Difficult Patient Encounters Research Articles

The healing power of the doctor-patient relationship.

Humane and empathic care are quintessential to the medical profession. In this narrative, a psychiatrist reflects on a difficult patient encounter which highlights the influence of trauma on a patient with psychosis and how the doctor-patient relationship is paramount in the treatment of any illness.

A Square Deal to clear the Air: Managing the Difficult Patient Encounters

Introduction: There are a number of patients in every clinical setting who are referred to as "difficult patients," and encounters with them can often evoke negative emotions in doctors. As compared to experienced clinicians, young doctors are often struggling while providing care to such patients. But we surprisingly know very little about young doctor’s perceptions of themselves and difficult patients while encountering them, so without proper understanding, strategies cannot be formulated to handle these challenging situations.Objective: The purpose of this study is to explore the patterns and contributing factors responsible for the difficult patient encounters faced by young doctors.Methods: A qualitative study was conducted among the house officers and medical officers of the medicine department at Islam Medical College Sialkot and Khawaja Muhammad Safdar Medical College Sialkot for a period of six months from February 2020 to July 2020. The purposive homogeneous sampling technique was chosen, and five focused group interviews were conducted for the data collection. Data was collected until saturation. The data was organized and entered into the Data Analysis Software NVIVO for the thematic analysis.Results: Thirty-four participants took part in this study. The results were presented in the form of themes and categories. Patient’s issues, health care issues, and young doctor’s issues were described as three major factors that play role in difficult patient encounters.Conclusion: Difficult patient encounters are not only due to patients or doctors; rather, they are a multi-factorial phenomenon very strongly influenced by the overall social, cultural, and behavioral associations.

Frequency of Difficult Patient Encounters in a Japanese University Hospital and Community Hospitals: A Cross-sectional Study.

Objective Difficult patient encounters (DPEs) are defined as encounters with patients causing strong negative feelings in physicians. In primary care settings, DPEs account for approximately 15% of visits among outpatients. To our knowledge, this is the first epidemiological study of DPEs in Japan. Methods We conducted a survey of 8 physicians (5.0±2 years of clinical experience) who examined first-visit patients ≥15 years old with clinical symptoms at the Department of General Medicine in Chiba University Hospital and 4 community hospitals over a 2-month period since December 2015. Materials We evaluated 10-Item Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10) scores (DPE ≥31 points; non-DPE ≤30 points) and patient age, sex, and presence of psychological or social problems. Results The valid response rate was 98.9% (94/95) and 98.4% (189/192) in the university and community hospitals, respectively. The percentage of DPEs was 39.8% (37/93) and 15.0% (26/173) in the university and community hospitals, respectively; the percentage of DPEs was significantly higher at the university hospital than at the community hospitals (p<0.001). The proportion of patients with psychosocial problems was significantly higher in the DPE group than in the non-DPE group (93.7% vs. 40.4%, p<0.001). Conclusion Our findings were similar to those reported in primary care settings in other countries in community hospital outpatient and general internal medicine departments, where patients are mostly non-referrals, although the values were higher in university hospital general medicine departments, where patients were mostly referrals. Patients involved in DPEs have a high rate of psychological and social problems.

Association Between Physician Empathy and Difficult Patient Encounters: a Cross-Sectional Study.

