The Value of Empathy in the Patient-Clinician Relationship Ceu · context of psychotherapy and about the role it plays in clinician-patient communication. ... cope with illness and
Post on 11-Feb-2021
0 Views
Preview:
Transcript
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
1
THE VALUE OF EMPATHY IN THE
PATIENT-CLINICIAN RELATIONSHIP
Introduction
Empathy is considered fundamental to successful patient engagement and
healthcare outcomes. An empathic clinician can affect a patient’s levels of
anxiety and stress, patient satisfaction and adherence, and patient
enablement. Within a health team, empathic treatment enhances
information exchange between health team members, diagnosis and
treatment outcomes. Specifically, there is a significant correlation between
the empathic clinician and patient responsiveness to treatment.
The Role of Empathy
Empathy is a component of the clinical and therapeutic relationship and is
key to quality healthcare. Researchers have written about empathy in the
context of psychotherapy and about the role it plays in clinician-patient
communication. Empathy has a major impact on lowering anxiety and
distress in patients and results in better clinical outcomes.
Neuroscientific researchers have most recently studied the science of
empathy. It is a new field of research with clinical implications. They have
reported on a neurobiological basis for empathy following discovery of the
mirror neuron system (MNS) that affects an individual’s ability to be
empathetic. The mirror neuron system provides a neural mechanism
whereby individuals can understand the actions of others.74-76
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
2
Recent studies using functional magnetic resonance imaging (fMRI)
experiments clinicians have looked at mirror neurons in the ventral premotor
cortex and parietal area of the brain. Neurons in the somatosensory areas
and in limbic and paralimbic structures are also seen. The insula, located
deep inside the lateral sulcus, within the cerebral cortex of the brain, plays a
role in connecting these regions. The fMRI experiments show that people
who score higher in a questionnaire measuring a tendency to relate to the
experiences of others activate the MNS region more strongly when listening
to other’s express their emotions.75 The neurobiological studies, however, do
not provide information about clinical outcomes.
Definition of Empathy in Healthcare
To assess the value of empathy in clinical practice, its definition must first be
understood. There is no standard definition of empathy but certain elements
can be identified. Empathy in healthcare is generally viewed as the
competence of a health clinician to understand the situation of a patient
including the patient’s perspective and feelings. It is also the ability to
communicate and to act on that understanding in a therapeutic way.1-5
Empathy can be defined as an attitude, competency, and behavior. Attitude
reflects in the respectfulness one shows toward another person. It also
reflects in the interest, impartial and receptive treatment one carries toward
others. Empathy is considered the basis of good clinician-patient
communication. It has an impact on patient satisfaction, adherence, anxiety
and stress, and on clinical diagnostics and outcomes.
Clinician competence can include empathic skill, communication skill, and
the skill to build a patient relationship based on mutual trust. Empathic skill
refers to how a health clinician can engage a patient by drawing close to
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
3
their inner world. By recognizing a patient’s health needs, a clinician can
gain the patient’s trust and thereby obtain needed health information from
the patient. With effective communication skills, a clinician is able to check,
clarify, support, understand, reconstruct, and reflect on the perception of the
thoughts and feelings of a patient. When a clinician-patient relationship
based on mutual trust is developed this reflects the ability of a clinician to
emotionally resonate with a patient.1-5
A clinician’s behavior indicates how well the clinician recognizes a patient’s
feelings and identifies with him or her. Behavior includes verbal and
nonverbal skills whereby the clinician shows recognition of the emotional
state of a patient in their situation, such as a change of environment, or of
suffering from anger, grief, and disappointment. The empathic clinician
reflects on and communicates an understanding of the patient’s
circumstance to the patient. Empathy is considered by both patients and
clinicians as patient-centered and humane. A majority of patients would
recommend an emphatic clinician to someone else.77
Barriers to Empathy
Barriers to empathy have been identified as including an increase in
technology and emphasis on productivity in medical practice, which
influences aspects of patient care. A decrease in effective communication
and a low level of empathy in clinician-patient relationships has been
correlated to the rise of medical technology and productivity in everyday
practice.
Various authors have reported on a greater interest by clinicians in
technological and biomedical aspects of care. Some express concern that an
emphasis on technology means less interest in empathy. Recipients of
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
4
healthcare may not feel clinicians are able to understand their situation and
then become dissatisfied with their care. The improvement of patient
satisfaction and adherence was addressed by Hojat, et al., who found a
correlation between patient satisfaction and perception of physician
empathic engagement.77,78 It was also found that the response of anxious
patients correlated with the response of their health clinician, and patients
tended to report lower levels of anxiety when under the care of an empathic
clinician.
Varied research studies confirmed data findings of patient satisfaction and
adherence. The data found links between health clinician empathy and
patient satisfaction in various clinical settings. Researchers reported that
empathy directly correlated with increased satisfaction, trust, and
adherence; and patients who were more satisfied with their care also
showed better adherence to treatment regimens. The same was found to be
true for Lelorain, et al.79 It was showed that a patient’s view of quality of
medical consultation related to health clinician competence and empathy.
Diagnosis and Clinical Outcomes
Better diagnostics and clinical outcomes were confirmed through the
research on empathy, indicating that communication between health
clinicians and patients is associated with underlying clinician attitudes.
Health clinicians with a positive attitude when addressing patient
psychosocial issues tended to show more concern and empathy. Improved
patient satisfaction and clinical outcomes correlated with patient appreciation
of empathy shown to them.3-5 An attitude of genuine empathy and concern
by the clinician, as well as an ongoing relationship with the clinician, was
highly valued by patients.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
5
Patients under the care of empathic health clinicians offered up more
personal information about social and psychological issues affecting their
health. Patients indicated how a clinician’s attitude hindered or helped them
when discussing their health problems. Patients also indicated how a
clinician helped them resolve or understand problems as well as supported
their efforts to change.
Hojat, et al., elaborated on a correlation with regard to health clinician
empathy and patients’ clinical outcomes. Patients with laboratory diabetes
testing who had been checked for their glycosylated hemoglobin (A1c) and
low density lipoprotein (LDL) were found to have better test results when
under the care of a clinician showing empathy. Empathy in the clinician-
patient relationship enhanced mutual understanding, trust and honesty
between both parties. It also provided good alignment of patient needs with
treatment plans, resulting in a more accurate diagnosis and improved
treatment adherence.77,78
Researchers have shown that when clinicians communicate with empathy
this can lead to better diagnostic and clinical outcomes. Patients talk more
about their symptoms and concerns, which enables clinicians to collect more
detailed personal health information, and to arrive at an accurate medical
and psychosocial evaluation, diagnosis, and treatment regimen. For a patient
group with higher health clinician empathy a duration of 5.89 days versus 7
days of hospital stay occurred.3-9
There have been reports that even the common cold may be less severe in
cases where empathy exists in the health clinician-patient relationship. More
evidence is needed about the effectiveness of empathy in the daily practice
of health clinicians.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
6
Patient Enablement
A higher level of patient enablement has been reported where health
clinician empathy exists. There is also a positive relationship between
enablement and changes in wellbeing and patient complaints. Patient
enablement may be measured through use of the Patient Enablement
Instrument (PEI). Questions in this test cover the ability of the patient to
cope with illness and life in general, as well as patient confidence about
health and the ability to remain independent.
