- Case discussion
- The Difficult Pediatric Encounter, Pediatrics in Review 2008
- Breuner and Moreno, Approaches to the Difficult Patient/Parent Encounter, Pediatrics 2011
- Difficult encounters are fairly common and stressful (though thankfully probably less in pediatrics than in adult medicine!). Adult providers have reported up to 1 in 6 encounters as difficult. There is less clear data for pediatrics, but we know they are still relatively common. Adverse effects from difficult encounters include higher job stress and dissatisfaction/burn-out.
- There are many potential triggers for difficult encounters, many of them are not in our control. These include patient / parent characteristics (e.g., mental health problems, multiple somatic complaints, threatening personality), provider characteristics (e.g., less comfort with diagnostic uncertainty, less experience, differences in cultural background than patients, etc.), and system factors (short time for appointments, busy/overbooked clinics).
- While difficult encounters are often beyond our control, we can prepare and control our reactions. Patient/parent rudeness is one mostly non-modifiable factor that has been studied. It’s been found that rudeness impacts our performance yet cognitive training preparing for it can help. In a study about NICU teams published in Pediatrics this year, authors found that “rudeness had adverse consequences not only on diagnostic and intervention parameters (mean therapeutic score 3.81 ± 0.36 vs 4.31 ± 0.35 in controls, P < .01), but also on team processes (mean teamwork score 4.04 ± 0.34 vs 4.43 ± 0.37, P < .05).” A preventative training on cognitive bias modification (CBM), which promoted a more positive/benign rather than threat-based interpretation of information, helped reduce most of the adverse effects of rudeness.
- Communication strategies include early acknowledgement and addressing concerns: A brief reflection such as “I see that what I said is upsetting to you. How can I help?” or “Let me try to say it another way” may buffer a statement that triggered a negative reaction. We can also apologize right up front for system factors and running late, or for inadvertently offending someone “I am sorry for appearing insensitive to you.” We should acknowledge feelings, and show we care about the patient/families’ situation and their health. “I really know this is hard for you, and I want to be as helpful as I can be to you and your child.” Knowing the patients’/parents’ agenda and their expectations has been shown to improve outcomes including compliance and follow-through.
- Utilize colleagues and modify appointments/ systems when possible: It’s appropriate to refer to a colleague or specialist when more help is needed. It’s often helpful to allow more time for patients/ encounters that we know may be difficult. Yet, it’s still important to set firm, clear limits on what time is available. For example in demands for completing forms/paperwork: “I have time scheduled now for meeting with patients, and then I complete paperwork at a later time after clinic visits.”