Physicians frequently experience patients as difficult. Our study explores whether more empathetic physicians experience fewer patient encounters as difficult. To investigate the association between physician empathy and difficult patient encounters (DPEs). Cross-sectional study. Participants were 18 generalist physicians with 3-8 years of experience. The investigation was conducted from August-September 2018 and April-May 2019 at six healthcare facilities. Based on the Jefferson Scale of Empathy (JSE) scores, we classified physicians into low and high empathy groups. The physicians completed the Difficult Doctor-Patient Relationship Questionnaire-10 (DDPRQ-10) after each patient visit. Scores ≥ 31 on the DDPRQ-10 indicated DPEs. We implemented multilevel mixed-effects logistic regression models to examine the association between physicians' empathy and DPE, adjusting for patient-level covariates (age, sex, history of mental disorders) and with physician-level clustering. The median JSE score was 114 (range: 96-126), and physicians with JSE scores 96-113 and 114-126 were assigned to low and high empathy groups, respectively (n = 8 and 10 each); 240 and 344 patients were examined by physicians in the low and high empathy groups, respectively. Among low empathy physicians, 23% of encounters were considered difficulty, compared to 11% among high empathy groups (OR: 0.37; 95% CI = 0.19-0.72, p = 0.004). JSE scores and DDPRQ-10 scores were negatively correlated (r = -0.22, p < 0.01). Empathetic physicians were less likely to experience encounters as difficult. Empathy appears to be an important component of physician perception of encounter difficulty.

Responding to Elder Abuse in GERiAtric care (REAGERA) educational intervention for healthcare providers: a non-randomised stepped wedge trial

IntroductionElder abuse is prevalent and associated with different forms of ill health. Despite this, healthcare providers are often unaware of abusive experiences among older patients and many lack training about...

Improving care for delusional infestation patients: What can dermatologists learn from an entomologist?

Delusional Infestation (DI), represents one of the most difficult patient encounters that dermatology practitioners may experience. It is common for DI patients to doctor shop. Thus, dermatologists are one of several disciplines that may encounter DI patients in their practices. Others include veterinarians, epidemiologists, emergency departments, mental health practitioners, and entomologists. In this article, entomologist, Dr. Gale E. Ridge, with extensive DI experience, was interviewed to find out what an entomologist's perspective has been and what we, the dermatology providers, can learn from that. This is followed by a discussion by the dermatology experts on how the experience of entomologists compares to our experience and what we can learn from them.

Simulation Design, Findings, and Call to Action for Managing Difficult Patient Encounters

Objective. To implement and evaluate a laboratory simulation for teaching difficult patient encounter skills to pharmacy students to improve their self-assessed communication abilities and skills in the affective domain.Methods. Twelve simulation scenarios that represented difficult patient encounters in a variety of practice settings were developed. All students completed a self-assessment of their ability to communicate during difficult patient encounters before and after the simulations, and wrote a guided reflection afterward. The impact of the simulation was evaluated using quantitative and qualitative methodology. Three student cohorts were analyzed to determine whether significant change occurred in students' self-perceived communication abilities. Thematic analysis of the qualitative reflection responses was performed.Results. Over three years, three student cohorts of third-year professional students participated in the simulations (n=236). Students self-rated their ability to communicate on a 0-100 scale. Mean self-rating of ability prior to the simulation was 57.7 (SD=15.9) and after was 79.2 (SD=15.2). This mean difference of 21.5 points equates to an approximate 20% increase in self-rated ability. Variability in self-ratings between the cohorts was not significant. Qualitative analysis revealed that the simulation identified for student areas needing further development which in turn promoted self-awareness. Students expressed that learning in the safe, formative environment provided by the simulation contributed to their professional growth and was relevant to their future practice of pharmacy.Conclusion. This simulation fills a gap in skills-based education, addresses the affective domain of the Accreditation Council for Pharmacy Education (ACPE) Standards, transfers easily to schools and colleges of pharmacy. This supports a call to action for pharmacy educators to provide purposeful opportunities for students to practice communicating with patients during difficult encounters.

