Baylor University, Waco, TX, USA
Keywords clinical safety, evaluation, person-centred medicine Correspondence James A. Marcum Department of Philosophy and Medical Humanities Program Baylor University One Bear Place #97273 Waco, TX 76798 USA E-mail: [email protected] Accepted for publication: 17 November 2014 doi:10.1111/jep.12312
Abstract Rationale, aims and objectives Challenging clinical encounters can often be frustrating and demoralizing not only for clinicians but also for patients. The paper’s aims are twofold. The first is to analyse the nature and origins of such encounters. The second is to appraise the CALMER and REBELS models for managing them. Methods After reviewing the medical literature on challenging clinical encounters, a clinical case is briefly reconstructed from it. The reconstructed case is then used to analyse the nature and origins of challenging encounters and to evaluate the two models for handling them. Results The reconstructed clinical case is an apt example for examining and evaluating the medical literature on challenging clinical encounters. In terms of what challenging encounters are and what elicits them, the literature captures their frustrating, demoralizing, demanding and, at times, insufferable dimensions – as well as the role of patients in their origins – as the clinical case also illustrates. With respect to managing them, the CALMER and REBELS models are effective strategies for handling challenging encounters – again, as the clinical case exemplifies. Conclusions Although the clinical case supports the medical literature on challenging clinical encounters, the literature fails to provide an adequate account of their nature and origins. Specifically, challenging encounters are a type of dysfunction – not pathophysiological but existential – in a clinical setting, with their origins not only in patients but also in clinicians and health care systems. Finally, based upon the dysfunctional nature of such encounters, revisions of the CALMER and REBELS models are proposed for better managing these encounters.
Introduction Challenging clinical encounters are often frustrating and demoralizing not only for clinicians, both professionally and personally, but also for patients. According to one clinical study of primary care practices, the prevalence of challenging encounters ranges from 11% to 20% [1], whereas another study reports prevalence just less than 30% [2]. Consequently, for a reasonably sized practice, challenging encounters occur, on average, three to four times per day [3]. They generally require more time than an average encounter because of patients’ multiple complaints and their negative attitudes towards clinicians and even health care systems. They thereby often represent a greater burden on health care resources – at times resulting in waste of those resources and greater cost. Although the medical literature provides an adequate analysis of the general characteristics of challenging encounters, it does not sufficiently explicate their fundamental nature and origins [4–7].
Journal of Evaluation in Clinical Practice (2015) © 2015 John Wiley & Sons, Ltd.
In the present paper, the current medical literature on challenging clinical encounters – often blamed on patients – and the evaluation of how to handle them are examined. To that end, two questions are asked. What are challenging clinical encounters in terms of their nature and origins? And, how should clinicians manage them? After considering the answers to these questions as discussed in the medical literature, a clinical case involving a challenging encounter is reconstructed from it. The reconstructed case is used to analyse the medical literature, with respect to both explicating challenging encounters and assessing how to provide the best care during such encounters. Although the medical literature is supported by the reconstructed clinical case in terms of characterizing challenging encounters and how to cope with them, it fails to provide an adequate account for explicating their nature and origins. Specifically, challenging encounters are a type of dysfunction – not pathophysiological but existential – in a clinical setting, with their origins not only in patients but also in clinicians and health care systems. Finally, based upon the dysfunctional 1
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nature of such encounters, revisions of the CALMER and REBELS models are proposed for better managing these encounters.
What are challenging clinical encounters? In general, challenging clinical encounters represent frustrating and demoralizing episodes in which forging a therapeutic relationship between health care providers and patients is difficult, if not almost impossible. Traditionally, patients are often, if not exclusively, held responsible in terms of explicating their nature and origins; recently, however, clinicians and health care systems are beginning to be recognized as important factors involved in challenging encounters, which must be included in strategies to manage them effectively [8–11]. In this section, the notion of challenging encounters is first explored in terms of difficult patients, followed by the role of health care systems and clinicians. Several alternative designations of difficult patients with respect to challenging clinical encounters are present in the medical literature. The first designation, ‘hateful’ patients, is divided into four categories [12,13]. The clinger, whose chief characteristic is dependency, represents an initial category of these patients. A clinger often evokes aversion from the clinician. Another category is the demander, whose chief characteristic is entitlement. A demander generally evokes a desire to counter-attack on part of the clinician. A third category is the help-rejecter, whose main characteristic is manipulation, and evokes depression in the clinician. A final category is the denier, whose chief characteristic is selfdestruction. A denier evokes malice from clinicians. In addition to ‘hateful’ patients, an alternative designation of difficult patients is ‘heartsink’ patients. ‘Heartsink’ patients are often dissatisfied with the medical care provided and cause clinician stress and clinical staff dread upon their appearance [14,15]. Finally, additional designations of difficult patients include ‘frustrating’ [16], ‘challenging’ [17], ‘dysphoric’ [18] and ‘problem’ [19] patients. Although no one characteristic defines the notion of difficult patient with respect to challenging clinical encounters, in a study of primary care practices, these patients are around twice as likely to present with mental illness [1]. In addition, they present with particular functional diseases, such as irritable bowel syndrome or tension headaches, compared to organic diseases, such as arthritis or diabetes. Difficult patients usually present in the clinic with more than a single chief complaint or disease, whether functional or organic. A study examining primary care doctors’ perceptions of these patients revealed three categories of difficult patients: a wide array of behavioural issues, multiple/unresolved complaints and mental illness [20]. Mental illness also includes personality disorders [21] and somatization syndrome [22,23]. Patients are not the only source of challenging clinical encounters in which the patient and clinician do not forge a therapeutic relationship [24,25]. Studies show that medical uncertainty and breakdown in patient–clinician communication are also contributing factors to challenging encounters [26,27]. In addition, the health care system and its fragmentation of health care delivery often represent sources of challenging encounters that patients and clinicians experience during a consultation. For example, one study reported that HMO (Health Maintenance Organization) policies often lead to challenging or demanding clinical encounters 2
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[28]. Finally, clinicians themselves can also be a source of challenging encounters. A study found that clinician factors contributing to challenging encounters include age of clinician (55 hours per week) and personal problems such as anxiety, depression or stress [29]. In summary, challenging clinical encounters as frustrating and demoralizing episodes are often blamed on patients, who are either envisioned as difficult or non-compliant. However, patients are but part of the phenomenon of challenging encounters; both health care systems and clinicians share considerable responsibility for the challenges associated with these encounters and must be included when considering their nature and origins, as well as how best to manage or handle them.
