Dysfunctional Consultations Ramesh Mehay. Aims Recognition of different types of Difficult Patients Whose problem is it? Why are they so important? How.

Dysfunctional Consultations

Ramesh Mehay

Aims

• Recognition of different types of Difficult Patients

• Whose problem is it?

• Why are they so important?

• How to Deal With Them

• Preparation for the MRCGP – a favourite in both orals and the written paper

Objectives

SESSION 1• Define a dysfunctional consultation?• Define a difficult patient?• Is it a problem in the patient or the doctor?

SESSION 2• Groves Classification of difficult patients• Specific Methods of dealing with them

SESSION 1

LET’S THINK ABOUT THEM Who are they and How do I recognise

them?

Brainstorming Session

Make a list of difficult types of patients you have encountered

Definition of a dysfunctional consultation

“An exhausting consultation between a doctor and a patient which often triggers off some

powerful emotions either in the doctor dealing with them, in the patient or both!

Most show a continuing, insatiable dependency on a physician.”

How Common Are They?

8

What’s all the Fuss?

• Doctor ReasonsStress, fear, anger, low morale, helplessness

• Patient Reasonsunnecessary Ix & Rx

• Society ReasonsExpensive!

Whose Problem is it Anyway?

• The patient• The doctor• The Dr – Pt relationship doctor

patient

Is it the Patient – list of features

• Female > male

• Age > 40

• Single, divorced or widowed (isolation)

• personal (marital, family) problems

• Co-existing depression

Is It the Doctor?

• Different people have different personalities and characteristics

Mathers et al (1996) Sheffield Survey of GP’s

65% variance amongst GP’s in their selection of heart sink patients

You can please SOME people ALL of the time BUT

You can never please ALL of the people ALL of the time

Is it the Doctor?

• Insecure Doctors

• Competitive Doctors

• Over caring Doctors

• Hard line Angry Doctors

• Doctors of Perfection

• Normal Doctors – Yes You!!!!

Is it the Dr-Pt Relationship?Flipchart

patient doctor

1. Unidirectional Consultations

Leading to• Failing to understand

patients ICE• Failing to appreciate affect on patients life• Failing to appreciate

patients coping mechanism

3. Certain Medical Illnessses - Christie & Hofmaster (1986)

2. Patient behaviour that annoys the doctor – Christie & Hofmaster (1986)

“Pull Yourself Together” report (2000), Mental Health Foundation)

How Can You Spot Them?

Brainstorm – how do you recognise them in practice? Think in these broad areas:

• Patient characteristics

• Patient Beliefs

• The consultations

SESSION 2

The Meaty Bit!How do I deal with them? ( and by the way,

who on Earth is Groves!)

The Main Man – Groves.

• MRCGP favourite• 1951, Described hateful patients!• 4 categories

1. The dependant clinger2. The entitled demander3. The manipulative help rejector4. The self destructive denier5. The malodorous minger (oops!...sorry, that’s one of

mine!)

1. What Sort of Patient is this?

Mrs Eileen Webster, age 58, widow

9 attendances this month, month isn’t even over yet!

Second to last patient on your surgery list

Running time – you are already 15 minutes late

Call her in………..

EILEEN WEBSTER1. What sort of patient is this according to Groves? Why…

what sort of characteristics helped you in your classification?

2. How did she make the doctor feel, can others identify the scenario with their experiences?

3. What factors before the consultation could you identify that might have led to the dysfunctional consultation.

4. What bits of the consultation led to doctor feelings5. Whose fault – doctor or patient? Why do they act the way

they do?6. What good methods did the doctor use to tackle the

situation? Any methods of controlling behaviour? Any unhelpful doctor behaviour?

7. Any other methods the audience can suggest of controlling patient behaviour?

2. What Sort of Patient Is this?

John Templer, age 42

Business man

Here on time. You collect the notes and receptionist informs you he is complaining a bit for keeping him waiting for 10 minutes

Middle of your consultation list

Call him in……….

JOHN TEMPLAR1. What sort of patient is this according to Groves? Why…

what sort of characteristics helped you in your classification?