Short report: sticks and stones may break my bones, but words can also hurt me: understanding language interpreters’ perceptions of stress/growth and needs in a pediatric medical setting

ABSTRACT An increased focus on quality, trauma-informed patient care also warrants examination of providers’ experiences of stress in medical settings. However, little is known about language interpreters’ experiences of stress in the pediatric hospital setting, despite their involvement in acute and difficult patient encounters. This pilot study evaluated language interpreters’ experiences and perceptions of stress in a large children’s hospital. Descriptive and qualitative analyses, using a novel survey measure of interpreters’ experiences, were performed to evaluate language interpreters’ experiences with stressful patient encounters and identification of available and desired supports. All interpreters surveyed endorsed experiencing stress during challenging patient encounters in the hospital, though the majority also identified positive changes to their worldview as a result of their work. Results highlighted interpreters’ strategies to cope with stress and perceived institutional needs to manage stressful encounters. Interpreters’ experiences of stress in the pediatric hospital underscores needs for prevention and intervention efforts aimed at helping interpreters manage job-related stress. Preliminary, trauma-informed recommendations for working with and supporting interpreters are proposed.

Practice Makes Perfect: Training Residents in Difficult Encounters.

A significant number of patient encounters are perceived to be difficult. Residents receive little training in managing difficult clinical encounters, and lectures or traditional simulated patient encounters may not provide the opportunity to practice learned skills. Deliberate practice has been shown to be effective in training clinical skills. We used simulation with deliberate practice and feedback to train residents in difficult patient encounters. Twelve second-year residents in the University of Missouri Family and Community Medicine residency program participated in simulated patient encounters with difficult patients. The patients represented challenging personalities identified in a resident focus group. Resident performance was scored by the standardized patient, resident observers, and faculty instructor. Following debriefing with feedback, the residents repeated the clinical encounter incorporating the feedback. The sessions were scored again by the same individuals. All scores improved from the first to second clinical encounter, except those that were at 100% for both encounters. The most improvement seen was in standardized patient scores. The smallest improvement was in provider self-scores. Resident performance improved according to all observers and their own self-assessments. These results are consistent with other studies that have demonstrated the effectiveness of deliberate practice in improving skills in other areas of medical education. Simulation-based learning with deliberate practice has the potential to improve resident management of difficult patient encounters.

Physician Burnout in a Rural Kansas Community

Physician wellness and burnout are topics of intense discussion and study, however, less is known about rural physician burnout. The aim of this study was to assess levels of physician burnout in the rural Kansas community of Salina. An electronic, confidential survey was conducted among 145 physicians with active privileges at the local health center and/or surgical center. The survey included demographic features, practice characteristics, and the abbreviated Maslach Burnout Inventory™ (aMBI). In addition, survey participants were invited to provide free-text responses to questions concerning specific causes of burnout and mechanisms to combat feelings of burnout. Of 145 invited, 76 physicians completed the survey. Thirty-six respondents self-identified as primary care physicians, 22 as subspecialists, and 18 as surgeons. aMBI scores for emotional exhaustion (EE), depersonalization (D) and personal accomplishment (PA) ranged from 0 to 18. The mean EE score was 8.4 (SD = 4.9), mean D score was 4.8 (SD = 3.9), and mean PA score was 15.2 (SD = 2.8). Using tertiles, physician burnout (i.e., those in the first tertile) for EE was 39% (30/76), D was 34% (26/76), and PA was 41% (31/75); 22% of physicians surveyed scored high on both EE and D as measured by tertiles, suggestive of more serious burnout. No significant differences in aMBI scores were observed for demographic features or practice characteristics; physicians who worked with medical students had higher PA scores. Contributing to burnout were demands of documentation and difficult patient encounters, while true time away might ameliorate rural physician burnout. As measured by aMBI constructs, burnout is prevalent among the responding rural physicians practicing in the Salina community.