How should clinicians manage challenging clinical encounters? The medical literature contains ample advice and strategies for managing challenging clinical encounters [30–33]. The ideal manner is to address the underlying cause(s) responsible for them, whether originating with patients, clinicians, health care systems or combination thereof. In the current medical literature, strategies for managing challenging encounters often pertain to commonsensical ways by which to cope with them, without compounding them. For example, advice for managing challenging encounters ranges from the practical, such as honesty with patients, to the creative, such as balancing multiple medications or ‘alchemical juggling’ [34]. In this section, two strategies, which are representative of the models within the literature, for managing challenging encounters – the CALMER and REBELS models – are discussed. The CALMER model consists of six steps [35]. The first is ‘Catalyst for change’ in which clinicians provide practical guidance to motivate patients to change their disruptive behaviour. In the next step – an application of the first through cognitive– behavioural techniques – clinicians assist difficult patients to ‘Alter thoughts to change feelings’, thereby restoring the ability of patients to control their behaviour. The third step requires clinicians to ‘Listen and then make a diagnosis’, so patients feel they are taken seriously and incorporated into the therapeutic process. The subsequent step invites clinicians to ‘Make an agreement’ with patients to meet regularly and to focus on specific medical issues that might compromise treatment. The fifth step includes ‘Education and follow-up’ in which clinicians assist patients in learning about their illness(es) and responsibility in the treatment plan. The final step encourages clinicians to ‘Reach out and discuss their feelings’ with colleagues, after challenging encounters. The REBELS model consists of six components [36]. The first commends clinicians to ‘Recognize’ a problem exists with a patient’s behaviour and then to inform the patient about the clinician’s perception of it. The following component encourages clinicians to exhibit ‘Empathy’ for patients, especially in terms of understanding the frustrations and fears surrounding their illness(es) that leads to clinical dysphoria. The third component requires clinicians to establish reasonable and secure ‘Boundaries’ during challenging encounters. The ensuing component urges clinicians to ‘Emphasize’ the welfare of patients when treating their illness(es). The fifth component encourages clinicians to utilize inclusive ‘Language’ when communicating with patients to motivate them to participate actively in their treatment. The final
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component counsels clinicians to shift emphasis from the problems patients face to their conceivable ‘Solutions’. Both the CALMER and REBELS models embody sound strategies for managing challenging clinical encounters. For example, clinicians honestly but sympathetically inform patients about uncertainties that exist in treating or managing their illness(es) but indicate that together they can develop a solution or treatment plan that respects patient preferences and dignity. The operative component is empathy, as delineated in the REBELS model, in which clinicians recognize patients may suffer not simply from organic disease(s) but also from mental and personality disorder(s) and from demanding situation(s) or context(s), which, in turn, need attending. In addition, clinicians set boundaries for challenging encounters in terms of not only patient behaviour but also clinician reaction to it. They then educate patients about possible treatment modalities and strategies, as recommended by the CALMER model, thereby including and motivating (and possibly empowering) them. Thus, both models converge to provide a comprehensive strategy for managing challenging encounters.
A clinical case of a challenging encounter Dr Jennifer Knox and colleagues from the Division of Hematology/Oncology at Princess Margaret Hospital in Toronto narrate a challenging clinical encounter [37]. Mr X – 62 years old – presented with a large renal mass with accompanying local adenopathy. He was retired from a successful business career and married. In a previous consultation with surgical staff, the patient was informed about treatment options either of nephrectomy or of neoadjuvant therapy in a clinical trial. He chose the former. But, near the day of the procedure, he cancelled the surgery – claiming he was concerned over risk of complication due to a heart murmur diagnosed during preoperative examination. After reassurance that the murmur would not complicate the surgery, Mr X agreed to the procedure. Unfortunately, he had waited too long – ‘many months’ – and the tumour was no longer operable. The authors conclude the patient’s surgical care accordingly. He was disappointed, understandably so, but also angry. His reluctance to proceed with surgery, last-minute cancelation, and delays in re-imaging were quickly forgotten and the finger of blame was pointed at his surgeon for the lack of surgical options. Accusations of negligence, incompetence, and lack of compassion were quickly made [37, p. 583]. The patient was then referred for an oncology consultation. During the first clinical encounter, the oncology staff informed Mr X about the treatment options either of standard chemotherapy or of experimental treatment in a clinical trial. The staff also explained the importance of a biopsy for determining the most effective therapy, and he consented to the procedure. However, on the day of biopsy, he cancelled. He was anxious over the biopsy but refused either counselling or anxiolytics for his anxiety. After informing Mr X of other possible clinical options – including symptom management and palliative care, both of which he rejected – he elected to undergo biopsy, which confirmed the diagnosis of metastatic renal cell carcinoma. He was started on sunitinib, and during the second cycle, he complained of bloody urine or haematuria. He was advised to undergo blood analysis and a urological assessment, which he refused, and also to discontinue
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taking the chemotherapeutic agent, but he continued to take it at half dosage. He eventually agreed to blood analysis. He also consented to a computed tomography (CT) scan to determine the drug’s efficacy, but he did not show on the day of the procedure. ‘A subsequent phone call regarding this was met again with anger and refusal to proceed. He expressed fear about the exposure to high levels of radiation with CT scans and was reassured’ [37, p. 584]. Eventually he agreed to an ultrasound, which indicated mild progression of the tumour. During the third cycle of treatment, Mr X again reported bloody urine. Once more, he refused blood analysis. During an hour-long evening consultation on the telephone, the patient expressed ‘disdain’ for medical advice and the telephone call became ‘vitriolic’. Eventually the patient consented to a CT scan, which revealed significant tumour progression, and chemotherapy was terminated. Although the patient assented to palliative radiation treatment, he failed to show for the scheduled appointment. The patient continued to experience haematuria, but refused to heed medical advice for managing it. Finally, the patient called one evening leaving a message about the continued bleeding but succumbed to the illness before assessment could be made. The following day, Mrs X called and stated, ‘My one regret is that you never called back last night, you deserted him at the end’ [37, p. 583].
Discussion The reconstructed clinical case represents an apposite example of a challenging clinical encounter. From the clinical staff’s perspective, Mr X exhibited many characteristics of a difficult patient, which contributed to its experience of challenging encounters. For example, the word ‘conflict’ is used to describe the relationship of the surgical staff with the patient, who at one point accused it with ‘negligence, incompetence, and lack of compassion’ [37, p. 583]. Also, the patient’s behaviour with the oncology staff is portrayed in terms of anger, disappointment and frustration. He raised objections to most, if not all, of the therapeutic recommendations, especially a psychiatric referral for addressing anxiety and fear over medical interventions. Moreover, he was non-compliant when advised to cease taking the therapeutic agent because of frank haematuria. Finally, he cancelled procedural appointments or simply failed to show for them. In summary, the patient certainly contributed to the challenging encounters in terms of dysfunctional and non-compliant behaviour in the clinical setting. Dr Knox and colleagues discussed the literature on ‘difficult’ patients in terms of ‘hateful’, ‘dysphoric’ and ‘heartsink’ patients [37]. Firstly, they identified the hateful patient as one whom the staff dread to attend, and Mr X’s anger certainly made him a person the clinical staff dreaded. To a lesser extent, as a hateful patient, he was a help-rejecter in that the patient exhibited ‘disdain’ for medical advice and was often non-compliant – especially when counselled to cease taking sunitinib because of haematuria. Next, they described the dysphoric patient as someone who causes a visceral reaction in the staff. Mr X’s behaviour certainly took a toll on the clinical staff’s emotional well-being. Finally, they characterize the heartsink patient as one who defeats the efforts of the clinical staff to provide necessary health care. Mr X’s refusal to participate in recommended procedures because of fear from medical interventions certainly prevented the staff from providing him with the care he needed. Overall, the clinical staff 3
