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DENVER – If you get the impression you’re dealing with more angry and manipulative patients than usual in the past several years, you’re not alone.
In 1999, as many as 15% of patient encounters were rated as difficult by health care providers, according to Tina S. Alster, MD (Arch Intern Med. 1999;159:1069-75). Today, upward of 30% of patient encounters are deemed difficult (Int J Res Med Sci. 2016;4[8]:3554-62). “That means one in three patients that you see have a problem that goes beyond the scope of our official training,” said Dr. Alster, who is the founding director of the Washington Institute of Dermatologic Laser Surgery and clinical professor of dermatology at Georgetown University, Washington. “If it was limited to a medical problem, we could handle it; that’s what we’re trained to do. The interpersonal issues and psychosocial implications of treatment are much more difficult.”
At the annual conference of the American Society for Laser Medicine and Surgery, Dr. Alster said that difficult patients put a strain on your practice and your relationship with them. “These patients put you on your heels. They often point out a problem that may or may not be related to something that you’re responsible for. It’s not usually because you are running late on the day of their visit and you make them late for something else. That situation is one you can prepare for, because you know you’re running late. It’s the other stuff you don’t realize that’s going on, which can cause problems.”
Setting limits
Being proactive can help lessen the ripple effect from patients who rock the boat. “You want to set limits with those patients before you even see them,” Dr. Alster said. “There are written contracts and policies that you should have in place. Since I perform mostly cosmetic procedures in my office, it is important that patients are made aware that payment is expected at the time of service and that my office does not bill nor accept insurance payments in order to prevent misunderstandings at check out.” She also declines requests to provide expert testimony for legal cases. “I’ve been in this business a long time, and every day I get requests to be an expert or to review a case involving a provider who may or may not have made a mistake. I really hate going down that rabbit hole.”
Another solution to keeping difficult patients in check is to collaborate with your entire office staff on how to best deal with them. “You need to present a united front with these patients: They’re going to divide and conquer, with complaints like, ‘How dare the doctor be so late. I’ve been waiting here for 30 minutes. Doesn’t she know I’m busy?’ ” Dr. Alster said. “You’re going to have to give them the tools to set limits as well. During our staff meetings, we review the upcoming patient schedule and identify potentially difficult situations in order to make sure the team is on the same page. Because my office is located in the power corridor of Washington [three blocks away from the White House] and my patient base is populated by prevalent personalities, expectations are extraordinarily high. As such, it is important that we set limits and rules that everyone can play by.”
Getting a sense of whether a patient is angry or manipulative can also help. An angry patient often holds an expectation that has been unmet, or harbors fears related to the treatment itself, she said, while a manipulative patient may engage in bullying, excessive flattery, or veiled threats. “They often expect specific treatments that have only worked for them in the past, even though it may be opposed to the treatment you recommend. They know better than you, even though you’re the expert.”
Communicating effectively with these two types of patients requires a slightly different approach. “With an angry patient, you want to share decision making,” Dr. Alster said. “Have them voice their concerns and come up with a plan together going forward. You’re not going to make that person less angry by telling them what to do.” The manipulative patient, meanwhile, requires a team approach. For example, she may ask your medical assistant for opinions on the treatment option you recommended during your office consultation with her, or second-guess your recommendation with that person altogether. “Everybody needs to know who the manipulative patients are and approach them as a team.”
The art of nonconfrontation
Dr. Alster brings a nonconfrontational approach to interactions with difficult patients. “You can apologize if you’ve kept them waiting, but you can’t apologize for everything all the time,” she said. “I may say something like, ‘I appreciate that your visit is running late. I apologize for the delay and want you to know that we take as much time as necessary for each patient and that unforeseen circumstances beyond our control sometimes arise.’ ” Another phrase she may use is, “I understand that this has been a stressful visit, but I want to talk to you about your experience and identify how we can improve subsequent appointments.”
Showing empathy never hurts. “Repeat back to them what you heard, and establish the fact that you understand,” Dr. Alster said. “Lower your voice, talk slowly, don’t get caught up in emotion. Otherwise, you’re going down in a sinkhole with them. Be wrong to be right. This encourages negotiation. You also want to document all patient interactions. Put every correspondence in the patient’s EMR.”
