Department of Medicine Department of Medicine Hartford Hospital Hartford Hospital

Quality Program

Morbidity & Mortality ConferenceJanuary 17th, 2013

This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health

care rendered

Morbidity & Mortality Morbidity & Mortality ConferenceConference

It is for the department faculty and residents to peer review case(s) from the inpatient service.

The primary objective is to improve overall patient care focusing on quality of care delivered, performance improvement, patient safety and risk management.

This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered

Morbidity & Mortality Conference

Goals: To review recent cases and identify areas for improvement for (all) clinicians involved Patient complications & deaths are reviewed with the purpose of educating staff, residents and medical students. To identify ‘system issues’, which negatively affect patient careTo modify behavior and judgment and to prevent repetition of errors leading to complications. To assess all six ACGME competencies and Institute of Medicine (IOM) Values in the quality of care delivered Conferences are non punitive and focus on the goal of improved and safer patient care

This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered

Morbidity & Mortality Morbidity & Mortality ConferenceConference

Every Defect is a TreasureEvery Defect is a Treasure

This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered

Every Defect is a TreasureEvery Defect is a Treasure

Errors are due to:

Processes – 80% Individuals – 20%

Translate all error into education

This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered

Every Defect is a TreasureEvery Defect is a Treasure

I request those that may recognize and may have been involved in the care of patients’ being presented not to take the discussion personally…

This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered

MANAGING THE MANAGING THE DIFFICULT PATIENT DIFFICULT PATIENT ENCOUNTERENCOUNTER

Learning Objectives

Identify common characteristics of difficult patients

Identifying unconscious physican physician responses to difficult patients and encounters

Learn coping strategies for physicians

Learn behavioral strategies to cope with difficult patients and encounters

DefinitionDefinition

The "difficult" medical patient experiences emotions and demonstrates behaviors that interfere with effective medical care. These

emotions and behaviors typically evoke negative feelings in caregivers, and this

aversive reaction leads to the designation of such patients as "difficult."

Who are “difficult” patients?Who are “difficult” patients?

What characteristics make a patient “difficult”?◦ Mental health disorders◦ Multiple symptoms or comorbidities◦ Chronic pain◦ Functional impairment◦ Unmet expectations◦ Lower satisfaction with care◦ High users of health care services –

“frequent fliers”

Dr. Tom O’Dowd coined the term “heartsink patient” BMJ, 1988

Components of a Difficult Components of a Difficult Patient EncounterPatient Encounter

Physician EmotionsPhysician Emotions

• Transference v. Countertransference• Hatred of Patients• Typing of Patients

Transference vs. Transference vs. CountertransferenceCountertransference

• Transference=feelings experienced by the patient toward the physician that recapitulate other important relationships within the patient’s life

• Countertransference=the analogous emotions experienced by the physician in this relation with the patient

Typing of Patients - Typing of Patients - Grove’s ClassificationGrove’s Classification

• Dependent clingers• Entitled demanders• Manipulative help-rejecters• Self-destructive deniers

Groves, 1978

NEJM

Sohr, 1996

Grove’s ClassificationGrove’s Classification

StereotypeStereotype MechanismMechanism Physician EmotionPhysician Emotion StrategyStrategy

Dependent ClingerDependent Clinger Regression into Regression into dependency. dependency. Patient has Patient has inexhaustible inexhaustible needs.needs.

Feelings of power Feelings of power initially followed by initially followed by aversionaversion

Set limits before Set limits before total destruction of total destruction of the relationship. the relationship. Schedule more Schedule more frequent visits and frequent visits and limit interruptions.limit interruptions.

Entitled DemanderEntitled Demander Unaware of Unaware of dependency. dependency. Terrified of Terrified of abandonment.abandonment.

Guilt, fear, angerGuilt, fear, anger Never disparage Never disparage feeling of feeling of entitlement. entitlement. Redirect feeling of Redirect feeling of entitlement to entitlement to acknowledged acknowledged right to good right to good health care.health care.

Sohr, 1996

Grove’s ClassificationGrove’s Classification

StereotypeStereotype MechanismMechanism Physician Physician EmotionEmotion

StrategyStrategy

Manipulative Help-Manipulative Help-RejecterRejecter

Afraid to get well Afraid to get well for fear of losing for fear of losing relationship with relationship with physician.physician.

Anxiety that Anxiety that treatable illness treatable illness has been has been overlooked.overlooked.

Put limits on Put limits on unrealistic unrealistic expectations. expectations. Share pessimism Share pessimism with patient.with patient.