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found providing health care for the patient laborious – if not – demoralizing. As they conclude, ‘interactions with patient X were charged with animosity intermingled with accusations of incompetence . . . interaction with this patient was difficult’ [37, pp. 584–585]. From Mr X’s perspective, the clinical staff also contributed to the challenging encounters he experienced during treatment of his illness. Obviously, the patient’s accusation that the surgical staff did not present him with sufficient treatment options represents a critical source for the development of ‘conflict’ between the staff and patient. The patient must trust the staff that it has thoroughly provided relevant treatment options. Mr X did not trust the surgical staff. Moreover, the delay – ‘many months’ – in the patient’s eventual consent to undergo nephrectomy cannot simply be the result of the patient’s belief that a heart murmur could complicate the procedure. Most likely, the fragmentation of health care impeded communication between patient and clinical staff and thereby could have been responsible for the delay. The oncology staff’s inability to discern the reason why Mr X was so fearful of medical intervention also contributed to the challenging encounters. The patient might have perceived the staff’s recommending psychiatric counselling for his fear as its abandonment of him, as his wife charged in her phone call. Finally, given Mr X’s fear of medical interventions, prescribing a drug for it was certainly problematic. Thus, both the clinical staff and health care institution were also responsible for the challenging encounters. The question arises next how to manage challenging or demanding encounters in the clinical case, especially in terms of the CALMER and REBELS models. With respect to the CALMER model, the clinical staff represent a viable Catalyst for motivating Mr X to change his attitude from viewing the staff with hostility and distrust to viewing it as a professional organization that he must empower through his trust in it and – in return – allow it to empower him. The clinical staff are also in a strategic position to assist Mr X – through cognitive techniques – to Alter his negative thoughts towards it; altered thoughts would eventually replace the feeling of dislike for the clinical staff with an appreciation that it is striving to provide him the best health care possible. However, the clinical staff must Listen to the patient intently and sympathetically before presenting recommendations for therapy. Only by inviting Mr X to narrate his illness story can the necessary information be obtain to assist him in transitioning from a difficult to an accommodating patient. For example, the clinical staff should have determined the source of Mr X’s intense fear of medical interventions, such as nephrectomy and renal biopsy, before discussing with him treatment options. After that transition, which for Mr X may take several consultations, the staff can Make an agreement with him to trust one another to manage his cancer treatment and its side effects – especially the frank haematuria. And, it can begin to Educate Mr X about the best possible therapies for his cancer. Finally, given the challenges in serving the patient, seeking assistance from colleagues and the literature, especially for the patient’s fear, after a challenging encounter is recommended. In terms of the REBELS model, the clinical staff – after Recognizing the challenge associated with treating Mr X – should explain to him that distrustful, fearful and non-compliant behaviour is counterproductive to providing the medical care he needs and deserves. Of course, Empathy provides the means by which the staff can access the origins of the Mr X’s non-compliant behaviour, 4
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especially his fear over medical procedures. Only through empathizing with the patient can the clinical staff appreciate the patient’s fear and the impact it has on his behaviour. And through understanding Mr X’s world of fear, the staff can help him construct Boundaries for behaviour that leads to overcoming or managing that world and thereby to forging a working therapeutic relationship with the staff that eventually promotes healing. At this point, the clinical staff can Emphasize to the patient that it is committed to providing him the best care possible. To that end, the staff must use appropriate Language and terminology to explain why certain procedures and referrals are required. For example, did the patient fully appreciate and comprehend the importance of the renal biopsy for ascertaining the best possible chemotherapy regimen and the CT scans for monitoring the therapy’s efficacy? Finally, the clinical staff must assure the patient that Solutions to his medical condition are possible but that they also require his cooperation. In summary, the clinical case is a robust example of challenging or demanding encounters. Mr X is certainly a patient who challenged the patience and emotional well-being of the clinical staff. He exhibited many of the characteristics of difficult patients described in the literature, including anger, non-compliance and accusatory behaviour. In addition, he elicited in the staff many of the reactions listed in the medical literature, such as guilt, self-doubt, failure, negligence and above all a heartlessness or a ‘heartsink’ reaction. However, the staff and the health care institution were also responsible for the challenging encounters, especially through the staff’s inability to determine his fear of medical interventions and through the institutionally fragmented care he received. Finally, both CALMER and REBELS models converge to provide an effective strategy for managing challenging encounters, such as explaining fully to the patient possible alternatives for treatment.
Conclusion Although the reconstructed clinical case is a good example of challenging clinical encounters and supports the literature on them, the question about their nature and origins remains inadequately answered. What then are challenging encounters? Are they simply a label for unpleasant or ‘heartsink’ encounters? And, what is responsible for or causes them? Are ‘difficult’ patients their only or chief source? The clinical case suggests that challenging encounters represent more than simply or chiefly a ‘heartsink’ encounter and that their origins are not just situated in ‘difficult’ patients. Moreover, the case reveals that they are not an outcome of naturalistic factors attributed to patients in terms of pathophysiology or pathopsychology. In other words, challenging encounters are not a medical condition per se, such as a disease or disorder. Rather, they are a type of dysfunction or an unhealthful existential condition in a clinical setting. As existential, the dysfunctional nature of challenging clinical encounters refers to a failure of patients and/or clinicians to comport or relate themselves or to be present towards one another in an authentic and a caring manner [38,39]. For the clinician, such comportment entails a genuine solicitation to help the patient with the healing process – whether physiological and/or psychological. To that end, the clinician must be with or pull alongside of the patient at a level that invites the patient to trust not only the clinician but also the health care system itself. But, often the clinical setting in challenging encounters is dysfunctional or
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inoperative so that the clinician and patient cannot form a therapeutic alliance. For example, the care that Mr X received was fragmented in that he was shuttled from one medical or surgical specialty to another, with little coherence or consistency in the clinical decisions made to manage his treatment. ‘Just as too many cooks can spoil the broth’ claims Einer Elhauge, ‘too many decision makers can spoil health care’ [40, p. 1]. Thus, challenging encounters due to fragmented health care, for example, can jeopardize the quality of care a patient might receive and subsequently the patient’s well-being or life. Critical in the explication of challenging clinical encounters are their sources or origins in terms of dysfunction experienced in a clinical setting. There are three possible sources. The first is the patient. For example, a patient may have multiple complaints that require an inordinate investment of time and resources. The next source is the clinician. A clinician, for instance, may find a patient offensive based upon the provider’s biases or prejudices. The final source of dysfunction is the health care system. Fragmented care, for example, introduces difficulty for the patient in negotiating the health care system. Importantly, the three sources can intersect or interact to augment the dysfunction of challenging encounters. A challenging encounter is exacerbated, for instance, when a clinician – who has a bias against a patient’s personality disorder – is treating such a patient. The present account of challenging clinical encounters in terms of existential dysfunction has implications for assessing strategies for treating patients during such encounters. For example, by identifying the source of dysfunction with the patient, the clinician can address it and thereby relieve – or at least lessen – its severity. The clinical case provides an apt illustration as the source of Mr. X’s fear of medical interventions was not determined. Had the source been determined, the clinical staff may have been able to manage effectively the challenges associated with treating him. Moreover, the account can be used to revise the CLAMER and REBEL models. Both models focus almost exclusively on patients as their source; and, they should be expanded to incorporate health care providers and systems as sources of challenging encounters. In the CALMER model, for instance, the ‘A’ or ‘alter thoughts to change feelings’ can be used to correct biases a provider may bring to the clinical encounter. An example for revising the REBEL model is the ‘R’ or ‘recognizing’ that the dysfunction fuelling the challenging encounter originates with the health care system. In conclusion, challenging clinical encounters can be frustrating and demoralizing for both patients and clinicians. The medical literature provides a necessary account of them in terms of patients but not a sufficient account with respect to the existential dysfunction in the clinical setting that involves not only patients but also health care providers and systems. Finally, by accounting for challenging encounters as dysfunctional that jeopardizes a patient’s health and well being, strategies for managing challenging encounters – such as the CALMER and REBEL models – can be revised to provide the best care possible during such encounters.