Dr. Alster advises clinicians to provide an outline of office policies and procedures to all patients, as well as written and verbal instructions related to their care. She also phones or emails patients undergoing a treatment for the first time. “Even if they’ve been in the practice for several years, if they received filler injections for the first time [instead of Botox], we still check in with those patients when they receive a first-time treatment to make sure they’re doing okay,” she said. “We’ll call them that evening or at the very least early the next morning to make sure that they don’t have any questions or concerns.”
If problems persist despite your best efforts, sometimes your best option is to dismiss difficult patients from your practice. “That’s only when everything else fails,” Dr. Alster said. “A concise termination letter should state a ‘breakdown in physician-patient relationship.’ I call it my ‘Dear John’ letter, and since 1990, I’ve only written six of these. A detailed explanation is usually not needed, but may be advisable depending on your state, to protect yourself from a liability standpoint. I instruct patients to contact the state medical society for referral to another provider and inform them that upon their written request, their medical records will be forwarded to their new provider. I also set up a reasonable timeline during which I will continue to see them for emergency visits to ensure that there is continuity of care, even when it is a cosmetic situation.”
Dr. Alster reported having no financial disclosures related to her presentation.
DENVER – If you get the impression you’re dealing with more angry and manipulative patients than usual in the past several years, you’re not alone.
In 1999, as many as 15% of patient encounters were rated as difficult by health care providers, according to Tina S. Alster, MD (Arch Intern Med. 1999;159:1069-75). Today, upward of 30% of patient encounters are deemed difficult (Int J Res Med Sci. 2016;4[8]:3554-62). “That means one in three patients that you see have a problem that goes beyond the scope of our official training,” said Dr. Alster, who is the founding director of the Washington Institute of Dermatologic Laser Surgery and clinical professor of dermatology at Georgetown University, Washington. “If it was limited to a medical problem, we could handle it; that’s what we’re trained to do. The interpersonal issues and psychosocial implications of treatment are much more difficult.”
At the annual conference of the American Society for Laser Medicine and Surgery, Dr. Alster said that difficult patients put a strain on your practice and your relationship with them. “These patients put you on your heels. They often point out a problem that may or may not be related to something that you’re responsible for. It’s not usually because you are running late on the day of their visit and you make them late for something else. That situation is one you can prepare for, because you know you’re running late. It’s the other stuff you don’t realize that’s going on, which can cause problems.”
Setting limits
Being proactive can help lessen the ripple effect from patients who rock the boat. “You want to set limits with those patients before you even see them,” Dr. Alster said. “There are written contracts and policies that you should have in place. Since I perform mostly cosmetic procedures in my office, it is important that patients are made aware that payment is expected at the time of service and that my office does not bill nor accept insurance payments in order to prevent misunderstandings at check out.” She also declines requests to provide expert testimony for legal cases. “I’ve been in this business a long time, and every day I get requests to be an expert or to review a case involving a provider who may or may not have made a mistake. I really hate going down that rabbit hole.”
Another solution to keeping difficult patients in check is to collaborate with your entire office staff on how to best deal with them. “You need to present a united front with these patients: They’re going to divide and conquer, with complaints like, ‘How dare the doctor be so late. I’ve been waiting here for 30 minutes. Doesn’t she know I’m busy?’ ” Dr. Alster said. “You’re going to have to give them the tools to set limits as well. During our staff meetings, we review the upcoming patient schedule and identify potentially difficult situations in order to make sure the team is on the same page. Because my office is located in the power corridor of Washington [three blocks away from the White House] and my patient base is populated by prevalent personalities, expectations are extraordinarily high. As such, it is important that we set limits and rules that everyone can play by.”
Getting a sense of whether a patient is angry or manipulative can also help. An angry patient often holds an expectation that has been unmet, or harbors fears related to the treatment itself, she said, while a manipulative patient may engage in bullying, excessive flattery, or veiled threats. “They often expect specific treatments that have only worked for them in the past, even though it may be opposed to the treatment you recommend. They know better than you, even though you’re the expert.”