Research studies have focused on the relationship between patient health
outcomes and clinician empathy. The use of empathy in communication was
raised as a soft element. Empirical evidence also exists relative to the
positive impact of clinician-patient interaction, including aspects of empathy
and patient satisfaction, adherence to treatment (during periods of patient
anxiety and distress), strengthening of patient enablement, and clinical
outcomes.77
Measuring Levels of Empathy
Researchers use various tests to measure levels of empathy, including those
outlined below.77-80
• Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE):
a self-report measuring scale for cognitive and attitude factors.
• Consultation and Relational Empathy (CARE):
a patient rating system that measures clinician communication skills
and attitudes.
• Roter Interaction Analysis System (RIAS):
an observer-rating system that measures empathy skills.
• Tape Assisted Recall (TAR):
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
7
measures the development of a long-working relationship.
A health clinician can be trained on ways to improve empathy and be tested
for empathy level and communication style. As mentioned earlier,
empathetic communication in the clinical encounter impacts the overall
satisfaction with healthcare service for a patient, adherence to regimens,
comprehension, and perception of a good relationship are related to the
interpersonal communication between a clinician and the patient. This is
particularly related to the clinician’s empathy. A warm communication style
can lead to a positive effect on patient anxiety and engagement.
The higher focus on research related to empathy in clinical practice has
emerged in the health literature. For example, in 2008 the World Health
Organization (WHO) raised the importance of primary healthcare in a report
Primary Health Care Now More Than Ever with the logo and key challenge to
clinicians to put people first, since good care is about people. Several
qualitative studies have shown that health clinicians link empathy to fidelity,
moral thinking, pro social behavior, good communication, patient and
professional satisfaction, good therapeutic relationships, fewer damage
claims, and good clinical outcomes.10 Ideally, the medical clinician can
communicate with patients, understand them, know the families, and regard
the patient as more than “a case.”
In a study on how primary care clinicians try to convey empathy to medical
students, basic principles of clinician empathy are raised. This includes moral
development in the clinician, a basic willingness to help, and a genuine
interest in the feelings of others. Limiting factors during clinical consultation
are time pressures, heavy workloads, a lack of skill, and a cynical view on
the effectiveness of empathy. Patients also tend to notice time pressures on
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
8
a medical clinician as a barrier. While empathy is generally viewed as part of
good clinician-patient communication, barriers exist for implementing this in
general practice.80
Empathy in medical school has been specifically studied. Several reports
showed that empathy appeared to increase during the first year of medical
school, and it decreased after the third year. Empathy remained low in the
final year of medical school, as measured using the Jefferson Scale of
Physician Empathy – Student Version. Additional studies had suggested that
the degree of empathy shown by medical students declined over the course
of their training.81 Hojat, et al., had previously noted that there were no
gender differences in empathy levels for medical clinicians. Quince, et al.,
recognized that among male medical students their affective empathy
declined slightly but cognitive empathy did not change. For females,
affective and cognitive empathy did not change.82
According to Treadway and Chatterjee, when a medical student finally
begins clinical practice after medical school, the student may begin to lose
empathy. Possible explanations of the decline in empathy were identified as
a lack of good role models, changes in culture, and ethical views on health
and illness.83
The evidence of a positive impact between empathy and clinical outcomes
needs to be emphasized more among health clinicians, especially in light of
current education trends focused on technological changes and systems
approaches within healthcare. The heightened emphasis on technology could
influence the clinician-patient engagement in a negative way and to
potentially undermine clinician empathy. On the other hand, there are some
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
9
who express the belief that clinician empathy will improve if it is stressed
more during education and training of all health clinicians.
Currently, a small empirically based examination explains the benefits of
empathy. There are some high-quality studies that show promising results
on evidence-based grounds but more research is needed. Neumann, et al.,
also highlighted the need for an examination of the cost-effectiveness of
empathy in light of the recent focus by policy makers and health insurers on
health systems and the efficiency of healthcare delivery. Raising awareness
on empathy in healthcare with policy makers to show it is an effective and
efficient way of managing patient outcomes has been pursued over the past
decade.84 Researchers have reported that empathy should improve the
clinician-patient relationship, and that more patients reported they want an
empathetic clinician.
A concern has existed that empirical studies on clinician empathy are
relatively scarce. However, the existing literature until now has clearly
revealed that empathy is an important factor in patient satisfaction and
adherence. It also helps decrease patient anxiety and distress and allows for
better diagnostic and clinical outcomes. Clinician empathy also strengthens
patient enablement and seems to improve physical and psychosocial health
outcomes. Importantly, empathy should result in satisfaction not just for the
patient but for the clinician because they will experience less compassion
fatigue or burnout. While more research is needed, clinicians need to learn
more about the practical use of empathy in healthcare settings, and focus
more on the effects of empathy in the clinician-patient relationship.
The above discussion highlights the measurement of empathy as an
important part of the current research and quality outcomes in healthcare
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
10
delivery. It is often based on subjective self-reports. Other remote, objective
findings identifying concrete feelings, experiences, and interpretations in
clinical practice from the perspective of the clinician-patient encounter have
improved the evidence on the value of empathy in healthcare. Patient
perceived empathy is related to patient outcomes; a patient perceived
empathy scale to measure the empathy of a clinician has been implemented
in some healthcare settings to identify gaps in patient-centered care within
an organizational culture.85
Many patients look for empathy from their health clinicians. Outside of the
medical setting, empathy means a human understanding that involves
emotional resonance. Medical education has increasingly recognized this
need.
Detached Cognition In The Health Clinician
The concept of detached cognition relates to the way educators in the
medical field define empathy with a focus on emotional attunement and
understanding of a patient’s emotions. Educational curriculums in healthcare
are being evaluated more closely for how they are designed to teach
empathy to health clinicians. Medical clinicians have a challenging role in
that they try to be detached yet reliably care for all patients regardless of
their personal feelings.33-37
Medical educators as well as professional bodies overseeing licensing and
continuing education for health clinicians are increasingly recognizing the
importance of empathy. They define empathy in a unique way to be
consistent with the idea of detachment. As mentioned, outside of medicine,
the term empathy means a way of understanding and involves being moved
by the experiences of another person. The Society for General Internal
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
11
Medicine defines empathy as the act of correctly acknowledging the
emotional state of another person without experiencing the state oneself. A
medical clinician cannot and should not experience the suffering of each
patient. The emphasis on clinician empathy is that it is intellectual and a way
of knowing how the other person may feel, but not emotional. The
assumption is that experiencing the emotion is not important for
understanding what the patient is feeling.3-5,33-37
The current medical literature defines health clinician empathy as cognitive
in contrast to sympathy. A clinician who is sympathetic could risk over
identifying with a patient.29 Emotional responses could be seen as a threat to
objectivity. In The New England Journal of Medicine and the Journal of the
American Medical Association during the 1950s and 1960s clinical empathy
was discussed as necessarily detached reasoning. This meant that the health
clinician would do what needed to be done for patient care without feeling
grief, regret, or other difficult emotions. The clinician was described as
having a primary role to observe the patient to predict a response to illness.
This concept of a detached clinician continues to persist throughout the
current literature. In a classic 1963 article, Training for Detached Concern,
Fox and Lief described how a medical student can dissect a cadaver without
disgust. This same detachment allows a clinician to listen empathically while
not becoming emotionally involved.