References 1. Hahn, S. R., Kroenke, K., Spitzer, R. L., Brody, D. & Linzer, M. (1996) The difficult patient: prevalence, psychopathology, and functional impairment. Journal of General Internal Medicine, 11 (1), 1–8.
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2. Crutcher, J. E. & Bass, M. J. (1980) The difficult patient and the troubled physician. Journal of Family Practice, 11 (6), 933–938. 3. Kroenke, K. (2009) Unburdening the difficult clinical encounter. Archives of Internal Medicine, 169 (4), 333–334. 4. Cohen-Cole, S. A. (1990) The ‘difficult’ medical patient. In Clinical Methods: The History, Physical, and Laboratory Examinations, 3rd edn (eds H. K. Walker, W. D. Hall & J. W. Hurst), pp. 1045–1049. Boston: Butterworths. 5. Short, D. (1994) Difficult patients. British Journal of Hospital Medicine, 51 (3), 128–130. 6. Koekkoek, B., van Meijel, B. & Hutschemaekers, G. (2006) ‘Difficult patients’ in mental health care: a review. Psychiatric Services, 57 (6), 795–802. 7. Teo, A. R., Du, Y. B., Javier, I. & Escobar, M. D. (2013) How can we better manage difficult patient encounters? Journal of Family Practice, 62 (8), 414–421. 8. Valeras, A., Gunn, W. & Valeras, A. (2013) An innovative model for systems-based curriculum: the complex continuity clinic. International Journal of Psychiatry in Medicine, 45 (4), 377–387. 9. Foster, E. (2013) Values and the transformation of medical education: the promise of autoethnographic research. Journal of Medicine and the Person, 11 (1), 19–23. 10. Steinberg, M. (2011) Motivational interviewing part 2: an overview of skills and challenging clinical encounters. Diabetes Spectrum, 24 (4), 231–233. 11. Roberts, J. H. (2012) Challenging clinical encounters: an investigation into the experiences of GPs consulting with young people experiencing emotional distress and an exploration of the GPs role. Doctoral dissertation, University of Sunderland. 12. Groves, J. E. (1978) Taking care of the hateful patient. New England Journal of Medicine, 298 (16), 883–887. 13. Balducci, L. (2013) The ‘hateful’ patient. Journal of Medicine and the Person, 11 (3), 113–117. 14. O’Dowd, T. C. (1988) Five years of heartsink patients in general practice. British Medical Journal, 297 (6647), 528–530. 15. Moscrop, A. (2011) ‘Heartsink’ patients in general practice: a defining paper, its impact, and psychodynamic potential. British Journal of General Practice, 61 (586), 346–348. 16. Lin, E. H., Katon, W. & Wagne, E. (1991) Frustrating patients. Journal of General Internal Medicine, 6 (3), 241–246. 17. Lalanda, M. (2009) The challenging patient. United Kingdom Casebook, 17 (2), 12–14. 18. Ellis, C. G. (1986) Making dysphoria a happy experience. British Medical Journal, 293 (6542), 317–318. 19. Gillette, R. D. (2000) ‘Problem patients’: a fresh look at an old vexation. Family Practice Management, 7 (7), 57–62. 20. Steinmetz, D. & Tabenkin, H. (2001) The ‘difficult patient’ as perceived by family physicians. Family Practice, 18 (5), 495–500. 21. Schafer, S. & Nowlis, D. P. (1998) Personality disorders among difficult patients. Archives of Family Medicine, 7 (2), 126–129. 22. Hahn, S. R., Thompson, K. S., Wills, T. A., Stern, V. & Budner, N. S. (1994) The difficult doctor-patient relationship: somatization, personality and psychopathology. Journal of Clinical Epidemiology, 47 (6), 647–657. 23. Birney, T. J. & Platt, F. (2012) Your Most Difficult Patient: The One with Nothing Wrong. AAOS Now. Available at: http://www.aaos.org/news/ aaosnow/apr12/managing5.asp (last accessed 9 December 2014). 24. Romano, S. E. & Schwenk, T. L. (2008) The challenging patient encounter. In Essentials of Family Medicine, 5th edn (eds P. D. Sloane, L. M. Slatt, M. H. Ebell, L. B. Jacques & M. A. Smith), pp. 31–38. Baltimore: Williams and Wilkins. 25. Stacey, C. L., Henderson, S., MacArthur, K. R. & Dohan, D. (2009) Demanding patient or demanding encounter? A case study of a cancer clinic. Social Science & Medicine, 69 (5), 729–737.
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Caring for patients
26. Schwenk, T. L., Marquez, J. T., Lefever, R. D. & Cohen, M. (1989) Physician and patient determinants of difficult physician-patient relationships. Journal of Family Practice, 28 (1), 59–63. 27. Pérez-López, F. R. (2011) Difficult (‘heartsink’) patients and clinical communication difficulties. Patient Intelligence, 3, 1–9. 28. Stearns, C. A. (1991) Physicians in restraints: HMO gatekeepers and their perceptions of demanding patients. Qualitative Health Research, 1 (3), 326–348. 29. Krebs, E. E., Garrett, J. M. & Konrad, T. R. (2006) The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data. BMC Health Services Research, 6 (1), 128. 30. Hawken, S. J. (2005) Strategies for dealing with the challenging patient. New Zealand Family Physician, 32 (4), 266–269. 31. Haas, L. J., Leiser, J. P., Magill, M. K. & Sanyer, O. N. (2005) Management of the difficult patient. American Family Physician, 72 (10), 2063–2068. 32. Williams, L. & Day, A. (2007) Strategies for dealing with clients we dislike. American Journal of Family Therapy, 35 (1), 83–92. 33. Stevens, L. A. (2010) Responding to the difficult patient. Bulletin of the American College of Surgeons, 95 (5), 12–15.
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34. Ellis, C. G. (1987) Dysphoria, a non-disease. South African Medical Journal, 71 (2), 69–70. 35. Pomm, H. A., Shahady, E. & Pomm, R. M. (2004) The CALMER approach: teaching learners six steps to serenity when dealing with difficult patients. Family Medicine, 36 (7), 467–469. 36. Hawken, S. J., Fox, R., van den Brink, R. & Moir, F. (2008) REBELS: an approach to communication challenges in the consultation. New Zealand Family Physician, 35 (5), 274–277. 37. Horgan, A. M., Cuffe, S. D. & Knox, J. J. (2011) When your best is not good enough. Journal of Cancer Education, 26 (3), 583–585. 38. Toombs, S. K. (1993) The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient. Dordrecht: Kluwer. 39. Svenaeus, F. (2000) The Hermeneutics of Medicine and the Phenomenology of Health: Steps Towards a Philosophy of Medical Practice. Dordrecht: Kluwer. 40. Elhauge, E. (2010) Why should we care about healthcare fragmentation and how to fix it? In The Fragmentation of US Health Care: Causes and Solutions (ed. E. Elhauge), pp. 1–20. New York: Oxford University Press.
© 2015 John Wiley & Sons, Ltd.