Communicating effectively with these two types of patients requires a slightly different approach. “With an angry patient, you want to share decision making,” Dr. Alster said. “Have them voice their concerns and come up with a plan together going forward. You’re not going to make that person less angry by telling them what to do.” The manipulative patient, meanwhile, requires a team approach. For example, she may ask your medical assistant for opinions on the treatment option you recommended during your office consultation with her, or second-guess your recommendation with that person altogether. “Everybody needs to know who the manipulative patients are and approach them as a team.”
The art of nonconfrontation
Dr. Alster brings a nonconfrontational approach to interactions with difficult patients. “You can apologize if you’ve kept them waiting, but you can’t apologize for everything all the time,” she said. “I may say something like, ‘I appreciate that your visit is running late. I apologize for the delay and want you to know that we take as much time as necessary for each patient and that unforeseen circumstances beyond our control sometimes arise.’ ” Another phrase she may use is, “I understand that this has been a stressful visit, but I want to talk to you about your experience and identify how we can improve subsequent appointments.”
Showing empathy never hurts. “Repeat back to them what you heard, and establish the fact that you understand,” Dr. Alster said. “Lower your voice, talk slowly, don’t get caught up in emotion. Otherwise, you’re going down in a sinkhole with them. Be wrong to be right. This encourages negotiation. You also want to document all patient interactions. Put every correspondence in the patient’s EMR.”
Dr. Alster advises clinicians to provide an outline of office policies and procedures to all patients, as well as written and verbal instructions related to their care. She also phones or emails patients undergoing a treatment for the first time. “Even if they’ve been in the practice for several years, if they received filler injections for the first time [instead of Botox], we still check in with those patients when they receive a first-time treatment to make sure they’re doing okay,” she said. “We’ll call them that evening or at the very least early the next morning to make sure that they don’t have any questions or concerns.”
If problems persist despite your best efforts, sometimes your best option is to dismiss difficult patients from your practice. “That’s only when everything else fails,” Dr. Alster said. “A concise termination letter should state a ‘breakdown in physician-patient relationship.’ I call it my ‘Dear John’ letter, and since 1990, I’ve only written six of these. A detailed explanation is usually not needed, but may be advisable depending on your state, to protect yourself from a liability standpoint. I instruct patients to contact the state medical society for referral to another provider and inform them that upon their written request, their medical records will be forwarded to their new provider. I also set up a reasonable timeline during which I will continue to see them for emergency visits to ensure that there is continuity of care, even when it is a cosmetic situation.”
Dr. Alster reported having no financial disclosures related to her presentation.
DENVER – If you get the impression you’re dealing with more angry and manipulative patients than usual in the past several years, you’re not alone.
In 1999, as many as 15% of patient encounters were rated as difficult by health care providers, according to Tina S. Alster, MD (Arch Intern Med. 1999;159:1069-75). Today, upward of 30% of patient encounters are deemed difficult (Int J Res Med Sci. 2016;4[8]:3554-62). “That means one in three patients that you see have a problem that goes beyond the scope of our official training,” said Dr. Alster, who is the founding director of the Washington Institute of Dermatologic Laser Surgery and clinical professor of dermatology at Georgetown University, Washington. “If it was limited to a medical problem, we could handle it; that’s what we’re trained to do. The interpersonal issues and psychosocial implications of treatment are much more difficult.”
At the annual conference of the American Society for Laser Medicine and Surgery, Dr. Alster said that difficult patients put a strain on your practice and your relationship with them. “These patients put you on your heels. They often point out a problem that may or may not be related to something that you’re responsible for. It’s not usually because you are running late on the day of their visit and you make them late for something else. That situation is one you can prepare for, because you know you’re running late. It’s the other stuff you don’t realize that’s going on, which can cause problems.”