Self-destructive Self-destructive DeniersDeniers

Dependents Dependents who have given who have given up. May appear up. May appear to take pleasure to take pleasure in their in their destruction.destruction.

Frustration. May Frustration. May with the patient’s with the patient’s death and death and experience guilt experience guilt about such about such wishes.wishes.

Realize that the Realize that the patient has given patient has given up and may truly up and may truly want to die. Order want to die. Order psychiatric psychiatric consultation.consultation.

The CALMER ApproachThe CALMER Approach• Physicians must understand how

their own attitudes and behavior may contribute.

• The CALMER approach assists physicians in reducing distress associated with interactions with problem patients.

CALMERCALMERC=catalyst for changeA=alter thoughts to change feelingsL=listen and then make a diagnosisM=make an agreementE=education and follow-upR=reach out and discuss feelings

CALMERCALMER Catalyst for Change

◦ See Physicians should remind themselves of what they can and cannot control about the situation.

◦ Physicians cannot control the patient’s behavior, but they can control their own reaction and try to be helpful by offering practical advice.

Alter thoughts (changes feelings)◦ Discuss patient's specific negative feelings and their impact on the

encounter◦ Providers should also identify their own negative feelings

Listen first (then diagnose)◦ Eliminate barriers to communication and find ways to improve

doctor-patient relationship Make Agreement

◦ Co-author a health improvement plan with the patient Education

◦ Set reasonable goals for the next appointment/interaction/day/week. Reach out

◦ Establish self-care strategy

Catalyst for ChangeCatalyst for ChangeThe patient needs to go through the cycle of change. Assess what

stage they are at and help them get to the next stage.

CALMERCALMER Catalyst for Change

◦ See Physicians should remind themselves of what they can and cannot control about the situation.

◦ Physicians cannot control the patient’s behavior, but they can control their own reaction and try to be helpful by offering practical advice.

Alter thoughts (changes feelings)◦ Discuss patient's specific negative feelings and their impact on the

encounter◦ Providers should also identify their own negative feelings

Listen first (then diagnose)◦ Eliminate barriers to communication and find ways to improve

doctor-patient relationship Make Agreement

◦ Co-author a health improvement plan with the patient Education

◦ Set reasonable goals for the next appointment/interaction/day/week. Reach out

◦ Establish self-care strategy

Alter Thoughts to Change FeelingsAlter Thoughts to Change Feelings

• The only way individuals can control their reactions is to alter their thoughts about the situation.

• Physicians should identify which feelings they are experiencing in response to the patient and then ask how these feelings might be affecting the physician-patient relationship and the management plan.

• “What can I tell myself about this situation that will make me feel less _______?”

Pomm, et al. (2004)

CountertransferenceCountertransference Doctor’s attitudes and

wishes based on past relationships projected onto present ones.

Everyday occurrence.

Learn to pay attention to your feelings and thoughts about patients. Use them (e.g., if you are anxious, patient may be also).

Try to determine if feeling is “real” or a projection.

Common signals of countertransference

Using derogatory labels (“crock,” “druggie”).

Increased use of tests or referrals.

Acting differently than usual (more time, asking more personal questions, avoidance).

Boredom, sleepiness, or irritability.

Excessive positive or negative feelings.

CALMERCALMER Catalyst for Change

◦ See Physicians should remind themselves of what they can and cannot control about the situation.

◦ Physicians cannot control the patient’s behavior, but they can control their own reaction and try to be helpful by offering practical advice.

Alter thoughts (changes feelings)◦ Discuss patient's specific negative feelings and their impact on the

encounter◦ Providers should also identify their own negative feelings

Listen first (then diagnose)◦ Eliminate barriers to communication and find ways to improve

doctor-patient relationship Make Agreement

◦ Co-author a health improvement plan with the patient Education

◦ Set reasonable goals for the next appointment/interaction/day/week. Reach out

◦ Establish self-care strategy

Managing Angry PatientsManaging Angry Patients

Always address anger; don’t ignore it. Take a “one down” position and apologize for real

transgressions or for not meeting patient’s expectations. Correct mistakes when possible. Avoid escalating anger. Ask patient to speak more slowly since you are having

trouble following him. Assess danger (prior history of violence, escalating behavior,

clenching fists, etc.); Get help. Arrange for both of you to be able to “escape” room if

necessary.

Leaving Against Medical Leaving Against Medical AdviceAdvice

The average patient who leaves AMA is young, male, living alone, and has additional medical issues. Psychosocial issues include anger, fear, and psychosis. 