Meanings of Empathy and Detachment
Medical clinicians are trained to view the emotions of a patient objectively;
however, they should recognize that they cannot overcome all emotions. The
model of detached concern involves knowing that a person is in a certain
emotional state. The clinician does not just label the person’s emotion but
tries to recognize what it feels like to experience that emotional state.29-31
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
12
Clinicians guided by empathy can know what emotional descriptor applies to
a patient. The following case examples illustrate the concepts of empathy
and detachment in clinical practice.
Example 1: Spinal Cord Injury Case
A 33-year old male patient has been paralyzed from the neck down following
a motor vehicle accident and becomes depressed and refuses treatment.
During a clinical encounter, the patient is immobile and struggles to whisper
through a tracheotomy tube to the clinician. The clinician responds to the
patient’s attempts to speak by speaking in a quiet and gentle way. Despite
the clinician’s gentle and non-threatening approach, the patient remains
withdrawn in his response to the clinician.
The clinician may feel shame and retreat, which is a reflection of what the
patient feels. Conversely, the clinician may recognize that continuing to
communicate to the patient in a quiet and gentle way might not be effective
because the patient is not engaging in treatment. The clinician may try
asking the patient what is bothering him in a more assertive manner, risking
an angry response from the patient to avoid sharing his true feelings. The
patient may even express feeling disrespected by such an approach to
engage. In such a scenario, the clinician and patient have engaged albeit
there may be emotional anger communication by the patient, and now the
clinician may begin an effective therapeutic approach.
Example 2: Pregnancy Case
A 20-year old pregnant patient meets with her obstetrician on what to
expect during her first labor and delivery. The young woman appears
anxious as the physician explains to her the options for pain relief. After he
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
13
explained in detail about the patient’s options she still appeared anxious and
became more withdrawn. The obstetrician asked the patient what was
making her anxious, however she did not answer. When the patient did not
respond, the obstetrician continued to explain in more depth the options for
pain, and attempted to cheer and reassure the patient that all would be fine.
Shortly after that encounter, the patient moved her care to a new physician.
In this case, the patient’s unresolved anxiety included an element of panic
as the obstetrician tried to reassure her about pain relief. She may have
imagined being tied to an intravenous (IV) line as he explained the process
of IV analgesia during delivery. She may have feared being restrained and
losing control. In the patient’s medical history questionnaire, she had
reported a past experience of sexual abuse as a rape victim, which triggered
fear of being confined to an IV line. When the obstetrician explained options
to the patient, not taking into account her history of sexual abuse, she likely
felt that her fear was not being recognized. She may have felt that the
obstetrician appeared unconcerned about her past experience of trauma, as
he did not pause to listen or use nonverbal observation skills to cue the
patient that he was paying attention and understood her trauma was the
basis of her fears.
On Reflection: Case Summary
With each of the two above case examples, the medical clinicians are
genuinely concerned. They both asked the same questions related to what
was making the patient feel anxious. In the first case, emotional attunement
guided the timing and tone of the clinical encounter. In the second case, that
appeared to not occur where the obstetrician observed the fear however did
not pause when observing the patient become more frightened.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
14
Nonverbal Attunement
In clinician-patient interactions nonverbal attunement allows the clinician to
pause at moments of observing a patient’s heightened anxiety. With
nonverbal attunement, the patient is able to disclose information. When
clinicians do not pause to allow nonverbal attunement, patients do not share
vulnerable information even when the clinician asks an appropriate and
accurate question.
The key point to remember is that people rarely give a full and useful
response when asked a direct question. Clinicians need to rely on emotional
cues and shifts in the emotions of patients to understand the basis of their
anxiety, and to pause to allow the patient to reveal more information and for
engagement to occur.
The Empathic Clinician And Emotional Attunement
In this section, the concept of emotional attunement is discussed in more
detail as it relates to the empathic clinician. The prior section discussed
detached concern, which some may confuse as being the same as emotional
attunement, however they are not the same. Emotional attunement shapes
what a person imagines about the experience of another person.94
A health clinician may imagine and resonate with what a patient is feeling.
Resonance is part of ordinary communication; it can be subtle and involve a
nonverbal sense of what another person is feeling. It does not always
involve resonating with a strong feeling and verbalization. Empathy does not
require that a health clinician fully experience the emotions of a patient. The
focus should not be on the introspective response of the clinician but rather
on the patient.93,94
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
15
In clinical practice, the challenge is to use skillful attunement in multiple,
rapid, and ordinary interactions. An example is if a patient reports stopping
prescribed medication and appears angry about the potential side effects.
The patient could also feel hopeless about having a certain diagnosis.
Addressing the patient appropriately depends on being attuned to the
emotions of the patient. In this case, the clinician’s best approach may be to
discover why the patient stopped taking medication, and to reflect on how to
respond empathically while deciding on other treatment options for the
patient.6,34-36
There are several ways a clinician can use their emotional response to
enhance patient care. First, they can use emotional attunement to
appreciate the meaning of the words of a patient. Second, their emotions
should focus and hold their attention on what is making a patient anxious.
Third, empathy can facilitate patient trust and disclosure. Empathy can
enhance a clinician’s individual practice and interactions with patients to be
more meaningful. In general, empathy is a way for the clinician to grasp the
emotional state of the patient.
Empathy in the clinical encounter involves perceptual activity however it also
operates alongside logical inquiry. If a clinician exercises the skill of logical,
objective reasoning as they reflect upon their empathic intuitions, this
enhances patient communication, and, as mentioned already, improves the
medical diagnosis and treatment options. A problem can arise if empathy is
viewed as dependent on emotional responses, which are outside of a
person’s immediate control.6,34-36
Listening to the Patient’s Story
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
16
Health clinicians can reliably and reasonably empathize with a patient even
when experiencing a negative emotion. Emotional resonance can flow easily
at times however a busy and overworked clinician could find being
responsive to patients challenging or even impossible. One way to train
clinicians on empathic responses is to encourage them to keep a natural
curiosity about the lives of their patients. Encouraging clinicians to be
curious about patients involves training them on concepts of listening to the
patient’s story and then retelling the story as the patient shared their illness
and personal circumstance.
Training clinicians to write narrative histories helps them to more carefully
listen to the words of the patient.41 An example would be a patient who
became paralyzed and expressed that treatments were useless and a waste
of time. If a clinician focuses on the narrative, it can be useful to elicit
feedback from other health team members or peers on how to engage the
patient by repeating back the narrative during another clinical session when
the patient feels more prepared to explore treatment options. The goal of
repeating the patient’s story would be to help the patient consider and agree
to treatment options rather than continuing to feel as though life after a
traumatic injury or major illness was useless and a waste of time.
Barriers to Empathy
Barriers to empathy are important to understand, and at times multiple
barriers can exist. Barriers can be due to both the patient and clinician
responses. For example, patients could experience anxiety or other emotions
that interfere with empathic responses; or the clinician could be pressured
by the lack of time to listen. A significant barrier to empathy is when
clinicians do not see the emotional needs of the patient as an important part
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
17
of care and illness. Research shows that clinicians communicate better if
they regularly include psychosocial dimensions of care in their practice.
An additional barrier to empathy concerns how negative emotions can arise
when tension exists between a clinician and patient.59,70,71 A clinician can feel
angry with a patient for not cooperating with treatment and this leads to
barriers to understand the perspective of the patient. Clinicians can be
educated to show tolerance and to be mindful of their own negative feelings,
such as when a psychiatry clinician learns to pay attention to
countertransference, which is redirection of the clinician’s feelings toward
the patient. Both empirical and theoretical work is needed to address these
barriers and to help provide steps for clinicians to include empathy into
everyday practice.
