HealthJuly 20, 2020

Setting expectations: How to manage challenging patients

By: Suneel Dhand, MD

Challenging patients are frustrated for a reason. Here’s how honest conversations about expectations can help maintain healthy relationships.

Understanding the finer nuances of the doctor-patient relationship, including negotiating patient expectations and managing so-called difficult patients, is an area historically undertaught in medical schools. Yet every practicing physician has been in the unfortunate situation of having to deal with the fallout of these issues. By learning a few important communication techniques, any doctor can help avoid misunderstandings.

Before anything else, try to eliminate the term "difficult patient" from your vocabulary. When you sit down with a patient to discuss the challenges they're facing, remember that their concern or frustration almost always has a basis in reality. It's our job to see things from their perspective and align expectations so the situation doesn't escalate.

What do we mean by patient expectations?

A patient seeking the help of a doctor does so with the hope that a medical problem will be fixed. In certain scenarios, the expectation is clear - for example, a patient with a simple bacterial conjunctivitis wants to get better as soon as possible by walking out with a prescription for antibiotic eye drops. But what about a patient with a chronic (and inevitably declining) condition such as chronic airways disease or a patient coming in for a preop surgical consultation prior to gastric banding surgery?

Many doctors assume that the patient wishes simply to "get better." But with chronic conditions, where that is never going to be the outcome, it's critical to establish the patient's thoughts and expectations. It's your responsibility to make your diagnosis, assessment and plan easy to understand and then be honest about the prognosis. This must obviously be done with compassion, allowing the patient (and often their family) time for questions.

Start by asking the patient simple questions like:

  • What are your expectations and goals?
  • What outcome are you looking for?
  • What do you want to be able to do?

In the rare cases where patients are completely unrealistic in their expectations, we must state the most likely outcome with empathy. Understand that for the patient, this diagnosis could be crushing news, so it needs to be delivered sensitively. This is the crucial moment when a doctor can learn the patient's goals, offer professional perspective and avoid problems - or even blame - later on.

To learn more, listen to "Meeting Patients' Expectations and Managing the Challenging Patient" on AudioDigest.

 

How to manage misaligned expectations

Suppose a 55-year-old patient expects that six months after having a knee replacement, he will be able to run a half-marathon. His doctor didn't tell him otherwise. Now, he's come back to see his surgeon four months post-op and is angry about the fact that he's nowhere near where he thought he would be.

How should you respond? The golden rule is to always first listen attentively to what the patient has to say. In this case, as soon as the patient expresses his disappointment, it's critical not to snap something like, "That was completely unrealistic!" Let the patient get everything off his chest for a few minutes. Absorb his anger and frustration and use active listening techniques like making eye contact, nodding and leaning forward.

When it's your turn to speak, always start with an empathetic statement like, "I'm sorry that you feel this way and that your expectations have not been met." Discuss the clinical situation and how research and statistics indicate a longer recovery time will be needed. Talk slowly and avoid excessive medical jargon. Be wary of coming across as overly authoritarian or patronizing. Finally, allow the patient to speak again before you summarize everything and confirm the patient's understanding.

Keep refining the doctor-patient relationship

Over the last decade of clinical practice, I've gotten a lot better at this. At the beginning of my career, I hadn't been trained to ask my patients about their expectations and would see many awkward or challenging situations almost as a personal attack on my medical skills. This made me revert to the old-fashioned "I'm the doctor" way of thinking.

I never do this now; I'm able to bite my tongue when a patient vents their frustrations to me. When patients are very unwell or have a poor prognosis, I am now able to have a direct but compassionate conversation with both them and their families.

Too many doctors mishandle challenging situations by becoming defensive. All that happens as a result? The patient finds another physician. Setting expectations early on is an important first step, and if and when a challenging situation arises afterward, the rules are always the same: Listen attentively, show empathy and compassion and formulate a path forward.

Suneel Dhand, MD