This article will provide risk management strategies to help physicians and practice staff:
- Better work with those patients who seem difficult
- Minimize the risk of liability represented by patients who persist in the behavior that earns them the label “difficult”
“Difficult” patients exist in every clinical setting. These patients may range from those who are noncompliant with their healthcare provider’s orders or advice to those who exhibit abusive behaviors. Approximately two-thirds of difficult patients are noncompliant. Communication issues may be responsible for the behaviors of some noncompliant patients, while other patients are noncompliant by choice.
Noncompliance Due to Communication Issues
The first step in addressing noncompliance is to identify its potential causes and develop strategies to improve patient understanding and adherence. A partial list of causes and strategies for improvement follows:
- The patient forgot the verbal instructions.
- The provider should provide written instructions, presented in easy-to-follow steps and written with minimal words in simple lay terms with oral instructions.
- The patient finds a drug or treatment regimen too complex.
- Include the patient in the treatment regimen, reviewing all medications prescribed by all providers.
- Consider a pharmacy consultation to work out a realistic schedule for patients with multiple medications.
- The patient is angry or depressed about the chronic condition that necessitates treatment.
- The provider needs to determine the level of the patient’s understanding of his/her problem or disease and the patient’s goals.
- The provider should consider resources to provide ongoing support and shared community for patients with chronic diseases.
The common thread in dealing with patients who are not noncompliant by choice is the need to communicate clearly and frequently regarding the purpose, goals and alternatives for treatment and medications. Some patients may not understand their behavior as noncompliant. Specifically naming their behavior may bring understanding – to both sides.
Noncompliance by Choice
Patients who are noncompliant by choice may fall into one of the categories described below. Potential strategies for dealing with each situation are included.
- The patient threatens to sue, “go to the papers” or go online with complaints when his/her wishes are denied.
- The provider should not allow the patient to intimidate or manipulate him or her, nor should he or she succumb to threats or respond in anger.
- Doing and documenting what is medically justified can be argued far more successfully in a malpractice case than giving into a patient whose demands are unrealistic and may be based on questionable website information.
- The patient does not pay his/her bill, even with reminders when appointments are scheduled.
- Billing practices should be posted in a visible place and patients should be informed of the billing and payment policies at their first visit.
- A payment schedule workable for the patient should be developed.
- Consideration needs to be given to terminating the professional relationship with the patient who is a chronic or persistent non-payer.
- Until that step is taken, the practitioner needs to continue to see the patient. Medicine takes precedence until the patient has been formally terminated from the practice.
- The patient becomes verbally or physically abusive when informed that the provider is running late due to an emergency or will not give him/her what he/she wants.
- The practice needs to develop and maintain a policy addressing management of the patient who exhibits violent behavior in the office. The policy should include steps up to and including isolating the individual to prevent injury to self and others.
- The staff should try to calm the patient.
- Police should be summoned if a patient becomes physically violent or demonstrates threatening behavior.
Difficult patients often are both a frustration and a challenge. Termination of the professional relationship should not be the first response to these individuals. Rather the “difficult” behavior needs to be identified and addressed with the patient. However, if efforts are unsuccessful, physicians have the right to practice in a safe environment, to have their professional ability valued and to have themselves, their schedules and their staff respected. When those rights are violated or irretrievably compromised by the patient’s actions or inactions, termination of the professional relationship may be a viable option.
Tara R. Gibson, CPCU, RPLU is Vice President of Risk Management, Coverys www.coverys.com