Dysfunctional Consultations

c/o Dr Ramesh Mehay www.bradfordvts.co.uk

Aims

• Recognition of different types of difficult patients

• Whose problem is it?

• Why are they so important?

• How to deal with them

Objectives

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

CoffeeSESSION 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?

What is a dysfunctional consultation?

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

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

both!

Brainstorming Session

Working in pairs make a list of difficult types of patients you have

encountered.

Brainstorming Session

Now working in groups of four share your lists and aggregate them into

common groups

How common are they?

EVERYGP has them

and so will you!

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?

Working in pairs – think how you might recognise them in practice?

Think in these broad areas:

• Patient characteristics

• Patient beliefs

• The types and nature of consultations

SESSION 2

The Meaty Bit!How do I deal with them?

Groves

In 1951 he described hateful patients! His four categories are just as applicable now!

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!)

Why GP’s Don’t Like Them

• Negative emotions ranging from hopelessness to anger

• Diagnostic difficulties and the ‘devil of uncertainty’

• Time (often long multiple appointments)

• Cost (emotional cost to you and the financial cost to the Practice and the NHS)

Why is it important to have a management plan?• Working in pairs list the reasons• Then in groups of four think about the ways in

which you can manage these four types of heartsinks; dependant clinger, entitled demander, manipulative help rejector and the self destructive denier

• Now form into 4 groups each taking one of the different classes, formulate and then present your plan

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

• Prevent chronic sick role• Reduce doctor dependency• Avoid doctor shopping• Maintain the doctor-patient relationship some how• To make the doctor feel comfortable in dealing

with them (exterminate negative emotions)• To avoid missing a true illness

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

Managing them (other solutions)

• Boundaries & Limits

• Share the workload

• Delayed Response

• Avoid difficult situations