P087: Pilot project: Implementation of a peer support network for geographically distributed learners in the NOSM family medicine/emergency medicine residency program

Innovation Concept: Residents bear an enormous burden of responsibility for patient care which can lead to stress and mental exhaustion, especially in the face-paced and acute environment of emergency medicine (EM). In addition to numerous demands faced by EM residents, being a member of a geographically distributive residency program presents many unique challenges from a support and wellness perspective. To address these issues we sought to implement a video conferenced peer support network in hopes to foster wellness in the NOSM Family Medicine/EM program, where learners are commonly separated for training. Methods: Participants completed a pre-pilot questionnaire that strongly showed interest for this type of novel network. Furthermore residents conveyed that they are reluctant to access formal services and commonly rely on co-residents for support. This pilot program intends to decrease barriers that geography and stigma create that negatively hinder seeking support throughout medical training. Keeping the network small, consisting of only co-residents maintains a collegial and confidential environment that enables colleagues to provide relevant help to one another. Offering this outlet allows the opportunity to debrief and share unique experiences, which can lead to improved knowledge and wellbeing. Curriculum, Tool or Material: Informal, co-resident run and easy to access sessions are held twice monthly and average one hour in length. Discussion topics commonly include residency issues, difficult patient encounters and challenging situations. These sessions are conducted via video conferencing making them easily accessible from a distance and also from a comfortable and convenient environment of the participants choosing. Residents have commented that this is a helpful platform to discuss important issues while providing and safe and confidential resource to help cope with residency challenges. Conclusion: Further data analysis is underway as we are in the initial stages of implementing the program. In the final stages (April 2018) a pending post-pilot questionnaire will be interpreted to explore barriers, limitations and to determine the role of the network going forward. If found to be effective it is something that can be implemented and adapted for future residents. Other programs can use this feasible model to increase wellness and foster the same supportive environment among residents, especially those separated geographically from peers who may benefit most.

Compassion Fatigue in Surgical Trainees

Compassion fatigue (CF) is the profound sense of emotional exhaustion that care providers can experience as the result of helping others in distress. CF can contribute to burnout (BO), depression, and stress-related illness. While surgeons and surgical trainees may be at high risk for developing CF, it has not been adequately characterized or explored in this population. The objective of this study was to examine the prevalence and impact of CF in surgical trainees with a view to inform a management strategy. A mixed method study was conducted using survey and interview methods. An email survey including the Professional Quality of Life Scale Version 5, an instrument to assess CF, was sent to all trainees in the Department of Surgery at the University of Toronto. Survey data were analyzed descriptively and using one-sample t tests. Semistructured interviews were conducted with volunteered trainees. Data collection and analysis occurred iteratively and inductively using the constant comparison method. One hundred fifteen trainees completed the survey representing a 47% response rate. Ninety-nine respondents (40.7%) completed the Professional Quality of Life Scale tool. The mean score on the compassion satisfaction subscale was 36.9 (SD 6.7), on the BO subscale was 26.2 (SD 5.6), and on the secondary traumatic stress (STS) subscale was 21.2 (SD 6.3). The mean on the compassion satisfaction subscale was not statistically different from the population mean (p = 0.22). The means for the BO and STS scales were statistically higher in our study sample compared to the normative data (p < 0.0001 for each). Thematic qualitative findings indicated trainees experienced CF symptoms. Participants described systemic barriers to mitigating CF including workload and a cultural expectation to be unemotional at work. Surgical trainees report high levels of BO and STS and currently use informal coping strategies outside of their academic and hospital environments. Trainees are likely to welcome and benefit from an organized response to support their emotional health when facing difficult patient encounters.

Difficult patient–doctor encounters in a Swiss university outpatient clinic: cross-sectional study

IntroductionPrevious research has shown that multiple factors contribute to healthcare providers perceiving encounters as difficult, and are related to both medical and non-medical demands.AimTo measure the prevalence and to identify...

Difficult Patient Encounters: Assessing Pediatric Residents' Communication Skills Training Needs.