Journal of Evaluation in Clinical Practice ISSN 1365-2753
Caring for patients during challenging clinical encounters James A. Marcum, PhD Professor, Department of Philosophy and Medical Humanities Program, Baylor University, Waco, TX, USA
Keywords clinical safety, evaluation, person-centred medicine Correspondence James A. Marcum Department of Philosophy and Medical Humanities Program Baylor University One Bear Place #97273 Waco, TX 76798 USA E-mail: [email protected] Accepted for publication: 17 November 2014 doi:10.1111/jep.12312
Abstract Rationale, aims and objectives Challenging clinical encounters can often be frustrating and demoralizing not only for clinicians but also for patients. The paper’s aims are twofold. The first is to analyse the nature and origins of such encounters. The second is to appraise the CALMER and REBELS models for managing them. Methods After reviewing the medical literature on challenging clinical encounters, a clinical case is briefly reconstructed from it. The reconstructed case is then used to analyse the nature and origins of challenging encounters and to evaluate the two models for handling them. Results The reconstructed clinical case is an apt example for examining and evaluating the medical literature on challenging clinical encounters. In terms of what challenging encounters are and what elicits them, the literature captures their frustrating, demoralizing, demanding and, at times, insufferable dimensions – as well as the role of patients in their origins – as the clinical case also illustrates. With respect to managing them, the CALMER and REBELS models are effective strategies for handling challenging encounters – again, as the clinical case exemplifies. Conclusions Although the clinical case supports the medical literature on challenging clinical encounters, the literature fails to provide an adequate account of their nature and origins. Specifically, challenging encounters are a type of dysfunction – not pathophysiological but existential – in a clinical setting, with their origins not only in patients but also in clinicians and health care systems. Finally, based upon the dysfunctional nature of such encounters, revisions of the CALMER and REBELS models are proposed for better managing these encounters.
Introduction Challenging clinical encounters are often frustrating and demoralizing not only for clinicians, both professionally and personally, but also for patients. According to one clinical study of primary care practices, the prevalence of challenging encounters ranges from 11% to 20% [1], whereas another study reports prevalence just less than 30% [2]. Consequently, for a reasonably sized practice, challenging encounters occur, on average, three to four times per day [3]. They generally require more time than an average encounter because of patients’ multiple complaints and their negative attitudes towards clinicians and even health care systems. They thereby often represent a greater burden on health care resources – at times resulting in waste of those resources and greater cost. Although the medical literature provides an adequate analysis of the general characteristics of challenging encounters, it does not sufficiently explicate their fundamental nature and origins [4–7].
Journal of Evaluation in Clinical Practice (2015) © 2015 John Wiley & Sons, Ltd.
In the present paper, the current medical literature on challenging clinical encounters – often blamed on patients – and the evaluation of how to handle them are examined. To that end, two questions are asked. What are challenging clinical encounters in terms of their nature and origins? And, how should clinicians manage them? After considering the answers to these questions as discussed in the medical literature, a clinical case involving a challenging encounter is reconstructed from it. The reconstructed case is used to analyse the medical literature, with respect to both explicating challenging encounters and assessing how to provide the best care during such encounters. Although the medical literature is supported by the reconstructed clinical case in terms of characterizing challenging encounters and how to cope with them, it fails to provide an adequate account for explicating their nature and origins. Specifically, challenging encounters are a type of dysfunction – not pathophysiological but existential – in a clinical setting, with their origins not only in patients but also in clinicians and health care systems. Finally, based upon the dysfunctional 1
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nature of such encounters, revisions of the CALMER and REBELS models are proposed for better managing these encounters.
What are challenging clinical encounters? In general, challenging clinical encounters represent frustrating and demoralizing episodes in which forging a therapeutic relationship between health care providers and patients is difficult, if not almost impossible. Traditionally, patients are often, if not exclusively, held responsible in terms of explicating their nature and origins; recently, however, clinicians and health care systems are beginning to be recognized as important factors involved in challenging encounters, which must be included in strategies to manage them effectively [8–11]. In this section, the notion of challenging encounters is first explored in terms of difficult patients, followed by the role of health care systems and clinicians. Several alternative designations of difficult patients with respect to challenging clinical encounters are present in the medical literature. The first designation, ‘hateful’ patients, is divided into four categories [12,13]. The clinger, whose chief characteristic is dependency, represents an initial category of these patients. A clinger often evokes aversion from the clinician. Another category is the demander, whose chief characteristic is entitlement. A demander generally evokes a desire to counter-attack on part of the clinician. A third category is the help-rejecter, whose main characteristic is manipulation, and evokes depression in the clinician. A final category is the denier, whose chief characteristic is selfdestruction. A denier evokes malice from clinicians. In addition to ‘hateful’ patients, an alternative designation of difficult patients is ‘heartsink’ patients. ‘Heartsink’ patients are often dissatisfied with the medical care provided and cause clinician stress and clinical staff dread upon their appearance [14,15]. Finally, additional designations of difficult patients include ‘frustrating’ [16], ‘challenging’ [17], ‘dysphoric’ [18] and ‘problem’ [19] patients. Although no one characteristic defines the notion of difficult patient with respect to challenging clinical encounters, in a study of primary care practices, these patients are around twice as likely to present with mental illness [1]. In addition, they present with particular functional diseases, such as irritable bowel syndrome or tension headaches, compared to organic diseases, such as arthritis or diabetes. Difficult patients usually present in the clinic with more than a single chief complaint or disease, whether functional or organic. A study examining primary care doctors’ perceptions of these patients revealed three categories of difficult patients: a wide array of behavioural issues, multiple/unresolved complaints and mental illness [20]. Mental illness also includes personality disorders [21] and somatization syndrome [22,23]. Patients are not the only source of challenging clinical encounters in which the patient and clinician do not forge a therapeutic relationship [24,25]. Studies show that medical uncertainty and breakdown in patient–clinician communication are also contributing factors to challenging encounters [26,27]. In addition, the health care system and its fragmentation of health care delivery often represent sources of challenging encounters that patients and clinicians experience during a consultation. For example, one study reported that HMO (Health Maintenance Organization) policies often lead to challenging or demanding clinical encounters 2
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[28]. Finally, clinicians themselves can also be a source of challenging encounters. A study found that clinician factors contributing to challenging encounters include age of clinician (55 hours per week) and personal problems such as anxiety, depression or stress [29]. In summary, challenging clinical encounters as frustrating and demoralizing episodes are often blamed on patients, who are either envisioned as difficult or non-compliant. However, patients are but part of the phenomenon of challenging encounters; both health care systems and clinicians share considerable responsibility for the challenges associated with these encounters and must be included when considering their nature and origins, as well as how best to manage or handle them.
