DOI: 10.1542/peds.2010-0072; originally published online December 20, 2010; 2011;127;163Pediatrics

Cora Collette Breuner and Megan A. MorenoApproaches to the Difficult Patient/Parent Encounter

  

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located on the World Wide Web at: The online version of this article, along with updated information and services, is

 

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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Approaches to the Difficult Patient/Parent Encounter

abstractMost pediatricians have experienced uneasy interactions involving pa-tients and/or their parents. Themajority of literature on this topic reflectsencounters in adult medicine, without providing much information forpediatricians who also face this challenge. Unique to the pediatric ap-proach is the added quotient of the parent/family dynamic. Patients ortheir parentsmay have personality disorders or subclinicalmental healthissues, physicians may be overworked or have a lack of experience, andthe health care systemmay be overburdened, fragmented, and inundatedwith poor communication. Recognizing the physical or emotional re-sponses triggeredby challengingpatients/familiesmayallow theproviderto effectively partner with, instead of confront, the patient or the family. Inthis article we review existing literature on this subject and describe pos-sible strategies for the pediatrician to use during a difficult encounter.Pediatrics 2011;127:163–169

CASE SCENARIOS

Case 1

Adam is a 7-year-old boy who was diagnosed with recurrent vomiting(rumination syndrome) after a long series of evaluations and consul-tations. His father, an attorney who specialized in medical negligence,was enraged with this diagnosis. The father’s tirades about Adam’sdiagnosis led him from doctor to doctor while he refused to under-stand the nature of his son’s illness; the threat of lawsuit was alwaysimminent. He continuously demanded more and more tests and con-sultations. Eventually, his doctors did not return his calls and acknowl-edged fear, frustration, and even anger with the father.

Case 2

Anna is a 9-year-old girl who presented with fatigue and a rash. Herpediatrician, through a few referrals and many laboratory tests, waseventually able to make the diagnosis of lupus. Fortunately, her illnessappeared mild. She and her mother responded to the diagnosis withthoughtful questions and eventually asked the pediatrician whether hewould follow her long-term for this chronic illness. Flattered, he vowedto do so. Later that day the patient’smother telephoned briefly to thankhim. In the following week, the mother e-mailed him twice, once pro-fessing great concern that her daughterwould die and the second time tothank him again for taking care of her child. As weeks passed, the moth-er’s calls and visits becamemore frequent, and the gratitude diminished.He began to dread communication from this mother. By the end of 2months the mother was calling him daily, both at the office and at home.

Case 3

Delores is a 15-year-old girl referred for headaches. She walked con-fidently into the examination room and declared: “I have had a night-

AUTHORS: Cora Collette Breuner, MD, MPH, FAAPa andMegan A. Moreno, MD, MSEd, MPH, FAAPb

aDivision of Adolescent Medicine, Department of Pediatrics,Seattle Children’s Hospital, Seattle, Washington; andbDepartment of Pediatrics, University of Wisconsin-MadisonSchool of Medicine and Public Health, Madison, Wisconsin

KEY WORDSpatient-doctor encounter, patient-provider relationship, patient-doctor communication

This article was based on workshops presented at the Societyfor Adolescent Medicine annual meeting, March 29, 2007,Denver, CO; and the Pediatric Academic Society, May 2, 2009,Baltimore, MD.

www.pediatrics.org/cgi/doi/10.1542/peds.2010-0072

doi:10.1542/peds.2010-0072

Accepted for publication Sep 15, 2010

Address correspondence to Cora Collette Breuner, MD, MPH,FAAP, Division of Adolescent Medicine, Department of Pediatrics,Seattle Children’s Hospital, Seattle, WA 98105. E-mail:cora.breuner@seattlechildrens.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2011 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

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mare headache since forever!” Withfurther history, the patient said shehas had a constant right-frontal head-ache since the age of 10. It varied inintensity between a 2 and a 10 on thepain scale. She missed between 5 and15 days/month of school because ofthe headaches. The headache seemedworse at the time of her menses. Asthe doctor asked questions, Delores in-terrupted: “You know, this is gettingreally irritating. All you doctors do isask questions and do nothing. I’m tell-ing you, nothing works. My regulardoctor is a total idiot, he has no ideawhat is going on. I saw another doctor,a ‘nervologist,’ and I thought she wassmart, but she was also a total loser.”While the doctor explained the treat-ment options to Delores, she sum-marily shot down each one, saying:“Tried that, didn’t work.”