IntroductionDifficult patient encounters (DPEs) are common and can lead to frustration and dissatisfaction among healthcare providers. Pediatric resident physician experiences with DPEs and curricula for enhancing necessary communication skills have not been well described.Materials and methodsWe used a cross-sectional survey research design for our needs assessment on resident experiences with DPEs. Thirty-three pediatric residents completed this anonymous survey. The survey assessed residents’ experiences with and self-efficacy regarding DPEs. Descriptive statistics were used to analyze the quantitative data. Additionally, two authors independently coded free response data to include in the narrative description of the survey results.ResultsThese survey results include the views of 92% of the residents in the program (33/36). Residents reported a greater frequency of difficult encounters in the inpatient setting than the outpatient setting. The majority of residents rated their communication skills during DPEs as “fair” or “good” (70%, 23/33). Residents tended to have lower confidence when discussing chronic pain, managing parental insistence on a plan, and breaking bad news. They generally reported higher levels of anxiety for scenarios involving angry patients and families, families insisting on a plan, and when breaking bad news. Residents cited many challenges, including working with angry and demanding families. Additionally, residents described difficulty with managing discordant opinions between the family and the healthcare team regarding the care plan. Residents expressed a preference for learning how to manage challenging patient encounters using clinical experiences. Simulation, discussion, and observation of role models also rated highly as educational methods for increasing skills, while most residents rated lectures as the least important means of training skills for these difficult encounters.DiscussionWe found that pediatric residents experience difficult encounters frequently, especially in the inpatient setting. Individual residents vary in their confidence and anxiety levels with different types of difficult encounters and may benefit from not only general communication skills training, but also from targeted training to equip them for the particular contexts they find most challenging. Residents value interactive structured learning activities, including discussion and simulation. Residents most consistently value the opportunity to lead challenging conversations in the clinical setting, especially when followed by effective debriefing and feedback by trained faculty preceptors.ConclusionsNext steps include creating a “Difficult Encounters” communication skills curriculum informed by this needs assessment, which aim to enhance patient care as well as increase resident self-efficacy. In addition to the curriculum development for residents, it may be helpful to initiate faculty development on how to supervise resident-led difficult conversations and provide effective debriefing and feedback to promote resident growth.

Staff Perception of Interprofessional Simulation for Verbal De-escalation and Restraint Application to Mitigate Violent Patient Behaviors in the Emergency Department

ProblemViolent behaviors in the emergency department are on the rise. Mitigation efforts are essential for staff and patient safety. The goal of this quality improvement project was to improve staff perception of knowledge, skills, abilities, confidence, and preparedness when managing violent patient behaviors using interprofessional simulation training and to evaluate staff learning style satisfaction and self-confidence using simulation. MethodsInterprofessional participants received individual computer-based training and simulation training on de-escalation techniques and restraint application. The participants’ perceptions were collected in a pre- and postsurvey and analyzed using Bowker’s test of symmetry. Revised tools from the National League for Nursing were used, including the Simulation Design Scale and Satisfaction and Self-Confidence in Learning, and results were analyzed by one-way analysis of variance, comparing results within and between the disciplines involved. ResultsGroup comparison (nursing, providers, security staff, and social services staff) using contingency tables illustrated a significant improvement (P < 0.0001) in knowledge (21%), skills (20%), abilities (19%), confidence (20%), and preparedness (30%). Satisfaction among nurses (P = 0.0021), patient care assistants (P = 0.0134), and security staff (P = 0.0060) was significantly greater than among social services staff. No significant differences were found among providers or by sex. Participants with less experience were more satisfied than those who have been in their role for 16 years or more (P = 0.0290). Implications for PracticeParticipants’ self-reported changes in knowledge, skills, ability, confidence, and preparedness demonstrated significance for a short-term change, with preparedness having the greatest increase. Simulation debriefing allowed participants to provide feedback; satisfaction was higher for persons with less experience. The application of skills through simulation can prepare staff to handle difficult patient encounters.

81 - Developing Personal and Professional Resident Wellness Through Resident Led Activities and Discussions

Background: The discussion of resident burnout, depression, and suicide has become more prominent amongst programs across the country as well as the ACGME. Residency is an intense period of our lives where we spend more time at work and less time with our families, compounded with the difficult patient encounters we experience. Unfortunately, these results increased rates of resident burnout, depression, and suicide. Due to the nature of residency and the education residency provides, we cannot change the hours or which patients residents see and must foster wellness within the work environment.