How should clinicians manage challenging clinical encounters? The medical literature contains ample advice and strategies for managing challenging clinical encounters [30–33]. The ideal manner is to address the underlying cause(s) responsible for them, whether originating with patients, clinicians, health care systems or combination thereof. In the current medical literature, strategies for managing challenging encounters often pertain to commonsensical ways by which to cope with them, without compounding them. For example, advice for managing challenging encounters ranges from the practical, such as honesty with patients, to the creative, such as balancing multiple medications or ‘alchemical juggling’ [34]. In this section, two strategies, which are representative of the models within the literature, for managing challenging encounters – the CALMER and REBELS models – are discussed. The CALMER model consists of six steps [35]. The first is ‘Catalyst for change’ in which clinicians provide practical guidance to motivate patients to change their disruptive behaviour. In the next step – an application of the first through cognitive– behavioural techniques – clinicians assist difficult patients to ‘Alter thoughts to change feelings’, thereby restoring the ability of patients to control their behaviour. The third step requires clinicians to ‘Listen and then make a diagnosis’, so patients feel they are taken seriously and incorporated into the therapeutic process. The subsequent step invites clinicians to ‘Make an agreement’ with patients to meet regularly and to focus on specific medical issues that might compromise treatment. The fifth step includes ‘Education and follow-up’ in which clinicians assist patients in learning about their illness(es) and responsibility in the treatment plan. The final step encourages clinicians to ‘Reach out and discuss their feelings’ with colleagues, after challenging encounters. The REBELS model consists of six components [36]. The first commends clinicians to ‘Recognize’ a problem exists with a patient’s behaviour and then to inform the patient about the clinician’s perception of it. The following component encourages clinicians to exhibit ‘Empathy’ for patients, especially in terms of understanding the frustrations and fears surrounding their illness(es) that leads to clinical dysphoria. The third component requires clinicians to establish reasonable and secure ‘Boundaries’ during challenging encounters. The ensuing component urges clinicians to ‘Emphasize’ the welfare of patients when treating their illness(es). The fifth component encourages clinicians to utilize inclusive ‘Language’ when communicating with patients to motivate them to participate actively in their treatment. The final
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component counsels clinicians to shift emphasis from the problems patients face to their conceivable ‘Solutions’. Both the CALMER and REBELS models embody sound strategies for managing challenging clinical encounters. For example, clinicians honestly but sympathetically inform patients about uncertainties that exist in treating or managing their illness(es) but indicate that together they can develop a solution or treatment plan that respects patient preferences and dignity. The operative component is empathy, as delineated in the REBELS model, in which clinicians recognize patients may suffer not simply from organic disease(s) but also from mental and personality disorder(s) and from demanding situation(s) or context(s), which, in turn, need attending. In addition, clinicians set boundaries for challenging encounters in terms of not only patient behaviour but also clinician reaction to it. They then educate patients about possible treatment modalities and strategies, as recommended by the CALMER model, thereby including and motivating (and possibly empowering) them. Thus, both models converge to provide a comprehensive strategy for managing challenging encounters.
A clinical case of a challenging encounter Dr Jennifer Knox and colleagues from the Division of Hematology/Oncology at Princess Margaret Hospital in Toronto narrate a challenging clinical encounter [37]. Mr X – 62 years old – presented with a large renal mass with accompanying local adenopathy. He was retired from a successful business career and married. In a previous consultation with surgical staff, the patient was informed about treatment options either of nephrectomy or of neoadjuvant therapy in a clinical trial. He chose the former. But, near the day of the procedure, he cancelled the surgery – claiming he was concerned over risk of complication due to a heart murmur diagnosed during preoperative examination. After reassurance that the murmur would not complicate the surgery, Mr X agreed to the procedure. Unfortunately, he had waited too long – ‘many months’ – and the tumour was no longer operable. The authors conclude the patient’s surgical care accordingly. He was disappointed, understandably so, but also angry. His reluctance to proceed with surgery, last-minute cancelation, and delays in re-imaging were quickly forgotten and the finger of blame was pointed at his surgeon for the lack of surgical options. Accusations of negligence, incompetence, and lack of compassion were quickly made [37, p. 583]. The patient was then referred for an oncology consultation. During the first clinical encounter, the oncology staff informed Mr X about the treatment options either of standard chemotherapy or of experimental treatment in a clinical trial. The staff also explained the importance of a biopsy for determining the most effective therapy, and he consented to the procedure. However, on the day of biopsy, he cancelled. He was anxious over the biopsy but refused either counselling or anxiolytics for his anxiety. After informing Mr X of other possible clinical options – including symptom management and palliative care, both of which he rejected – he elected to undergo biopsy, which confirmed the diagnosis of metastatic renal cell carcinoma. He was started on sunitinib, and during the second cycle, he complained of bloody urine or haematuria. He was advised to undergo blood analysis and a urological assessment, which he refused, and also to discontinue
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taking the chemotherapeutic agent, but he continued to take it at half dosage. He eventually agreed to blood analysis. He also consented to a computed tomography (CT) scan to determine the drug’s efficacy, but he did not show on the day of the procedure. ‘A subsequent phone call regarding this was met again with anger and refusal to proceed. He expressed fear about the exposure to high levels of radiation with CT scans and was reassured’ [37, p. 584]. Eventually he agreed to an ultrasound, which indicated mild progression of the tumour. During the third cycle of treatment, Mr X again reported bloody urine. Once more, he refused blood analysis. During an hour-long evening consultation on the telephone, the patient expressed ‘disdain’ for medical advice and the telephone call became ‘vitriolic’. Eventually the patient consented to a CT scan, which revealed significant tumour progression, and chemotherapy was terminated. Although the patient assented to palliative radiation treatment, he failed to show for the scheduled appointment. The patient continued to experience haematuria, but refused to heed medical advice for managing it. Finally, the patient called one evening leaving a message about the continued bleeding but succumbed to the illness before assessment could be made. The following day, Mrs X called and stated, ‘My one regret is that you never called back last night, you deserted him at the end’ [37, p. 583].