Clinician Education
Education curriculum has already been raised as a way to address barriers to
empathy in the clinician-patient relationship. Specifically, clinicians can be
trained to focus on the beginning of a patient interview, giving the patient
time to speak without interruption. This helps set the tone for patient
disclosure and trust to develop. Education can also focus on how the clinician
perceives the psychosocial needs of the patient as important and integral to
good diagnostic outcomes.
Clinicians also need to be educated to focus on their own self-care, and
potential anxiety as they often function within overworked and short-staffed
health teams. They need to be educated to acknowledge and seek
interventions for their own emotional needs.
Neural Basis Of Empathy
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
18
Empathy is fundamental to the emotional and social lives of people and is
defined in general as the ability to share the feelings of others. As
mentioned, human imaging studies have been used to determine how
empathy consistently showed activation in regions of the brain that involve
experiencing pain. This suggests that empathy is based at least in part on
shared representations of firsthand and imagined experiences.86 These
emphatic responses are not static. They can be modulated by the
characteristics of a person such as the degree of alexithymia, which is the
subclinical inability to identify and describe emotions within oneself. This is a
marked dysfunction in emotional awareness, interpersonal relationships, and
social attachment.
Empathy-related insular and
cingulate activity (with the
cingulate cortex part of the brain
situated in the medial aspect of the
cerebral cortex) can reflect a
domain general computation,
representing and predicting feeling
states in oneself and others, and
believed to guide responses and
goal-directed behavior in dynamic
social contexts. Empathic neuronal
activation can also be modulated by
contextual appraisal that includes
perceived fairness or group
membership with others. Empathy
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
19
can involve co-activation in further networks that are associated with social
cognition. This depends on the specific situation and the information
available in an environment.
Empathic Negotiation And Confrontation
Avoiding confrontations is often considered the best approach to handling a
difficult patient. However, a closer look at the topic of confrontation with
patients is needed to identify concepts and methods for coping strategies.
Kontos, Querques, and Freudenreich provided insights into the rationale and
responsibilities in patient confrontation. They identified that all clinicians can
find themselves challenged with patients who are behaviorally inflexible,
demanding, and temperamentally difficult.87
Being prepared through education on the empathic approach when dealing
with patients is the ideal in order to carry forward empathetic negotiation
and persuasion. There can be a natural reluctance to confront patients if
they are unresponsive to these approaches, and at times the confrontation
can be mishandled. Confrontation is defined as a clinical interaction that is
interpersonal, face-to-face, and has the potential for an emotional clash,
forcing a comparison of two points of view on medical care. Confrontation
can also be a communication tool for a clinician to use when attempting to
make decisions in a patient’s best interest. It can also be a patient-centered
approach and relies on shared responsibility.
Kontos, Querques, and Freudenreich made the case for effective use of
confrontation in patient care. Other interpersonal and social interventions
were raised. The goal was to discuss an approach that could improve
therapy, reduce clinician frustration, and minimize misallocation of
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
20
resources. The authors noted that medical literature and training can neglect
guiding a clinician in managing poor patient behavior and attitudes.88
Confrontation with patients can seem inconsistent with medical best
practices. But there is an argument that confrontation and healing are not
mutually exclusive. Some have argued that clinician assertiveness has
therapeutic value with hesitant or oppositional patients. There needs to be a
balanced focus on patient care outcomes and clinician duty to confront a
situation. A poor confrontation with a patient can give a clinician a sense of
powerlessness with respect to the clinician’s concerns and judgment on safe
and appropriate patient care. Confrontation that is poorly executed can be
counter-therapeutic and sever the clinician-patient relationship.
The authors proposed three questions to help clinicians decide if
confrontation can be in the best interest of patients. The first question is:
Does my patient prioritize health? The second question is: Is Confrontation
of My Patient Ethically Permissible? The third question is: What If
Confronting My Patient Is Emotionally Gratifying? The authors recommended
that the clinician does not want to subdue the patient as an opponent.
Rather, the clinician wants to turn the patient into an ally to fight for their
own better health.
The most important question to ask in choosing if patient confrontation is an
option relates to whether the patient prioritizes health.89 The business of the
clinician includes patient attitudes and behaviors that negatively impact
clinical progress. If proper patient care cannot proceed, confrontation could
be justified. The proposal could be a negotiated change. If a patient does not
prioritize health, the clinician should explore and try to work with the
priorities of the patient. The clinician can try to influence the patient but
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
21
cannot impose on the patient to minimize disease burden except in special
circumstances.
Problems can arise if a patient makes demands and does not highly prioritize
health. Take for example a 55-year-old patient with type 2 diabetes mellitus
and long standing poor glycemic control due to nonadherence who attends
appointments sporadically, refuses nutritional guidance, and has comorbid
heart disease. In this case, confrontation could be justified. In such a case,
the patient seeking care needs to improve cooperation with the diabetes
care being provided. Cooperation does not mean passivity. A responsible
patient should engage actively in their pursuit of health and in medical
decision-making. If there is clinical inefficacy due to a defect in the clinician-
patient relationship, this should be considered in the decision concerning
patient confrontation.
Ineffective clinical care can be due to an imbalance between the health
clinician’s and the patient’s responsibility. Confrontation could be justified to
bring these two components into a productive balance. For example, a
psychiatric illness could cause a failing clinician-patient relationship, such as
with a sociopathic patient who is angry and hateful. Challenging such a
patient, who may also have comorbid conditions related to the mental
illness, such as an addiction disorder, personality disorder, or other
psychopathology, is challenging however it is important for the clinician to
identify if a barrier to health is resolvable, and if the patient is invested in
his/her own health.
Avoiding conflict might not be the best option. Patients sincerely tending to
their health would likely inform the clinician of their needs and hope for a
remedy to their ailment. However, after identifying, adjusting to, and
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
22
reducing barriers to care, if the patient is not invested in his/her own health
then confrontation could be an option to potentially correct the imbalance in
the clinician-patient relationship and ineffective clinical outcomes.
Confrontation and Ethics
Confrontation could be considered a violation of patient autonomy and
concerns medical ethics. Patient autonomy is a cornerstone of current
healthcare, but simply respecting a patient’s decision could be a dangerous
oversimplification. For example, consider the case of a 55-year old patient
with coronary artery disease who presents repeatedly to an emergency
department with worsening symptoms of shortness of breath and chest pain.
Each time the patient leaves the emergency department against medical
advice after receiving nitroglycerin and morphine. Confrontation by the
clinician might be the only way such a patient would stop with decisions that
are not helping his/her health.
In the clinician-patient relationship it is assumed that patients can do no
wrong. However, a clinician can use their expertise and authority to make
medical decisions and request patient accountability. In an ideal situation,
the clinician-patient relationship is between two autonomous parties with a
mutual goal, and where the clinician can have legitimate expectations of the
patient. The relationship should ideally include truthfulness, respect, and
adhering to a plan for care that is negotiated. In an honest relationship,
respectful confrontation can occur when one person bears a burden in a
failing direction. Because the clinician is considered a caring stakeholder in a
patient’s health, if the health of a patient is deteriorating due to patient
action or inaction and other avenues of intervention are exhausted, the
clinician should care (and be justified) to confront.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
23
The main point in this section is that confrontation can become an option.
When the patient’s health is deteriorating, harm can occur through passivity
and a superficially inoffensive relationship between the clinician and patient.