Setting limits
Being proactive can help lessen the ripple effect from patients who rock the boat. “You want to set limits with those patients before you even see them,” Dr. Alster said. “There are written contracts and policies that you should have in place. Since I perform mostly cosmetic procedures in my office, it is important that patients are made aware that payment is expected at the time of service and that my office does not bill nor accept insurance payments in order to prevent misunderstandings at check out.” She also declines requests to provide expert testimony for legal cases. “I’ve been in this business a long time, and every day I get requests to be an expert or to review a case involving a provider who may or may not have made a mistake. I really hate going down that rabbit hole.”
Another solution to keeping difficult patients in check is to collaborate with your entire office staff on how to best deal with them. “You need to present a united front with these patients: They’re going to divide and conquer, with complaints like, ‘How dare the doctor be so late. I’ve been waiting here for 30 minutes. Doesn’t she know I’m busy?’ ” Dr. Alster said. “You’re going to have to give them the tools to set limits as well. During our staff meetings, we review the upcoming patient schedule and identify potentially difficult situations in order to make sure the team is on the same page. Because my office is located in the power corridor of Washington [three blocks away from the White House] and my patient base is populated by prevalent personalities, expectations are extraordinarily high. As such, it is important that we set limits and rules that everyone can play by.”
Getting a sense of whether a patient is angry or manipulative can also help. An angry patient often holds an expectation that has been unmet, or harbors fears related to the treatment itself, she said, while a manipulative patient may engage in bullying, excessive flattery, or veiled threats. “They often expect specific treatments that have only worked for them in the past, even though it may be opposed to the treatment you recommend. They know better than you, even though you’re the expert.”
Communicating effectively with these two types of patients requires a slightly different approach. “With an angry patient, you want to share decision making,” Dr. Alster said. “Have them voice their concerns and come up with a plan together going forward. You’re not going to make that person less angry by telling them what to do.” The manipulative patient, meanwhile, requires a team approach. For example, she may ask your medical assistant for opinions on the treatment option you recommended during your office consultation with her, or second-guess your recommendation with that person altogether. “Everybody needs to know who the manipulative patients are and approach them as a team.”
The art of nonconfrontation
Dr. Alster brings a nonconfrontational approach to interactions with difficult patients. “You can apologize if you’ve kept them waiting, but you can’t apologize for everything all the time,” she said. “I may say something like, ‘I appreciate that your visit is running late. I apologize for the delay and want you to know that we take as much time as necessary for each patient and that unforeseen circumstances beyond our control sometimes arise.’ ” Another phrase she may use is, “I understand that this has been a stressful visit, but I want to talk to you about your experience and identify how we can improve subsequent appointments.”
Showing empathy never hurts. “Repeat back to them what you heard, and establish the fact that you understand,” Dr. Alster said. “Lower your voice, talk slowly, don’t get caught up in emotion. Otherwise, you’re going down in a sinkhole with them. Be wrong to be right. This encourages negotiation. You also want to document all patient interactions. Put every correspondence in the patient’s EMR.”
Dr. Alster advises clinicians to provide an outline of office policies and procedures to all patients, as well as written and verbal instructions related to their care. She also phones or emails patients undergoing a treatment for the first time. “Even if they’ve been in the practice for several years, if they received filler injections for the first time [instead of Botox], we still check in with those patients when they receive a first-time treatment to make sure they’re doing okay,” she said. “We’ll call them that evening or at the very least early the next morning to make sure that they don’t have any questions or concerns.”
If problems persist despite your best efforts, sometimes your best option is to dismiss difficult patients from your practice. “That’s only when everything else fails,” Dr. Alster said. “A concise termination letter should state a ‘breakdown in physician-patient relationship.’ I call it my ‘Dear John’ letter, and since 1990, I’ve only written six of these. A detailed explanation is usually not needed, but may be advisable depending on your state, to protect yourself from a liability standpoint. I instruct patients to contact the state medical society for referral to another provider and inform them that upon their written request, their medical records will be forwarded to their new provider. I also set up a reasonable timeline during which I will continue to see them for emergency visits to ensure that there is continuity of care, even when it is a cosmetic situation.”
Dr. Alster reported having no financial disclosures related to her presentation.
EXPERT ANALYSIS FROM ASLMS 2019