Discussion The reconstructed clinical case represents an apposite example of a challenging clinical encounter. From the clinical staff’s perspective, Mr X exhibited many characteristics of a difficult patient, which contributed to its experience of challenging encounters. For example, the word ‘conflict’ is used to describe the relationship of the surgical staff with the patient, who at one point accused it with ‘negligence, incompetence, and lack of compassion’ [37, p. 583]. Also, the patient’s behaviour with the oncology staff is portrayed in terms of anger, disappointment and frustration. He raised objections to most, if not all, of the therapeutic recommendations, especially a psychiatric referral for addressing anxiety and fear over medical interventions. Moreover, he was non-compliant when advised to cease taking the therapeutic agent because of frank haematuria. Finally, he cancelled procedural appointments or simply failed to show for them. In summary, the patient certainly contributed to the challenging encounters in terms of dysfunctional and non-compliant behaviour in the clinical setting. Dr Knox and colleagues discussed the literature on ‘difficult’ patients in terms of ‘hateful’, ‘dysphoric’ and ‘heartsink’ patients [37]. Firstly, they identified the hateful patient as one whom the staff dread to attend, and Mr X’s anger certainly made him a person the clinical staff dreaded. To a lesser extent, as a hateful patient, he was a help-rejecter in that the patient exhibited ‘disdain’ for medical advice and was often non-compliant – especially when counselled to cease taking sunitinib because of haematuria. Next, they described the dysphoric patient as someone who causes a visceral reaction in the staff. Mr X’s behaviour certainly took a toll on the clinical staff’s emotional well-being. Finally, they characterize the heartsink patient as one who defeats the efforts of the clinical staff to provide necessary health care. Mr X’s refusal to participate in recommended procedures because of fear from medical interventions certainly prevented the staff from providing him with the care he needed. Overall, the clinical staff 3
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found providing health care for the patient laborious – if not – demoralizing. As they conclude, ‘interactions with patient X were charged with animosity intermingled with accusations of incompetence . . . interaction with this patient was difficult’ [37, pp. 584–585]. From Mr X’s perspective, the clinical staff also contributed to the challenging encounters he experienced during treatment of his illness. Obviously, the patient’s accusation that the surgical staff did not present him with sufficient treatment options represents a critical source for the development of ‘conflict’ between the staff and patient. The patient must trust the staff that it has thoroughly provided relevant treatment options. Mr X did not trust the surgical staff. Moreover, the delay – ‘many months’ – in the patient’s eventual consent to undergo nephrectomy cannot simply be the result of the patient’s belief that a heart murmur could complicate the procedure. Most likely, the fragmentation of health care impeded communication between patient and clinical staff and thereby could have been responsible for the delay. The oncology staff’s inability to discern the reason why Mr X was so fearful of medical intervention also contributed to the challenging encounters. The patient might have perceived the staff’s recommending psychiatric counselling for his fear as its abandonment of him, as his wife charged in her phone call. Finally, given Mr X’s fear of medical interventions, prescribing a drug for it was certainly problematic. Thus, both the clinical staff and health care institution were also responsible for the challenging encounters. The question arises next how to manage challenging or demanding encounters in the clinical case, especially in terms of the CALMER and REBELS models. With respect to the CALMER model, the clinical staff represent a viable Catalyst for motivating Mr X to change his attitude from viewing the staff with hostility and distrust to viewing it as a professional organization that he must empower through his trust in it and – in return – allow it to empower him. The clinical staff are also in a strategic position to assist Mr X – through cognitive techniques – to Alter his negative thoughts towards it; altered thoughts would eventually replace the feeling of dislike for the clinical staff with an appreciation that it is striving to provide him the best health care possible. However, the clinical staff must Listen to the patient intently and sympathetically before presenting recommendations for therapy. Only by inviting Mr X to narrate his illness story can the necessary information be obtain to assist him in transitioning from a difficult to an accommodating patient. For example, the clinical staff should have determined the source of Mr X’s intense fear of medical interventions, such as nephrectomy and renal biopsy, before discussing with him treatment options. After that transition, which for Mr X may take several consultations, the staff can Make an agreement with him to trust one another to manage his cancer treatment and its side effects – especially the frank haematuria. And, it can begin to Educate Mr X about the best possible therapies for his cancer. Finally, given the challenges in serving the patient, seeking assistance from colleagues and the literature, especially for the patient’s fear, after a challenging encounter is recommended. In terms of the REBELS model, the clinical staff – after Recognizing the challenge associated with treating Mr X – should explain to him that distrustful, fearful and non-compliant behaviour is counterproductive to providing the medical care he needs and deserves. Of course, Empathy provides the means by which the staff can access the origins of the Mr X’s non-compliant behaviour, 4
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especially his fear over medical procedures. Only through empathizing with the patient can the clinical staff appreciate the patient’s fear and the impact it has on his behaviour. And through understanding Mr X’s world of fear, the staff can help him construct Boundaries for behaviour that leads to overcoming or managing that world and thereby to forging a working therapeutic relationship with the staff that eventually promotes healing. At this point, the clinical staff can Emphasize to the patient that it is committed to providing him the best care possible. To that end, the staff must use appropriate Language and terminology to explain why certain procedures and referrals are required. For example, did the patient fully appreciate and comprehend the importance of the renal biopsy for ascertaining the best possible chemotherapy regimen and the CT scans for monitoring the therapy’s efficacy? Finally, the clinical staff must assure the patient that Solutions to his medical condition are possible but that they also require his cooperation. In summary, the clinical case is a robust example of challenging or demanding encounters. Mr X is certainly a patient who challenged the patience and emotional well-being of the clinical staff. He exhibited many of the characteristics of difficult patients described in the literature, including anger, non-compliance and accusatory behaviour. In addition, he elicited in the staff many of the reactions listed in the medical literature, such as guilt, self-doubt, failure, negligence and above all a heartlessness or a ‘heartsink’ reaction. However, the staff and the health care institution were also responsible for the challenging encounters, especially through the staff’s inability to determine his fear of medical interventions and through the institutionally fragmented care he received. Finally, both CALMER and REBELS models converge to provide an effective strategy for managing challenging encounters, such as explaining fully to the patient possible alternatives for treatment.
Conclusion Although the reconstructed clinical case is a good example of challenging clinical encounters and supports the literature on them, the question about their nature and origins remains inadequately answered. What then are challenging encounters? Are they simply a label for unpleasant or ‘heartsink’ encounters? And, what is responsible for or causes them? Are ‘difficult’ patients their only or chief source? The clinical case suggests that challenging encounters represent more than simply or chiefly a ‘heartsink’ encounter and that their origins are not just situated in ‘difficult’ patients. Moreover, the case reveals that they are not an outcome of naturalistic factors attributed to patients in terms of pathophysiology or pathopsychology. In other words, challenging encounters are not a medical condition per se, such as a disease or disorder. Rather, they are a type of dysfunction or an unhealthful existential condition in a clinical setting. As existential, the dysfunctional nature of challenging clinical encounters refers to a failure of patients and/or clinicians to comport or relate themselves or to be present towards one another in an authentic and a caring manner [38,39]. For the clinician, such comportment entails a genuine solicitation to help the patient with the healing process – whether physiological and/or psychological. To that end, the clinician must be with or pull alongside of the patient at a level that invites the patient to trust not only the clinician but also the health care system itself. But, often the clinical setting in challenging encounters is dysfunctional or
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inoperative so that the clinician and patient cannot form a therapeutic alliance. For example, the care that Mr X received was fragmented in that he was shuttled from one medical or surgical specialty to another, with little coherence or consistency in the clinical decisions made to manage his treatment. ‘Just as too many cooks can spoil the broth’ claims Einer Elhauge, ‘too many decision makers can spoil health care’ [40, p. 1]. Thus, challenging encounters due to fragmented health care, for example, can jeopardize the quality of care a patient might receive and subsequently the patient’s well-being or life. Critical in the explication of challenging clinical encounters are their sources or origins in terms of dysfunction experienced in a clinical setting. There are three possible sources. The first is the patient. For example, a patient may have multiple complaints that require an inordinate investment of time and resources. The next source is the clinician. A clinician, for instance, may find a patient offensive based upon the provider’s biases or prejudices. The final source of dysfunction is the health care system. Fragmented care, for example, introduces difficulty for the patient in negotiating the health care system. Importantly, the three sources can intersect or interact to augment the dysfunction of challenging encounters. A challenging encounter is exacerbated, for instance, when a clinician – who has a bias against a patient’s personality disorder – is treating such a patient. The present account of challenging clinical encounters in terms of existential dysfunction has implications for assessing strategies for treating patients during such encounters. For example, by identifying the source of dysfunction with the patient, the clinician can address it and thereby relieve – or at least lessen – its severity. The clinical case provides an apt illustration as the source of Mr. X’s fear of medical interventions was not determined. Had the source been determined, the clinical staff may have been able to manage effectively the challenges associated with treating him. Moreover, the account can be used to revise the CLAMER and REBEL models. Both models focus almost exclusively on patients as their source; and, they should be expanded to incorporate health care providers and systems as sources of challenging encounters. In the CALMER model, for instance, the ‘A’ or ‘alter thoughts to change feelings’ can be used to correct biases a provider may bring to the clinical encounter. An example for revising the REBEL model is the ‘R’ or ‘recognizing’ that the dysfunction fuelling the challenging encounter originates with the health care system. In conclusion, challenging clinical encounters can be frustrating and demoralizing for both patients and clinicians. The medical literature provides a necessary account of them in terms of patients but not a sufficient account with respect to the existential dysfunction in the clinical setting that involves not only patients but also health care providers and systems. Finally, by accounting for challenging encounters as dysfunctional that jeopardizes a patient’s health and well being, strategies for managing challenging encounters – such as the CALMER and REBEL models – can be revised to provide the best care possible during such encounters.