Once the clinician has thought through in advance about whether a patient
has enough opportunity to control certain variables, the clinician should hold
the patient accountable.
Clinicians are also considered stewards of healthcare resources and if the
patient is unfairly and unjustifiably using finite resources, this should be
confronted as well. The issue of confronting a patient is a challenging issue
that some clinicians may prefer to avoid, but it is an increasing topic in the
health literature relative to clinician-patient engagement and a topic that
clinicians are recommended to focus on in terms of professional
development and competency.
Confrontation and Emotional Gratification
At times a clinician can feel frustration or anger with a patient and feel
compelled to step back. This frustration or anger can be due to
countertransference or simple human emotion. A good approach is not to
simply act on a positive or negative response, but to evaluate responses in
context of the clinician’s relationship with the patient.
A clinician must not simply indulge in self-gratification. On the other hand,
avoiding feelings and reactions could cut off a potentially helpful decision
about clinical action and result in harmful decisions. While a clinician can
love, hate, or fear a patient, he or she should acknowledge these feelings
and examine motives in clinical decision-making affecting patient health. An
example would be a 40-year old with systemic lupus erythematosus (SLE)
who is inconsistent with keeping medical appointments. Other complicating
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
24
factors could be that the patient is verbally abusive, refusing treatment and
yet accuses the clinician for not meeting health expectations. If the patient is
not cooperative, threatening and showing unacceptable behavior, avoiding
and/or disregarding the patient’s displeasure could pose risks for the
clinician in the end. If an unfavorable imbalance exists in the clinician-
patient relationship, it can lead to the clinician feeling constrained in terms
of communicating options to continue versus discontinuing the relationship
with the patient. In such cases, while the confrontation could be difficult it
may be needed and, in the end, helpful.
A patient can also have a powerful emotion and act in a way that renders a
clinician to act on them before the clinician realizes what is happening. This
is an unfortunate outcome, and is known as projective identification. If the
clinician disavows these feelings, a patient can sometimes escalate an
already irrational behavior.87-90 Although such circumstances can be
challenging, there is still an opportunity to turn the situation toward a more
therapeutic encounter. The clinician can choose to either tolerate the
unpleasant emotions or examine them from the patient’s perspective. The
patient may be helped to identify, understand, and manage their own state.
If a clinician responds in a way that is strategic and mature, this can be
useful and gratifying to all involved.
Judgment can be clouded by the need for self-gratification. Reactions to a
patient and projective identification can involve complex motives and
feelings. Clinicians should be aware of these possible outcomes in the patient
relationship when considering the need for confrontation. The ideal is that
the clinician is reflective and can self-assess their own feelings and
responses before, during, and after patient confrontation, and seeks periodic
consultation to make sure all factors are weighed responsibly.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
25
In a clinician-patient relationship confrontation can be a legitimate option if
that relationship suffers from an imbalance related to a person’s privileges
and duties. Kontos, et al., focused more on principles and not on specific
techniques of confrontation.90 Some patients will be confronted and find
another health clinician to do what they want. More could be said in the
medical literature relative to patient confrontation, such as how to stay
consistent with the goals of patient-centered medicine though values of
honesty, social responsibility, and mutual accountability.87-90
Letting Go of Anger
Letting go of anger is a positive step for both a patient and health clinician.
If the clinician holds on to anger, he/she cannot effectively move forward
with a solution to problems. If a patient feels anger, they need to be guided
as well to let go of it.
Clinicians who feel anger, due to what a patient said or some other reason,
cannot effectively act as a health professional. If the clinician or patient are
not able to get rid of anger, the price could be high. Not letting go of anger
could cause individuals to suffer physically, emotionally, and spiritually; it
can lead to bitterness, lack of enjoyment of the present, depression, anxiety,
and a lack of connectedness with others. Letting go of anger is a conscious
decision, and it opens options for better feelings of understanding, empathy,
and compassion. When a person lets go of anger this leads to healthier
relationships, greater psychological wellbeing, less anxiety, less hostility,
less stress, lower blood pressure, fewer symptoms of depression, a stronger
immune system, improved heart health, and higher self-esteem.91-93
Techniques To Deal With A Difficult Patient
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
26
Insight on the art of handling difficult patients has been offered by
Chesanow who notes these patients can be the one many clinicians and staff
dread to see walk into a clinic or admitted to hospital. Difficult patients are
regarded as those who are angry, disrespectful, rude, demanding of certain
drugs or tests even when they are not needed, abusive, and even ask
clinicians to submit a fraudulent bill so that insurance will cover the cost of
treatment.94
One approach to dealing with the difficult patient is to draw boundaries.
Clarify what behavior is allowed and require them to act respectfully. A
patient may not be aware that they are being difficult and demanding. If
setting such boundaries does not work, the clinician could suggest to the
patient that he/she is not the best clinician for the patient. Alternatively,
another approach is to overcome the issues encountered with a difficult
patient. Trying to determine what the patient is unhappy about in the
clinician-patient relationship and being willing to apologize can help even if it
is not the fault of the clinician. For example, the patient may have had a
long waiting room stay or not happy with a specialist referral. The patient
could be forgiving with the clinician if they detect the clinician is genuinely
sorry for the patient’s unhappiness.
There is a reported 5 percent of patients that can cause 95 percent of the
problems in a clinician’s practice. It may not always be prudent to dismiss
the patient from the clinician’s practice; in that case, the clinician must deal
effectively with a rude and abusive patient. The clinician and the general
office staff need to be prepared to assist in the needs of a difficult patient.
The clinician should have staff prepared to deal with, for example, a patient
who gets impatient when an appointment wait is long.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
27
In cases of unresolved conflict, the clinician may opt to write the patient a
letter or address the patient in the presence of an office manager. An
example would be when the clinician needs to calmly inform a patient that a
basic ingredient in the relationship needs to be addressed. If the patient’s
behavior appears to lack cooperation with the clinician and office staff, this
makes it impossible to engage with the patient to promote good health
outcomes. Options in such situations are to advise a patient to find another
medical clinician, provide a referral to them or ask for a referral from
another primary care physician. While the patient is seeking another medical
clinician, he/she can be advised that emergency care will be provided for one
month from the date of the termination of care letter. Any subsequent
behavioral issues should be documented.
Not all clinicians feel comfortable terminating a patient relationship. Some
have not been able to identify ever interacting with a difficult patient or
consider they have been effective with a difficult patient by listening to their
story without interruption. Much depends on the medical specialty and type
of clinical practice engaging with patients. A clinician can guide the
conversation if it becomes unproductive with unnecessary detail.
If a health clinician feels pressured for time, it may be hard to not show
impatience. This can inflame a situation. It is hard to feel compassion for
someone who is not cooperating. A clinician can also fear harming a patient
by missing a diagnosis or not recognizing a drug interaction, forgetting to
check a lab or missing a call back. A problem patient can cut into the time
needed for all of this. But a medical clinician can recognize that dealing with
a difficult patient is inevitable and requires clear boundaries to be
established for both patient and staff.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
28
Frequent Flyers
There are certain patients that arrive at the hospital emergency department
as if it was home. Such patients are often on a first name basis with the
staff. For example, they could have a history of substance use and addiction,
and staff tend to regard them as a regular visitor or frequent flyer.95
The medical frequent flyer generally refers to patients with a number of
health needs. Some are rebounding and challenged by alcohol and drug use
issues, and others need mental health care. Typically, frequent flyers use
the emergency department because they have no health insurance. They
usually have no primary care clinician. The frequent flyer may be driven by
anxiety and fear, chronic pain, yet feel reluctant to make an appointment to
see a primary care clinician.