Case 4

Joseph is an overweight 8-year-old boybrought in by his stepfather, who isalso obese. Both the child and his step-father were eating a big carton offrench fries and sharing a large sodain the office. Joseph had “no-showed”the past 3 times for his nutrition andsocial work appointments, and he hadnot been regularly attending school,because it was “too hard for him towalk up and down the steps.” Hisweight during this appointment was135 lb. The stepfather laughed andsaid, “he still weighs less than me. Iclock in at 320!” It had become com-mon knowledge that the more theteam tried to help this child, the morehe and his family would resist. Whenthe family moved to California, theteam was relieved.

The medical encounter usually consti-tutes a source of mutual satisfactionfor both physician and patient. Thereare, however, patients/parents whoevoke negative emotions in physicianssuch as anger, guilt, and depression.

Pediatricians are not immune to thisexperience and may even be in a moreunique position because of their rela-tionship to the patient and the family.In adult practice, nearly 1 of 6 outpa-tient visits is considered difficult byphysicians1–3; it is unknown what thisfrequency is in pediatric practice. Pe-diatricians may be at special risk fordifficult encounters because of thecomplexity of dealing with a parentwho may be both desperate and dedi-cated to his or her child with majorneeds.

Difficulties during patient encoun-ters may be traced to patient/parent,physician, or health care system fac-tors. Patient/parent issues can in-clude psychiatric disorders, person-ality disorders, subclinical behaviortraits, and information overload.3

Physician features can include poorinteraction or communication skills,inadequate experience with difficultpatients, and/or general unease withdiagnostic uncertainty. Factorswithin the health care system can in-clude productivity and finance pres-sures. The purpose of this article isto review the current literature re-garding difficult patient/parent en-counters by using existing health in-formation databases such asMedline, PubMed, ProQuest, PsycInfoand to discuss strategies for ap-proaching these challenging situa-tions in order for the pediatrician toprovide the best care for patientsand their families.

EXPLORING THE DIFFICULTENCOUNTER

Patient Characteristics

Several previous studies have exam-ined how physicians characterize apatient or patient encounter as diffi-cult. In 1 study of 449 general inter-nists and family practitioners, physi-cians noted several characteristicsthat they associated with difficult pa-

tients. These characteristics in-cluded patients with mental healthproblems or �5 somatic symptomsand patients with threatening orabrasive personalities. In addition,patients who brought a list of com-plaints to a visit or were frequent us-ers of the health care system werealso considered difficult.4

In another survey of neurologists, par-ticipants were presented with 30 pa-tient behaviors. They were then askedhow frequently patients had exhibitedthese behaviors in the preceding yearand how “bothersome” the behaviorswere to them. The most bothersomebehaviors included not showing up foran appointment, being verbally abu-sive to staff, showing poor compliancewith medications or treatment, arriv-ing late, and not knowing the medica-tions that they are taking. Other aggra-vating behaviors included answeringcell phones during office visits, unnec-essary after-hours calls, delaying co-pays, and the “add-on” symptom.5

Frustrating patient personality char-acteristics included displaying a lackof respect and challenging recommen-dations on the basis of incorrect Inter-net information.6 Encounters werealso considered bothersome if multi-ple family members called and toomany nonessential people (friends,other children) were in the examina-tion room.