References 1. Hahn, S. R., Kroenke, K., Spitzer, R. L., Brody, D. & Linzer, M. (1996) The difficult patient: prevalence, psychopathology, and functional impairment. Journal of General Internal Medicine, 11 (1), 1–8.
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2. Crutcher, J. E. & Bass, M. J. (1980) The difficult patient and the troubled physician. Journal of Family Practice, 11 (6), 933–938. 3. Kroenke, K. (2009) Unburdening the difficult clinical encounter. Archives of Internal Medicine, 169 (4), 333–334. 4. Cohen-Cole, S. A. (1990) The ‘difficult’ medical patient. In Clinical Methods: The History, Physical, and Laboratory Examinations, 3rd edn (eds H. K. Walker, W. D. Hall & J. W. Hurst), pp. 1045–1049. Boston: Butterworths. 5. Short, D. (1994) Difficult patients. British Journal of Hospital Medicine, 51 (3), 128–130. 6. Koekkoek, B., van Meijel, B. & Hutschemaekers, G. (2006) ‘Difficult patients’ in mental health care: a review. Psychiatric Services, 57 (6), 795–802. 7. Teo, A. R., Du, Y. B., Javier, I. & Escobar, M. D. (2013) How can we better manage difficult patient encounters? Journal of Family Practice, 62 (8), 414–421. 8. Valeras, A., Gunn, W. & Valeras, A. (2013) An innovative model for systems-based curriculum: the complex continuity clinic. International Journal of Psychiatry in Medicine, 45 (4), 377–387. 9. Foster, E. (2013) Values and the transformation of medical education: the promise of autoethnographic research. Journal of Medicine and the Person, 11 (1), 19–23. 10. Steinberg, M. (2011) Motivational interviewing part 2: an overview of skills and challenging clinical encounters. Diabetes Spectrum, 24 (4), 231–233. 11. Roberts, J. H. (2012) Challenging clinical encounters: an investigation into the experiences of GPs consulting with young people experiencing emotional distress and an exploration of the GPs role. Doctoral dissertation, University of Sunderland. 12. Groves, J. E. (1978) Taking care of the hateful patient. New England Journal of Medicine, 298 (16), 883–887. 13. Balducci, L. (2013) The ‘hateful’ patient. Journal of Medicine and the Person, 11 (3), 113–117. 14. O’Dowd, T. C. (1988) Five years of heartsink patients in general practice. British Medical Journal, 297 (6647), 528–530. 15. Moscrop, A. (2011) ‘Heartsink’ patients in general practice: a defining paper, its impact, and psychodynamic potential. British Journal of General Practice, 61 (586), 346–348. 16. Lin, E. H., Katon, W. & Wagne, E. (1991) Frustrating patients. Journal of General Internal Medicine, 6 (3), 241–246. 17. Lalanda, M. (2009) The challenging patient. United Kingdom Casebook, 17 (2), 12–14. 18. Ellis, C. G. (1986) Making dysphoria a happy experience. British Medical Journal, 293 (6542), 317–318. 19. Gillette, R. D. (2000) ‘Problem patients’: a fresh look at an old vexation. Family Practice Management, 7 (7), 57–62. 20. Steinmetz, D. & Tabenkin, H. (2001) The ‘difficult patient’ as perceived by family physicians. Family Practice, 18 (5), 495–500. 21. Schafer, S. & Nowlis, D. P. (1998) Personality disorders among difficult patients. Archives of Family Medicine, 7 (2), 126–129. 22. Hahn, S. R., Thompson, K. S., Wills, T. A., Stern, V. & Budner, N. S. (1994) The difficult doctor-patient relationship: somatization, personality and psychopathology. Journal of Clinical Epidemiology, 47 (6), 647–657. 23. Birney, T. J. & Platt, F. (2012) Your Most Difficult Patient: The One with Nothing Wrong. AAOS Now. Available at: http://www.aaos.org/news/ aaosnow/apr12/managing5.asp (last accessed 9 December 2014). 24. Romano, S. E. & Schwenk, T. L. (2008) The challenging patient encounter. In Essentials of Family Medicine, 5th edn (eds P. D. Sloane, L. M. Slatt, M. H. Ebell, L. B. Jacques & M. A. Smith), pp. 31–38. Baltimore: Williams and Wilkins. 25. Stacey, C. L., Henderson, S., MacArthur, K. R. & Dohan, D. (2009) Demanding patient or demanding encounter? A case study of a cancer clinic. Social Science & Medicine, 69 (5), 729–737.
5
Caring for patients
26. Schwenk, T. L., Marquez, J. T., Lefever, R. D. & Cohen, M. (1989) Physician and patient determinants of difficult physician-patient relationships. Journal of Family Practice, 28 (1), 59–63. 27. Pérez-López, F. R. (2011) Difficult (‘heartsink’) patients and clinical communication difficulties. Patient Intelligence, 3, 1–9. 28. Stearns, C. A. (1991) Physicians in restraints: HMO gatekeepers and their perceptions of demanding patients. Qualitative Health Research, 1 (3), 326–348. 29. Krebs, E. E., Garrett, J. M. & Konrad, T. R. (2006) The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data. BMC Health Services Research, 6 (1), 128. 30. Hawken, S. J. (2005) Strategies for dealing with the challenging patient. New Zealand Family Physician, 32 (4), 266–269. 31. Haas, L. J., Leiser, J. P., Magill, M. K. & Sanyer, O. N. (2005) Management of the difficult patient. American Family Physician, 72 (10), 2063–2068. 32. Williams, L. & Day, A. (2007) Strategies for dealing with clients we dislike. American Journal of Family Therapy, 35 (1), 83–92. 33. Stevens, L. A. (2010) Responding to the difficult patient. Bulletin of the American College of Surgeons, 95 (5), 12–15.
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34. Ellis, C. G. (1987) Dysphoria, a non-disease. South African Medical Journal, 71 (2), 69–70. 35. Pomm, H. A., Shahady, E. & Pomm, R. M. (2004) The CALMER approach: teaching learners six steps to serenity when dealing with difficult patients. Family Medicine, 36 (7), 467–469. 36. Hawken, S. J., Fox, R., van den Brink, R. & Moir, F. (2008) REBELS: an approach to communication challenges in the consultation. New Zealand Family Physician, 35 (5), 274–277. 37. Horgan, A. M., Cuffe, S. D. & Knox, J. J. (2011) When your best is not good enough. Journal of Cancer Education, 26 (3), 583–585. 38. Toombs, S. K. (1993) The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient. Dordrecht: Kluwer. 39. Svenaeus, F. (2000) The Hermeneutics of Medicine and the Phenomenology of Health: Steps Towards a Philosophy of Medical Practice. Dordrecht: Kluwer. 40. Elhauge, E. (2010) Why should we care about healthcare fragmentation and how to fix it? In The Fragmentation of US Health Care: Causes and Solutions (ed. E. Elhauge), pp. 1–20. New York: Oxford University Press.
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