How to Approach Difficult Patient Encounters: ROAR

How to Approach Difficult Patient Encounters: ROAR

Ice cream rounds: The adaptation, implementation, and evaluation of a peer-support wellness rounds in an emergency medicine resident training program.

A needs assessment survey was conducted among EM residents at The University of Ottawa to gauge interest and obtain resident input regarding program design. The structure of the sessions was adapted from similar initiatives in Canadian Pediatric Residency programs.Curriculum, Tool or MaterialConfidential peer-support sessions were created and piloted. Residents preferred peer facilitators, rather than staff, so two residents obtained training the Faculty of Medicine's Wellness Program to lead sessions. Attendance at rounds was voluntary; however, overall attendance was recorded along with feedback from pilot sessions. Discussion topics included difficult patient encounters, poor patient outcomes, challenges in residency, and ethical issues. Post implementation feedback demonstrated that Ice Cream Rounds was a helpful forum for residents to discuss important issues with colleagues. This is the first Canadian EM training program to adapt, implement, and evaluate peer-support wellness rounds for debriefing, and this initiative can be easily adopted by any EM training program.

West Virginia University's Department of OB/GYN Resident Resiliency Curriculum: A Focus on Well-Being

BACKGROUND: Stress and burnout impact physicians at all stages of training and practice, but resident physicians are particularly at risk. Resiliency skills may protect physicians from the dangers of stress and burnout and may provide improved coping skills. METHODS: The Department of Obstetrics and Gynecology conducted monthly meetings with the Residents to discuss resiliency topics in an off-site, private setting without judgment, evaluation consequences, or attending participation. RESULTS: During the 2015–2016 academic year, 12 sessions were conducted focusing on Communication Styles, Conflict Resolution, Leadership Skills, Difficult Patient Encounters, Physician Wellness, Resiliency, and Stress/Burnout Management. After completion, residents were anonymously surveyed and sessions were evaluated for effectiveness based on a Likert scale of 1–5. Eleven of 12 sessions returned a 4 or 5 rating, corresponding with a moderately or strongly agree from 100% of the residents. Only one session revealed one resident with a neutral response, or 3. DISCUSSION: Sessions explored difficult patient encounters, sentinel events, and interpersonal and professional conflicts. Positive mindfulness-based resilience interventions were discussed. Resident communication about perceived failures and stressors promoted positive discussion and insight. Sessions were almost all uniformly positively scored, with the highest ratings in communication styles, leadership/team-building, and conflict resolution. Resiliency is a key coping skill for physicians to maintain well-being. A residency resiliency curriculum has shown to be well-received in our institution and should be considered as integral in curricula as medical knowledge concepts.

A Difficult Patient Encounter: Using a Standardized Patient Scenario to Teach Medical Students to Treat Medication-Seeking Patients.

Substance dependence and the misuse of prescription narcotic medications have recently been a topic of increased national attention. Since this is both a difficult and increasingly important area for medical student training, we created an addition to our psychiatry clerkship curriculum to address this need using a standardized patient scenario. Standardized patient scenarios are a useful instructional and assessment tool for providing medical students with exposure to specific clinical scenarios that could not be consistently and reliably encountered in clinical rotations. We present a standardized patient scenario designed to challenge psychiatry clerkship students with recognizing and managing substance use disorders in patients with a difficult interaction style and medication-seeking behavior. Our scenario is unique in its expectations of students to appropriately manage a difficult clinical interaction in which collaborative treatment planning and advanced communication skills are critical to treatment success. In a narrative analysis of student postencounter reflections on this experience, most students who provided feedback indicated that the encounter was valuable to their psychiatry clerkship education. The inclusion of this learning opportunity in our clerkship has added value by assessing students' interpersonal communication skills and clinical ability to evaluate and manage substance use disorders, as well as by instructing students to manage a common and difficult clinical scenario regardless of their future specialty choice.