Even at subclinical levels, certain disor-dered personality traits in the patientsor their parents cause problems inphysician-patient interaction. Patients/family members with personality disor-ders may be excessively dependent, de-manding, manipulative, or stubborn, orthey may self-destructively refuse treat-ment (Table 1).7

Difficult Parents

In the pediatric population, it is oftenthe parent who is the contributor to adifficult patient encounter rather than

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the patient. Educators who have writ-ten on this topic have offered sugges-tions of what to do when confrontedwith challenging parents in the schoolsetting.8,9 These authors have offered arepertoire of skills for working withparents who bully or are aggressive orapathetic. Occasionally a pediatricianmay say something that triggers a neg-ative response, yet a quick reflectionsuch as “I see that what I said is upset-ting to you. How can I help?” or “Let metry to say it another way” may turn itaround. Parents of children withchronic illnesses may be consideredchallenging; these parents are vulner-able or even frantic because they arecoping day after day with an ill child.

Despite recent clinical advances,many chronic diseases cause greatsuffering and uncertainty. Pediatricmental disorders also bring theadded stress of stigma and parentalguilt when resources for treatmentor respite are hard to access. In 1article a parent’s thoughts regard-ing acting as the child’s advocatewere described: “Maybe if the par-ents or patient are ‘special’ then thedoctor will use all the resourcesavailable, including time, expertiseand advocacy for the child. . . .”10 Ifthe parents can get that special levelof treatment for their child, only thenhave they been good parents or thebest parents.

Physician Factors

The source of these challenging encoun-ters may be the interaction between thedoctorandhis orherpatient andnot justthe patient. The difficulty may derivefrom the doctor’s personality, from cul-tural gaps between the patient and phy-sician, or from external circumstancesthat affect the encounter.3,11–15

Physicians with less experience maybe more at risk for perceiving the en-counter as difficult. The authors of 1study found that younger physiciansreported more challenging patientencounters than older colleagues.11

In addition, physicians who are un-comfortable with diagnostic uncer-

TABLE 1 Classes of Difficult Patients/Parents

Patient/Parent Physician Response Suggested Response

I. Dependant clinger1. Initial mild/appropriate requests2. Secondary escalation to repeateddemands3. Ultimate perception that physician isinexhaustible

1. Early feeling of being special2. Progression to weary aversion3. Final sense of exhaustion and depletion

1. Recogize that sense of “superman” isoccurring2. Begin to limit visits to regular office hours/specific times3. Continue to remind patient/parent their child’shealth will be monitored but less frequently asthey improve

II. Entitled demander1. Early in visit patient/parent may useintimidation, devaluation and blame2. Patient/Parent may act smug, self-important and superior3. Unable to recognize that theirhostility is a reflection of their “terrorof abandonment” by physician4. Does not acknowledge their fear andlack of control surrounding theirchild’s illness

1. Preliminary desire to engage in conflict withpatient/parent.2. Secondary reaction may be rage andfrustration3. Final response is for physician to “secondguess”/doubt the effectiveness of their careof the patient and then order more tests/interventions than they normally wouldhave done

1. Resist urge to enter into conflict; use personalradar/“early warning system”2. Support efforts of patient/parent to assurethat they are getting best care3. Reassure patient/parent that they will not be“abandoned”4. Discuss case/get feedback from previousphysicians and current physician colleagues

III. Manipulative help rejecter1. Immediately reject the possibility thatany treatment can help2. Act self assured at return visits theywere right and physician wrong i.e.symptoms persist3. Continue to show up at appointmentsangry at everyone in the clinic

1. Initial response that physician may haveoverlooked something, that a diagnosis wasmissed2. Secondary sense of trying to win overpatient/parent-that they will be the only onethat can “fix it”3. Ultimate implication that physician is afailure

1. Stop and listen to patient/parent2. Reflect back to patient/parent that previouslythey may not had an partnership withtreatment team3. Recognize that their won response may be areflection of their own exhaustion/burnout4. Take a break; suggest another colleague

IV. Self destructive denier1. Unconscious self destructive healthbehaviors2. Helpless and hopeless endeavors todefeat physician attempts atimproving health

1. Physican may feel loathing and even disgust2. Ultimately come up with excuses to not seepatient/parent; become unavailable andunconsciously provide substandard care

1. Recognise feelings/self monitor and disengage2. Understand that these patients/parents mayhave significant mental health needs3. Discuss case with colleagues4. Elicit assistance from mental healthprofessionals to help provide the care of thesepatents/parents

Adapted with permission from Groves JE. N Engl J Med. 1978;298(16):883–887.

