Difficult Patient Encounters: Case 1
Mr. D is a 64-year-old man with multiple complex medical problems including uncontrolled diabetes, untreated depression, coronary artery disease (status post myocardial infarction with multiple stents), painful peripheral vascular disease, hypertension, hyperlipidemia, chronic hepatitis C, spinal stenosis and ongoing 2 pack per day tobacco use. He is on a long list of 16 medications and insulin, though does not take any of his medications with regularity. Mr. D returns to clinic and all of the above medical problems are not well controlled. He has not been taking medication or following up with specialty care as advised. He continues to smoke and has not improved his extremely sedentary activity level. He requests that something more be done.
Be aware of your own feelings. It is frustrating to devote time and compassion to patients when they do not take your advice. Still, you provide essential service to the patient by listening to his concerns and providing an opportunity for care. Prepare for the visit by acknowledging your frustrations before seeing the patient and strategize about how you will make the most of his visit. Set your own goal for the visit. Also ask him why he is coming to see you. If it is unrealistic to expect Mr. D to comply with all his medical therapies, if he feels respected and heard, he will be more likely to heed your advice. Consider asking which of his medical problems is bothering him most and negotiate with him on ways that he can work toward mutually agreed upon goals. Explore causes of his non-compliance and problem solve together toward a more coherent medical plan. Emphasize that the two of you work together to improve his health and establish one or two goals for his next visit (e.g. better diabetes control). Plan to maintain a patient and respectful demeanor even though you might actually be feeling frustrated. Enlist other providers (pharmacist, nurse, counselor or social worker) to help.