When helping patients with multiple issues, which is a common scenario, the physician might start by asking, “What would you like to address today?”14 Keep a list of the issues so you do not forget the patient’s concerns, and then ask: “What do you think is going on?” Give patients time to verbalize their concerns. Physicians should:
- validate concerns: “I understand where you’re coming from.”
- offer empathy: “I can see how difficult this has been for you.”
- reframe: “Let me make sure I hear you correctly.”
- refocus: “Let’s agree on what we need to do at this visit.”
Find common ground. When the patient and physician have different ideas on diagnosis or treatment, finding common ground is another way to resolve a difficult encounter. Difficulties arise when there appears to be little common ground, which often results from unrealistic expectations. Patients might be seen as “demanding” or “manipulative”’ if they push for a diagnosis or treatment the doctor is not comfortable with. As soon as there is some overlap and common ground, the difficulty rapidly subsides.
Set clear boundaries and limits. Physicians should set limits on what patient behavior might “cross the line.” A “behavioral contract” (or “treatment contract”) can help by setting explicit expectations. For example, showing up late for appointments or inappropriately seeking drugs of abuse (eg, opioids, benzodiazepines) might be identified as violations of the contract. Once the contract is set, the patient should be asked to restate key components. Clarify any confusion or barriers to compliance and define clear expectations. The patient should be informed of potential consequences of contract violations, including termination.
Staff members involved in the patient’s care should agree with the terms of any behavioral contract, and should receive a copy of it. Patients should have “buy in,” meaning that they have had an opportunity to provide input to the contract and have agreed to its elements. Both the physician and patient should sign the document.
When all else fails
When there is a breakdown in rapport that makes it difficult or impossible to continue offering treatment, consider termination. This could be due to threatening or abusive patient behavior, sexual advances, repeated no-shows, treatment noncompliance that jeopardizes patient safety, refusal to follow the treatment plan, or violating the terms of a behavioral contract. In some settings, it might be the failure to pay bills.
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