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tainty are more likely to regardpatients as difficult if they are non-compliant or have vague complaintsand/or diagnoses.1,16

Health Care System Factors

Health care system factors may alsoincrease the likelihood or frequency ofdifficult patient/parent encounters.Having overbooked clinics and over-worked physicians leads to greaternumbers of patients seen in a dayand greater numbers of patients whoare considered difficult.17 Within abusy clinic, patients/parents who feelrushed or ignored during a clinic visitmay repeat themselves and prolongtheir visits.18 If the process of receivingmedical care results in unmet expecta-tions, patients are more likely to bedissatisfied with their visits.19–22 Dis-satisfied patients/parents may be-come more demanding, and physi-cians may feel less able to respond totheir needs, thus transforming theproblems of the health care systeminto interpersonal frustration.

Risks to Physicians

Difficult patient scenarios are associ-ated with negative long-term conse-quences for physicians. Physicianswho experience more job stress andjob burnout/dissatisfaction are morelikely to report a higher number of dif-ficult patient encounters.23,24 It is notclear whether such encounters con-tribute to pediatrician exhaustion andsubsequent negative health outcomes.More research is needed on the effectof possible negative interactions onmedical career choice.

APPROACHES TO THE DIFFICULTPATIENT/PARENT ENCOUNTER

Patient Assessment and Referral:A Team Approach

In many challenging patient/parent sit-uations, expanding the care team maybe warranted. For patients in whom

you suspect a mental health compo-nent contributing to difficult encoun-ters, prompt assessment and referralis recommended. For patients withmultiple somatic symptoms in whichyou may suspect a psychological com-ponent, introduce this possibility earlyin your encounters, evenwhile ongoingmedical evaluations are taking place.Avoid introducing a psychological com-ponent to the illness after all test re-sults have come back negative, be-cause thatmay lead to resistance fromthe patient and a desire for more med-ical tests. For some challenging situa-tions, a referral to another general pe-diatrician, even one of your partners,may be of benefit to provide the patientand family another generalist’s viewon a complex situation.

Physician Communication

Many difficult patient/parent scenar-ios involve faulty physician-patient/parent interactions. It may be helpfulfor physicians to elicit feedback ontheir communication skills. Possiblesources include staff, trusted pa-tients/parents, or a review of audio-tapes or videotapes of patient/parentvisits.25,26 Improving physician commu-nication can lead to increased patient/parent satisfaction, increased job sat-isfaction, improved patient healthoutcomes,27 and a decrease in com-plaints and lawsuits.28,29 Key aspects ofphysician communication include en-suring that patients/parents under-stand that the physician comprehendstheir situation and cares about theirhealth.30,31 In addition, understandingthe patients’/parents’ agenda andexpectations is associated with im-proved compliance and follow-through7

and can reduce patients’ reportedfears of serious illness and patient/parent complaints at follow-up visits.32

Specific communication techniquesand greater patient involvement inthe process of care may enhancethe physician-patient/parent relation-

ship.5 Other recommendations includeteaching strategies to help physiciansmanage difficult encounters. Copingtechniques should also be sup-ported, including learning moreabout empathy, nonjudgmental lis-tening, and effective communication(Table 2).33

Practice Modifications

Physicians should consider modifyingscheduling systems to allowmore timefor difficult patients. However, physi-cians should set firm and clear limitson what time is available to the patientboth in and out of the office, especiallyfor difficult patients/parents (Table 3).