Some health facilities are considering new ways of taking care of medical
frequent flyer patients, and to manage their needs in a more cost effective
way. Hospitals, healthcare systems, and academics have been prompted by
the urgent need to address the health of medical frequent flyers. The goal is
to curtail a problem some believe could become even worse without clear
planning and solutions to address it.19-26,95
Insurance companies are also working with hospitals to implement new
programs, for example for the frequent flyer with a mental illness or for
others with chronic conditions. The attempt is to divert these patients into
coordinated care plans that are hospital-sponsored. They also connect with
government and community-provided services. Often, case managers are
assigned to monitor these medical frequent flyers. The manager follows up
after an emergency department visit to prevent a recurring hospital stay.
Hospitals are now using electronic medical record programs to flag frequent
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
29
flyers for primary care clinicians and community organizations. Hospitals
may also assign social workers and nurses to look over records and identify
patients who come to the hospital often. They alert these patients that they
may need psychological or primary medical care rather than repeated
admissions to the emergency department.11-13,15-26
A medical frequent flyer may arrive at an emergency department as many
as five times per month. Patients who arrive at the emergency department
with such frequency may have drug or alcohol use disorders. Some are also
homeless. Often, frequent flyers in the emergency department have complex
and severe medical problems. Combined homelessness and addiction issues
can complicate the medical picture in the emergency department, for
example, the person may be intoxicated and having a myocardial
infarction.95 They may have fallen and hit their head and sustained a skull
fracture. Impaired patients cannot always explain how they are feeling.
Complexities are associated with frequent flyers and their use of emergency
departments. The use of an emergency department by a frequent flyer
involves a high health cost burden for a hospital. It is also a strain because
frequent flyers add to overcrowding in emergency departments, impacting
the patient waiting times and delaying emergency, life threatening
interventions for those in need. An urgent need exists for policy makers and
insurers of healthcare to address the growing needs of homeless and
uninsured individuals that become frequent flyers in hospital emergency
departments.11-13,15-17
Summary
There is no standard definition of empathy but certain elements can be
identified. Empathy in healthcare is generally viewed as the competence of a
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
30
clinician to understand the situation of a patient including their perspective
and feelings. It is also the ability to communicate and to act on that
understanding in a therapeutic way.
Empathy is considered the basis of good clinician-patient communication. It
has an impact on patient satisfaction, adherence, decrease of anxiety and
stress, better diagnostics and outcomes. Barriers to empathy exist and are
important to understand through clinical education and ongoing training.
Understanding patient anxiety or other emotions that could potentially
interfere with empathic responses is essential, and clinicians need to be
aware of their own detachment and emotional attunement to avoid patient
perceptions of a lack of time to listen and engage.
Clinicians can be trained on ways to improve empathy and their
communication style with patients. Empathetic communication in the clinical
encounter impacts the overall patient satisfaction with healthcare service,
and patient adherence to regimens, comprehension, and perceptions. A
warm communication style by clinicians can lead to a positive effect on
patients and lead to improved engagement and health outcomes.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
31
Reference Section The References below include published works and in-text citations of published works that are intended as helpful material for your further reading. [References are for a multi-part series on THE DIFFICULT PATIENT]. 1. Ervin, S. (2017). The difficult patient. Retrieved online at
http://www.clinicaladvisor.com/hospital-medicine/the-difficult-patient/article/604126/
2. Lampert, L. (2016). How to handle difficult patients. Retrieved online at https://www.ausmed.com/articles/how-to-handle-difficult-patients/
3. Shorey, J. and Spollen, J. (2018). Approach to the patient. UpToDate. Retrieved online at https://www.uptodate.com/contents/approach-to-the-patient?search=empathy%20in%20practice&source=search_result&selectedTitle=9~150&usage_type=default&display_rank=9
4. Wynne, M. (2015). Dealing with difficult patients. Retrieved online at https://nurse.org/articles/dealing-with-difficult-patients/
5. Vavrosky, K. (2014) Patients’ bad attitudes. Retrieved online at http://www.rdhmag.com/articles/print/volume-34/issue-11/columns/encouraging-excellence/patients-bad-attitudes.html
6. French, L. (2016). Communicate with angry patients. Retrieved online at https://books.google.com/books?id=Zci5DQAAQBAJ&pg=PA127&lpg=PA127&dq=patient+with+a+defensive+attitude&source=bl&ots=BK-2sEDOMs&sig=mbXc9KR220WMFQhPcKXS4xydQto&hl=en&sa=X&ved=0ahUKEwjo3LTWvIzXAhVp54MKHeoeARAQ6AEISjAG#v=onepage&q=patient%20with%20a%20defensive%20attitude&f=false
7. Ervin, S. (2017). The difficult patient. Retrieved online at http://www.clinicaladvisor.com/hospital-medicine/the-difficult-patient/article/604126/
8. Lampert, L. (2016). How to handle difficult patients. Retrieved online at https://www.ausmed.com/articles/how-to-handle-difficult-patients/
9. Wynne, M. (2015). Dealing with difficult patients. Retrieved online at https://nurse.org/articles/dealing-with-difficult-patients/
10. World Health Organization (2018). The World Health Report 2008: Primary Health Care (Now More Than Ever). WHO. Retrieved online at http://www.who.int/whr/2008/en/.
11. Krishnamoorthi, R. (2011). Hospitals’ “Frequent Flyers”: More Than Just Ending Bonus Miles for Re-admissions. Retrieved online at http://www.drsforamerica.org/blog/hospitals-frequent-flyers-more-than-just-ending-bonus-miles-for-re-admissions
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
32
12. Hennessy-Fiske, M. (2011). California is cutting preventable hospitalizations. Retrieved online at http://articles.latimes.com/2011/jan/04/local/la-me-hospital-race-20110104
13. Landi, H. (2016). Is it Unethical to Identify Patients as “Frequent Flyers” in Health IT Systems? Retrieved online at https://www.healthcare-informatics.com/news-item/ehr/it-unethical-identify-patients-frequent-flyers-health-it-systems
14. Joy, M., Clement, T., and Sisti, D. (2016). The Ethics of Behavioral Health Information Technology- Frequent Flyer Icons and Implicit Bias. JAMA. 316(15):1539-1540. Retrieved online at https://jamanetwork.com/journals/jama/article-abstract/2551660
15. Landi, H. (2016). Is it Unethical to Identify Patients as “Frequent Flyers” in Health IT Systems? Retrieved online at https://www.healthcare-informatics.com/news-item/ehr/it-unethical-identify-patients-frequent-flyers-health-it-systems
16. Torrey, T. (2017). What Is a (Healthcare) Frequent Flyer? High-Utilizers Clog Emergency Rooms. Retrieved online at https://www.verywell.com/what-is-a-healthcare-frequent-flyer-2615173
17. Baggett, T. and O’Connell, J. (2018). Health care of homeless persons in the United States. UpToDate. Retrieved online at https://www.uptodate.com/contents/health-care-of-homeless-persons-in-the-united-states?search=homeless&source=search_result&selectedTitle=1~83&usage_type=default&display_rank=1.
18. Jacobs, B. J., et al. (2012). Implementing Brenner’s Collaborative Super-Utilizer Model [PowerPoint slides]. Collaborative Family Healthcare Association 14th Annual Conference.