2. How did she make the doctor feel, can others identify the scenario with their experiences?

3. What factors before the consultation could you identify that might have led to the dysfunctional consultation.

4. What bits of the consultation led to doctor feelings5. Whose fault – doctor or patient? Why do they act the way

they do?6. What good methods did the doctor use to tackle the

situation? Any methods of controlling behaviour? Any unhelpful doctor behaviour?

7. Any other methods the audience can suggest of controlling patient behaviour?

3. What Sort of Patient is This?

• Mary Tyler, age 45, non smoker• Asked for you specifically, no-one else will do• Aches and pains in both legs (you have are very familiar with this

complaint of hers)• Duration : 3 years• Previous Investigations NAD• Orthopaedic/Neuro/Vascular referral – NAD. ?Depressed ?Nerve

Pain• PMH : similar sort of picture for her headaches and tummy pains!• Requesting Pain relief• Call her in……………..

MARY TYLER1. What sort of patient is this according to Groves? Why…

what sort of characteristics helped you in your classification?

2. How did she make the doctor feel, can others identify the scenario with their experiences?

3. What factors before the consultation could you identify that might have led to the dysfunctional consultation.

4. What bits of the consultation led to doctor feelings5. Whose fault – doctor or patient? Why do they act the way

they do?6. What good methods did the doctor use to tackle the

situation? Any methods of controlling behaviour? Any unhelpful doctor behaviour?

7. Any other methods the audience can suggest of controlling patient behaviour?

4. What Sort of Patient is This?

• Sarah Nopes, age 51, morbidly obese

• Known COPD 10 years, still smokes 40 per day – smells of fag ash

• Getting worse again

• Also has arthritis – again worsening

• Call her in

SARAH NOPES1. What sort of patient is this according to Groves? Why…

what sort of characteristics helped you in your classification?

2. How did she make the doctor feel, can others identify the scenario with their experiences?

3. What factors before the consultation could you identify that might have led to the dysfunctional consultation.

4. What bits of the consultation led to doctor feelings5. Whose fault – doctor or patient? Why do they act the way

they do?6. What good methods did the doctor use to tackle the

situation? Any methods of controlling behaviour? Any unhelpful doctor behaviour?

7. Any other methods the audience can suggest of controlling patient behaviour? (James Heron 1990)

Personality Disorders

• Synonyms – psychopathy, sociopathy

Somatisers

• Abnormal consultation

• Strong beliefs

• Frequent Ix

• Social Difficulties

• Depression

• Nothing “works”

Why GP’s Don’t Like Them

• Hopelessness

• Diagnostic Difficulties

• Time

• Cost

Why Is it Important to Have a Management Strategy For them?

• Prevent chronic sick role

• Reduce dr dependency

• Avoid dr shopping

• Maintain the dr-pt relationship some how

• To make the dr feel comfortable in dealing with them (exterminate negative emotions)

• To avoid missing a true illness

Managing them (Peter Tate)

1. Discuss your perceptions of the abnormal illness behaviour

2. Discuss patients denial and avoidance behaviour3. Verbalise your patients anxiety4. Describe the way your patient is trying to influence you

back to them5. Discuss your own feelings with them6. Carify patients complaints to gain more insight7. Avoid too much advice8. Ensure the advice is specific and tailored to the specific

patient9. Encourage patient to find their own solutions

Managing them (other solutions)

• Boundaries & Limits

• Share the workload

• Delayed Response

• Avoid difficult situations

RULES FOR ALL OF THEM 1

• Recognise own feelings• Build rapport• Encourage more patient responsibility• Firm structured consistent approach• Keep in control• Frequent attenders – boundaries/limits, hierarchical

problem list, share the workload, delayed response

• “Whose problem is it?”• House keep yourself

RULES FOR ALL OF THEM 2

Be careful- getting the right balance

• True illness being missed vs too many Ix or referrals• Reaction to External Factors• Stresses not being dealt with• Stigma ……of being labelled as “mad” or “neurotic”

Experiential Practice makes Perfect

EVALUATION

• What things did you like about today • Did they meet the objectives• What things would you have liked done

differently• Any bits that you thought should have been

included or expecting?• Would it be helpful for future registrars to

repeat the session?