Physicians’ Self-care

Physicians who experience ongoingdifficulties with difficult patients/parents or how they themselves dealwith them may need additional sup-port, particularly to avoid burnout.Options for support include a trustedcolleague, a support group, or apsychotherapist. 34

Physicians are encouraged to practicegoal-oriented self-management, whichincludes acknowledging and acceptingtheir own emotional responses to pa-tients35,36 and attempting to ensurepersonal well-being37,38 (Table 4).

CONCLUSIONS

Pediatricians have unique challengeswhen providing care in difficult situa-tions that involve challenging patientsor parents. Previous work has outlinedmany common challenges and strate-gies for handling them. Future studiesshould investigate difficult clinical en-counters in the pediatric setting. Strat-egies for improving difficult scenarioscan include physician adaptation of ap-proach toward difficult patients andparents, improved communicationawareness and skills, and modificationsin the practice structure. It is gratifying

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whenanencountercanbechanged fromone that is extremely challenging to onefor which there is a positive outcome foreveryone. The pediatricians’ sense ofpride in theirworkwhen they cansteer adifficult encounter toward health is re-warding andmay even help prevent can-cer burnouts.

CASE CONCLUSIONS: WHAT HAVE WELEARNED, AND WHAT DID WE DO?

Case 1

In the case of Adam, the 7-year-oldmale patient with the father who maybe called an “entitled demander,” thedoctor asked the parents about what

effect the illness has had on the family,empathized with their worries andconcerns, and elicited help in the treat-ment of their child. After a few briefconversations with the family, the par-ent/doctor team became more cohe-sive and less conflicted. The child im-proved with biofeedback.

TABLE 2 Helpful Communication Techniques34–36

Goal Activity Suggested Phrase

Improve listening and understanding Summarize the patient’s chief concerns “What I hear from you is that. . . . Did I get that right?”Interrupt lessOffer regular, brief summaries of what you arehearing from the patientReconcile conflicting views of the diagnosis orthe seriousness of the condition

Improve partnership with the patient Discuss the fact that the relationship is lessthan ideal; offer ways to improve care

“How do you feel about the care you are receiving from me?It seems to me that we sometimes don’t work togethervery well.”

Improve skills at expressing negative emotions Decrease blaming statements “It’s difficult for me to listen to you when you use that kindof language.”Increase “I” messages (eg, “I feel . . .” as

opposed to “you make me feel . . .”Increase empathy; ensure understanding ofpatient’s emotional responses to conditionand care

Attempt to name the patient’s emotional state;check for accuracy and express concern

“You seem quite upset. Could you help me understand whatyou are going through right now?”

Negotiate the process of care Clarify the reason for the patient seeking care “What’s your understanding of what I am recommending,and how does that fit with your ideas about how to solveyour problems?”

Indicate what part the patient must play incaring for his or her healthRevise expectations if they are unrealistic

“I wish that I (or a medical miracle) could solve thisproblem for you, but the power to make the importantchanges is really yours.”

TABLE 3 Suggestions for Better Practice Management

Suggestion Activity

Access community resources Develop on-site or community-based links to mental health and social work professionals.Ensure adequate follow-up Schedule regular follow-up visits at two- to three-week intervals, especially if high dependency needs are suspected.

Educate the patient in appropriate use of telephone or e-mail contact as an alternative to more frequent visits.Promote continuity of care Educate patients that the involvement of multiple health care professionals may result in conflicting or confusing

approaches; help the patient maintain a primary care provider.Schedule appropriately Length of visits should fit patients’ perceived needs and expectations.

Modify scheduling systems to allow more time for certain patients at the request of the physician.Set firm limits Discuss and enforce your policies regarding abuse of staff, insistence on immediate telephone access, or obstruction of

the process of care. Terminating the relationship with the patient is a last resort and should be done with care.

