Dysfunctional Consultations Ramesh Mehay Aims Recognition

Dysfunctional Consultations Ramesh Mehay

Aims • Recognition of different types of Difficult Patients • Whose problem is it? • Why are they so important? • How to Deal With Them • Preparation for the MRCGP – a favourite in both orals and the written paper

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

Brainstorming Session Make a list of difficult types of patients you have encountered

Definition of a dysfunctional consultation “An exhausting consultation between a doctor and a patient which often triggers off some powerful emotions either in the doctor dealing with them, in the patient or both! Most show a continuing, insatiable dependency on a physician. ”

How Common Are They? 8

What’s all the Fuss? • Doctor Reasons Stress, fear, anger, low morale, helplessness • Patient Reasons unnecessary Ix & Rx • Society Reasons Expensive!

Whose Problem is it Anyway? • The patient • The doctor • The Dr – Pt relationship patient doctor

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 of Perfection Normal Doctors – Yes You!!!!

Is it the Dr-Pt Relationship? Flipchart 1. Unidirectional Consultations patient doctor Leading to • Failing to understand patients ICE • Failing to appreciate affect on patients life • Failing to appreciate patients coping mechanism 2. Patient behaviour that annoys the doctor – Christie & Hofmaster (1986) “Pull Yourself Together” report (2000), Mental Health Foundation) 3. Certain Medical Illnessses - Christie & Hofmaster (1986)

How Can You Spot Them? Brainstorm – how do you recognise them in practice? Think in these broad areas: • Patient characteristics • Patient Beliefs • The consultations

SESSION 2 The Meaty Bit! How do I deal with them? ( and by the way, who on Earth is Groves!)

The Main Man – Groves. • • • MRCGP favourite 1951, Described hateful patients! 4 categories 1. 2. 3. 4. 5. The dependant clinger The entitled demander The manipulative help rejector The self destructive denier The malodorous minger (oops!. . . sorry, that’s one of mine!)

1. What Sort of Patient is this? Mrs Eileen Webster, age 58, widow 9 attendances this month, month isn’t even over yet! Second to last patient on your surgery list Running time – you are already 15 minutes late Call her in………. .

1. 2. 3. 4. 5. 6. 7. EILEEN WEBSTER What sort of patient is this according to Groves? Why…what sort of characteristics helped you in your classification? How did she make the doctor feel, can others identify the scenario with their experiences? What factors before the consultation could you identify that might have led to the dysfunctional consultation. What bits of the consultation led to doctor feelings Whose fault – doctor or patient? Why do they act the way they do? What good methods did the doctor use to tackle the situation? Any methods of controlling behaviour? Any unhelpful doctor behaviour? Any other methods the audience can suggest of controlling patient behaviour?

2. What Sort of Patient Is this? John Templer, age 42 Business man Here on time. You collect the notes and receptionist informs you he is complaining a bit for keeping him waiting for 10 minutes Middle of your consultation list Call him in……….

1. 2. 3. 4. 5. 6. 7. JOHN TEMPLAR What sort of patient is this according to Groves? Why…what sort of characteristics helped you in your classification? How did she make the doctor feel, can others identify the scenario with their experiences? What factors before the consultation could you identify that might have led to the dysfunctional consultation. What bits of the consultation led to doctor feelings Whose fault – doctor or patient? Why do they act the way they do? What good methods did the doctor use to tackle the situation? Any methods of controlling behaviour? Any unhelpful doctor behaviour? Any other methods the audience can suggest of controlling patient behaviour?

3. What Sort of Patient is This? • Mary Tyler, age 45, non smoker • Asked for you specifically, no-one else will do • Aches and pains in both legs (you have are very familiar with this complaint of hers) • Duration : 3 years • Previous Investigations NAD • Orthopaedic/Neuro/Vascular referral – NAD. ? Depressed ? Nerve Pain • PMH : similar sort of picture for headaches and tummy pains! • Requesting Pain relief • Call her in……………. .

1. 2. 3. 4. 5. 6. 7. MARY TYLER What sort of patient is this according to Groves? Why…what sort of characteristics helped you in your classification? How did she make the doctor feel, can others identify the scenario with their experiences? What factors before the consultation could you identify that might have led to the dysfunctional consultation. What bits of the consultation led to doctor feelings Whose fault – doctor or patient? Why do they act the way they do? What good methods did the doctor use to tackle the situation? Any methods of controlling behaviour? Any unhelpful doctor behaviour? Any other methods the audience can suggest of controlling patient behaviour?

4. What Sort of Patient is This? • Sarah Nopes, age 51, morbidly obese • Known COPD 10 years, still smokes 40 per day – smells of fag ash • Getting worse again • Also has arthritis – again worsening • Call her in

1. 2. 3. 4. 5. 6. 7. SARAH NOPES What sort of patient is this according to Groves? Why…what sort of characteristics helped you in your classification? How did she make the doctor feel, can others identify the scenario with their experiences? What factors before the consultation could you identify that might have led to the dysfunctional consultation. What bits of the consultation led to doctor feelings Whose fault – doctor or patient? Why do they act the way they do? What good methods did the doctor use to tackle the situation? Any methods of controlling behaviour? Any unhelpful doctor behaviour? Any other methods the audience can suggest of controlling patient behaviour? (James Heron 1990)

Personality Disorders • Synonyms – psychopathy, sociopathy

Somatisers • • • Abnormal consultation Strong beliefs Frequent Ix Social Difficulties Depression Nothing “works”

Why GP’s Don’t Like Them • • Hopelessness Diagnostic Difficulties Time Cost

Why Is it Important to Have a Management Strategy For them? • • • Prevent chronic sick role Reduce dr dependency Avoid dr shopping Maintain the dr-pt relationship some how To make the dr feel comfortable in dealing with them (exterminate negative emotions) • To avoid missing a true illness

Managing them (Peter Tate) 1. Discuss your perceptions of the abnormal illness behaviour 2. Discuss patients denial and avoidance behaviour 3. Verbalise your patients anxiety 4. Describe the way your patient is trying to influence you back to them 5. Discuss your own feelings with them 6. Carify patients complaints to gain more insight 7. Avoid too much advice 8. Ensure the advice is specific and tailored to the specific patient 9. Encourage patient to find their own solutions

Managing them (other solutions) • • Boundaries & Limits Share the workload Delayed Response Avoid difficult situations

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

RULES FOR ALL OF THEM 2 Be careful- getting the right balance • • True illness being missed vs too many Ix or referrals Reaction to External Factors Stresses not being dealt with Stigma ……of being labelled as “mad” or “neurotic” Experiential Practice makes Perfect

EVALUATION • What things did you like about today • Did they meet the objectives • What things would you have liked done differently • Any bits that you thought should have been included or expecting? • Would it be helpful for future registrars to repeat the session?