19. American College of Emergency Physicians. (n.d.). Frequent users of the ER fact sheet. Retrieved online at http://newsroom.acep.org/fact_sheets?item=30011
20. Miller, S., Ghaemmaghami, C., and O’Connor, R. (2012). Annals of Emergency Medicine, “Characteristics of Repeat Emergency Department Users at a University Medical Center,” Vol. 60, Nov 48.
21. Billings, J., and Raven, M. (2013). Health Affairs, Dispelling An Urban Legend: Frequent Emergency Department Users Have Substantial Burden of Disease. Retrieved online at http://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2012.1276
22. Lacalle, E. (2010). Annals of Emergency Medicine, Frequent Users of Emergency Departments: The Myths, the Data and the Policy Implications.
23. Wolfson, D., and Mende, S. (2015). Reduce unnecessary care, choosing wisely moves from awareness to implementation. Retrieved
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
33
online at http://healthaffairs.org/blog/2015/06/30/to-reduce-unnecessary-care-choosing-wisely-moves-from-awareness-to-implementation/
24. Institute of Medicine. (2012) Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Retrieved online at http://books.nap.edu/openbook.php?record_id=13444&page=9
25. Liu, S. (2012). Frequent Users of the Emergency Department: Do They Make Visits That Can Be Addressed in a Primary Care Setting. Annals of Emergency Medicine.
26. Brennan, J., et al. (2012). Multiple Hospital Emergency Department Visits Among ‘Frequent Flyer’ Patients with a Psychiatric-Associated Discharge Diagnosis. Annals of Emergency Medicine
27. Doran, K., Misa, E., and Shah, N. (2013). New England Journal of Medicine, Housing as Health Care – New York’s Boundary-Crossing Experiment. Retrieved online at http://www.nejm.org/doi/full/10.1056/NEJMp1310121
28. Rapp, A. (2016). How body language impacts doctor to patient relationship. eMedCert. Retrieved online at https://emedcert.com/blog/how-body-language-impacts-doctor-to-patient-relationship.
29. Liao, L. (2017). The physician as person framework: How human nature impacts empathy, depression, burnout, and the practice of medicine. Can Med Educ J. 2017 Dec 15;8(4):92-96.
30. Lampert, L. (2016). How to handle difficult patients. Retrieved online at https://www.ausmed.com/articles/how-to-handle-difficult-patients/
31. Lindsley, I., Woodhead, S., et al. (2015). The concept of body language in medical consultation. Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/26417735
32. Rider, T., Malik, M., and Chevassut, T. (2014). Hematology patients and the internet - The use of on-line health information and the impact on the patient-doctor relationship. Patient Educ Couns; 97:223-38
33. Agius, M. (2014). The medical consultation and the human person. Psychiatr Danub; 26(Suppl 1):15-18
34. Silverman, J., Kurtz, S., Draper, J. (2013). Skills for Communicating With Patients. Third Edition. Oxford: Radcliffe.
35. Salisbury, C., Procter, P., et al. (2013). The content of general practice consultations: cross-sectional study based on video recordings. British Journal of General Practice 2013; 63:e751-e759.
36. Little, P., et al. (2015). Randomised controlled trial of a brief intervention targeting predominantly non-verbal communication in general practice consultations. British Journal of Family Practice.
37. Beckman H. (n.d.). Behavior Medicine: A Guide for Clinical Practice. Chapter 4: Difficult Patients. Retrieved online at
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
34
http://accessmedicine.mhmedical.com/Content.aspx?bookId=373§ionId=39732000
38. Texas Medical Association. (2017). How to handle patient confrontations. Retrieved online at https://www.texmed.org/template.aspx?id=1597
39. American Cancer Society. (2015). Anxiety, fear, and emotional distress. Retrieved online at https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/changes-in-mood-or-thinking/anxiety-and-fear.html
40. Cohen-Cole, S. (1990). Clinical Methods: The History, Physical, and Laboratory, Examinations. Chapter 228 – the “difficult” medical patient. Retrieved online at https://www.ncbi.nlm.nih.gov/books/NBK339/
41. Heinerichs, S., Curtis, N., and Gardiner-Shire, A. (2014). Perceived Levels of Frustration During Clinical Situations in Athletic Training Students. J Athl Train. 49(1): 68–74.
42. Deveney, C., et al. (2014). Neural Mechanisms of Frustration in Chronically Irritable Children. Am J Psychiatry. 170(10): 1186–1194.
43. Shapiro, J., (2011). Coping with loss of control in the practice of medicine. Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/21417521
44. Aronson, L. (2013). “Good” patients and “difficult” patients – rethinking our definitions. N Engl J Med 2013; 369:796-797. Retrieved online at http://www.nejm.org/doi/full/10.1056/NEJMp1303057#t=article.
45. Evans, A. and Mints, G. (2018). Evidence-based medicine. UpToDate. Retrieved online at https://www.uptodate.com/contents/evidence-based-medicine?search=evidence%20based%20medicine&source=search_result&selectedTitle=1~22&usage_type=default&display_rank=1.
46. Campbell, D. (2012). Hospital patients complain of rude staff, lack of compassion, and long waits. Retrieved online at https://www.theguardian.com/society/2011/feb/23/hospital-patients-rude-staff-long-waits.
47. Steele, R. and Linsley, K. (2015) Relieving in-patient boredom in general hospitals: the evidence for intervention and practical ideas. BJPsych Advances. 21 (1) 63-70; Retrieved online at http://apt.rcpsych.org/content/21/1/63
48. Vavrosky, K. (2014). Patients’ bad attitude. Retrieved online at http://www.rdhmag.com/articles/print/volume-34/issue-11/columns/encouraging-excellence/patients-bad-attitudes.html
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
35
49. Edgoose, Y., Regner, C., and Zekletskaia, L. (2014). Difficult patients: exploring the patient perspective. Fam Med. 46(5):335-9. Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/24915475
50. Salter College. (2016) Three tips to staying calm in a healthcare emergency. Retrieved online at https://www.saltercollege.com/3-tips-to-staying-calm-in-a-healthcare-emergency/#.WfDwohNSyT8
51. Adams, G. (n.d.). Tips to stay calm as a nurse. Retrieved online at https://www.ultimatemedical.edu/blog/tips-to-stay-calm-as-a-nurse/
52. Jahromi, V., et al (2016). Active listening: The key of successful communication in hospital managers. Electron Physician. 8(3): 2123–2128. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4844478/
53. Kourkouta, L. and Papathanasiou, I. (2014). Communication in Nursing Practice. Mater Sociomed. 26(1): 65–67. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990376/
54. HIMSS. (2017). What is patient engagement? Retrieved online at http://www.himss.org/library/patient-engagement-toolkit
55. Healthaffairs.org. (2013). Patient engagement. Retrieved online at http://www.healthaffairs.org/do/10.1377/hpb20130214.898775/full/.
56. Delbanco, T. and Gerteis, M. (2018). A patient-centered view of the clinician-patient relationship. UpToDate. Retrieved online at https://www.uptodate.com/contents/a-patient-centered-view-of-the-clinician-patient-relationship?search=patient%20communication&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.