Reproduced with permission from Haas LJ, Leiser JP, Magill MK, Sanyer AN. Haas LJ, Leiser JP, Magill MK, Sanyer ON. Am Fam Physician. 2005;72(10):2066.

TABLE 4 A Pediatrician’s Guide to the Difficult Patient/Parent Encounter

Consider the parents’ perspectives: ask parents about how the child’s illness has affected the family. What were their hopes before the illness occurred? Howmuch of a loss did they experience when it became clear that the illness would have a major impact on the child or on the family’s future? Have there beenother recent or past losses in the family or in their childhood that were similar or as momentous as what they are facing now? Empathize with their worriesand concerns.Remember the child as the patient and your role as a pediatrician. Do not try to manipulate or control the child. Provide the child empathy, even during a difficultvisit.Learn about the family’s/patient’s existing strengths and preferences: what in their past relationships with the health care system did they find helpful or nothelpful?Be aware of changes in your pattern of treating a child or his or her family. Listen to internal feelings of frustration, anger, or resentment, and address them.During a difficult visit, approach the visit in a way that is process-oriented rather than outcome-oriented.View these challenging visits as something you can do, something you have trained for, and are ready to handle.Promise yourself a reward for getting through an encounter without losing your cool.

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Case 2

Anna is the 9-year-old female with adiagnosis of lupus whose mothermay loosely be called a “dependantclinger.” The doctor, after recognizinghis response to this parent, becamemore clear with the limits on telephon-ing after hours, reassured the motherthat he would see her daughter regularly,and asked for support fromhis fellowpro-viderswhen hewas not in the office.

Case 3

Delores had headaches and may, ather young age, be considered a

“manipulative help-rejecter.” Deloresneeded to be angry, and her doctorjust needed to listen for awhile, reflect-ing on the frustrations she was experi-encing, and then ask what Deloreswanted. Her desire was merely to haveher headaches “go away.” Theyworkedas partners, acknowledging it maytake awhile for the headaches to de-crease intensity and have less of animpact on her life. Together, theysought consultations, including formental health, biofeedback, and acu-puncture. Delores helped make herheadaches “go away.”

Case 4

Joseph and his stepfather had weightissues and for all appearances were“self-destructive deniers.” This situa-tion was difficult for the doctor, andwhen the family moved, she recognizedher mixed feelings. She called the familyand asked permission to talk with theirnewdoctors. Thestepfatherwasactuallyglad to hear from her and happy to helpwith the new information. Joseph andhis stepfather went to the new pediatri-cian and were actually successfully en-rolled in the clinic’sweight-managementprogram.

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COLLEGE STUDY ABROAD: A few weeks ago, my eldest son announced that heplanned to spend next fall studying in Japan. While of course I was excited forhim, part of me thought “Could you have picked a more expensive place tostudy?” The expense of college study abroad may be on the minds of lots ofparents these days. As reported on USAToday.com (November 15, 2010:1–2), thenumber of U.S. students earning college credit abroad dipped in the 2008–2009academic year. While not much of a dip, this is the first recorded decline in 25years. Based on a survey of 3000 colleges, approximately 260,000 studentsearned college credit abroad during the same academic year. That ismore thantwice as many students who studied abroad 10 years ago, but still down from262,000 the previous year. The U.S. recession played a large role in the decline.Families had fewer resources to pay for overseas study. Furthermore, the re-cession increased interest in new and oftentimes more affordable programs indeveloping countries. Although Europe is by far and away the most popularstudy destination, the number of students going to Europe dropped 4%. Enroll-ments in African and South American programs increased 16%and 13% respec-tively. According to the Institute of International Education press release, 15 ofthe top 25 destinations for studywere outside of Western Europe.Moneywas notthe only reason for deferring overseas study. The H1N1 epidemic and increasingdrug violence both contributed to a 26% decline in U.S. students studying inMexico. As for my son, he will be one of a small number of Americans in Japan,as Japan was not one of the top 25 destinations for college study abroad.

Noted by WVR, MD

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