A signed AMA form is not an absolute defense of medical liability. In fact, if the patient left AMA after a dispute with the physician, courts may view the premature discharge as a retaliatory move by the physician and then view the physician as liable.

What can we do?What can we do? Try to determine why he or she insists on leaving. They may be

afraid of being hospitalized or about financial implications, in which case you may be able to offer treatment options that may not require hospitalization.

Identifying family members or friends who might be persuasive can help eliminate the need for an AMA discharge. Even bargaining for time—such as by offering a meal—can be helpful in avoiding an AMA discharge. The added wait may allow the patient to reconsider the decision.

determine whether the patient has the capacity to make the decision to leave AMA. Patients who are under the influence of drugs or alcohol should probably not be allowed to leave. It may be necessary to obtain a psychiatric evaluation to determine mental competency.

In the event that an AMA discharge cannot be avoided, make sure to document that the patient understands the nature of the illness and the consequences of leaving against medical advice. Also document that the patient possesses the mental capability in making this decision. 

Finally, ascertain that the patient does not meet the state standard for involuntary psychiatric hospitalization.

8 Parts of the Safe AMA 8 Parts of the Safe AMA ProcessProcess1. Capacity

This term refers to the patient’s medical ability to make a decision. Documenting that the patient “understood” offers little protection, while documenting a patient’s ability to carry on a conversation and demonstrate reason provides a much more compelling example of their capacity to make decisions. Additionally patients should be noted to be clinically sober as a way to support their capacity. Example: “The patient is clinically sober, free from distracting injury, appears to have intact insight and judgment and reason and in my opinion has the capacity to make decisions.”

2. Signs and Symptoms

The patient and provider need to agree on both the patient’s symptoms and also the providers concerns. Example: “The patient presents with abdominal pain. I have explained that I am concerned that this may represent appendicitis; they have verbalized an understanding of my concerns.”

3. Extent and Limitation of the Exam

Document what has been done as well as the limitations that still exist. Example: “I have told the patient that while their labs were normal, they could still have appendicitis.”

4. Current Treatment Plan

Example: “I have discussed the need for a CT scan to get more information about potential causes of the patient’s pain.”

5. Risks of Foregoing Treatment

Simply documenting “you could die if you leave” is inadequate. Patient should be informed of reasonably foreseeable complications including disability and death. Specific threats such as loss of fertility for testicular/ovarian pathology or loss of vision for ocular complaints should be included when appropriate. Example: “I have told the patient that if they leave and have appendicitis, they could get much worse, could become critically ill, and could possibly become disabled or die.”

6. Alternatives to Suggested TreatmentProviders should clearly document the efforts they have made to prevent the patient from leaving AMA. In addition to alternative diagnostics and treatments, discussions with family and friends can be included. Example: “I have offered to give the patient more pain medication. I have asked them to stay in the hospital for serial abdominal exams. I have offered to have an ultrasound performed instead of a CT scan. I have discussed these concerns with the patient’s wife who is at the bedside and she is unable to convince them to stay for further evaluation.”

7. Explicit Statement of AMA and About What the Patient RefusedExample: “The patient is not willing to undergo a CT scan. He is unwilling to stay overnight for monitoring. He is refusing any further care and is leaving against medical advice.”

8. Questions, Follow-up, Medicines, InstructionsWhen patients leave AMA, providers should do whatever is possible to limit bad medical outcomes. A commonly held misconception is that providing a patient with prescriptions or paperwork somehow negates their AMA status and places the provider at risk. In reality, refusing to provide any discharge medication or instructions only increases the chance that the patient will have a bad outcome, which significantly increases the provider’s risk. For instance, if a patient with pneumonia is leaving AMA, they should be given appropriate antibiotics, and the provider should offer to set up outpatient follow-up. All questions should be answered. Example: “I am unable to convince the patient to stay, I have asked them to return as soon as possible to complete their evaluation. I have spoken with coverage for their primary care doctor in regards to their abdominal pain. I have answered all their questions.”

8 Parts of the Safe AMA 8 Parts of the Safe AMA ProcessProcess

Final ThoughtsFinal Thoughts If you have been manipulated by a patient, you may be angry with them and yourself.

These feelings are normal and natural.

Once recognized, forgive yourself (we have all been manipulated at one time or another).

Treat manipulation as a symptom and be curious about the cause.

Indentify and adopt strategies to reduce personal stress associated with these encounters and to change patient behavior.

Just don’t say this……

QUESTIONS ?QUESTIONS ?