57. Carman, K., Dardess, P., et al. (2013). Patient and Family Engagement: A Framework for Understanding the Elements and Developing Interventions and Policies, Health Affairs 32, no. 2: 223-31
58. Carman, K., Dardess, P., et al. (2013). Patient and Family Engagement: A Framework for Understanding the Elements and Developing Interventions and Policies, Health Affairs 32, no. 2: 223-31
59. Légaré, F., and Witteman, H. (2013). Shared Decision Making: Examining Key Elements and Barriers to Adoption into Routine Clinical Practice, Health Affairs 32, no. 2: 276-84
60. Veroff, D., Marr, A., and Wennberg, D. (2013). Enhanced Support for Shared Decision Making Reduced Costs of Care for Patients with Preference-Sensitive Conditions, Health Affairs 32, no. 2: 285-93
61. Hibbard, J., Greene, J., (2013). What the Evidence Shows about Patient Activation: Better Health Outcomes and Care Experiences; Fewer Data on Costs, Health Affairs 32, no. 2: 207-14
62. Hibbard, J., Greene, J., and Overton, V. (2013). Patients with Lower Activation Associated with Higher Costs; Delivery Systems Should Know Their Patients' 'Scores,' Health Affairs 32, no. 2: 216-22
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
36
63. Bisognano, M., and Goodman, E. (2013). Engaging Patients and Their Loved Ones in the Ultimate Conversation, Health Affairs 32, no. 2: 203-6
64. Koh, H., Brach, C., et al. (2013). A Proposed 'Health Literate Care Model' Would Constitute a Systems Approach to Improving Patients' Engagement in Care, Health Affairs 32, no. 2: 357-67
65. Bernabeo, E., and Holmboe, E. (2013). Patients, Providers, and Systems Need to Acquire a Specific Set of Competencies to Achieve Truly Patient-Centered Care. Health Affairs 32, no. 2: 250-8
66. Nease, R., Frazee, S., et al. (2013). Choice Architecture Is a Better Strategy Than Engaging Patients to Spur Behavior Change, Health Affairs 32, no. 2: 242-9.
67. Sommers, R., Goold, S., et al. (2013). Focus Groups Highlight That Many Patients Object to Clinicians' Focusing on Costs. Health Affairs 32, no. 2: 338-46
68. Yegian, J., Dardess, P., et al. (2013). Engaged Patients Will Need Comparative Physician-Level Quality Data and Information about Their Out-of-Pocket Costs. Health Affairs 32, no. 2: 328-37
69. Lin, G., et al. (2013). An Effort to Spread Decision Aids in Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles, Health Affairs 32, no. 2 (2013): 311-20
70. Legare, F. and Witteman, H. (2013). Shared Decision Making: Examining Key Elements and Barriers to Adoption into Routine Clinical Practice. Health Affairs 32, no. 2: 276-84. Retrieved online at http://www.healthaffairs.org/doi/full/10.1377/hlthaff.2012.1078
71. Friedberg, M., Van Busum, K., et al. (2013). A Demonstration of Shared Decision Making in Primary Care Highlights Barriers to Adoption and Potential Remedies, Health Affairs 32, no. 2: 268-75
72. Grob, R., et al. (2013). The Affordable Care Act's Plan for Consumer Assistance with Insurance Moves States Forward but Remains a Work in Progress, Health Affairs 32, no. 2: 347-56. Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/23381528
73. Mitchell, W. (2016) Positive language leads to positive wellbeing. BMJ 354:i4426. Retrieved online at http://www.bmj.com/content/354/bmj.i4426.
74. Derksen, F., Bensing, J., Lagro-Janssen, A. (2013). Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract. 63(606): e76-84. Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/23336477
75. Reynolds, J., et al. (2015). A systematic review of mirror neuron system function in developmental coordination disorder: Imitation, motor imagery, and neuroimaging evidence. Res Dev Disabil. 47:234-83. Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/26458259
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
37
76. Bernhardt, B. and Singer, T. (2012). The neural basis of empathy. Annu Rev Neurosci. 2012;35:1-23. Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/22715878
77. Hojat, M., Louis, D.Z., Maxwell, K., et al. (2011). A brief instrument to measure patients’ overall satisfaction with primary care physicians. Fam Med. 43(6):412–417
78. Hojat, M., Louis, D.Z., Markham, F.W., et al. (2011). Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med. 86(3):359–364
79. Lelorain, S., et al (2012). A systematic review of the associations between empathy measures and patient outcomes in cancer care. Psycho-Oncology. 10:1–10
80. Heje, H.N., et al (2011). General practitioners’ experience and benefits from patient evaluations. BMC Fam Pract. 12:116–146
81. Konrath, S.H., et al. (2011). Changes in dispositional empathy in American college students over time: a meta-analysis. Pers Soc Psychol Rev. 15(2):180–198
82. Quince, T.A., et al. (2011). Stability of empathy among undergraduate medical students: a longitudinal study at one UK medical school. BMC Med Educ. 11:90
83. Treadway, K. and Chatterjee, N. (2011). Into the water - the clinical clerkships. N Engl J Med. 364(13):1190–1193
84. Mazzi, M.A., et al. (2011). How do lay people assess the quality of physicians’ communicative responses to patients’ emotional cues and concerns? An international multicentre study based on videotaped medical consultations. Pat Educ Couns. 2011.
85. Derksen, F., Bensing, J., and Largo-Janssen, A. (2013). Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract. 63(606): e76–e84. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3529296/
86. Bernhardt, B., and Singer, T. (2012). The neural basis of empathy. Annu Rev Neurosci. 35:1-23. Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/22715878
87. Skodol, A. and Bender, D. (2018). Establishing and maintaining a therapeutic relationship in psychiatric practice. UpToDate. Retrieved online at https://www.uptodate.com/contents/establishing-and-maintaining-a-therapeutic-relationship-in-psychiatric-practice?search=patient%20confrontation&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2.
88. Freudenreich, O., Kontos, N., and Querques, J. (2010). The muddles of medicine: a practical, clinical addendum to the biopsychosocial model. Psychosomatics. 51(5):365–369
89. Kontos, N. (2011). Biomedicine: menace or straw man? Reexamining the biopsychosocial argument. Acad Med. 86(4):509–515.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
38
90. Kontos, N., Querque, J., and Freudenreigh, O. (2012). Fighting the Good Fight: Responsibility and Rationale in the Confrontation of Patients. Mayo Clin Proc. 87(1): 63–66. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498125/
91. Mayo Clinic. (2014). Forgiveness: Letting go of grudges and bitterness. Retrieved online at https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/forgiveness/art-20047692
92. Coccaro, E. (2015) Intermittent explosive disorder in adults: Epidemiology, clinical features, assessment, and diagnosis. UpToDate. Retrieved online at https://www.uptodate.com/contents/intermittent-explosive-disorder-in-adults-epidemiology-clinical-features-assessment-and-diagnosis?source=search_result&search=patient+anger&selectedTitle=18~150
93. Levenson, J. (2016). Psychological factors affecting other medical conditions: Management. UpToDate. Retrieved online at https://www.uptodate.com/contents/psychological-factors-affecting-other-medical-conditions-management?source=search_result&search=patient+anger&selectedTitle=1~150
94. Lebow, J. (2018). Overview of psychotherapies. UpToDate. Retrieved online at https://www.uptodate.com/contents/overview-of-psychotherapies?search=motivational%20and%20emotional%20attunement&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5.
95. Cantlupe, J., (2013). Hospitals Crack Down on ED Repeat Users. Retrieved online at http://www.healthleadersmedia.com/health-plans/hospitals-crack-down-ed-repeat-users
top related