Кожного дня лікар в своїй практичній діяльності зустрічається зі складними ситуаціями та спілкується з пацієнтами у різних емоційних та психологічних станах. В більшості випадків пацієнти змушені звертатись до лікаря, а не тому, що вони бажають цього. Іноді вони навіть небажано були приведені до лікарні членом своєї родини або другом. В даній оглядовій статті представлені типові рекоменданції щодо взаємодії з пацієнтами в різних клінічних ситуаціях.
Every day the doctor encounters complex situations in his practice and communicates with patients in various emotional and psychological conditions. In most cases, patients are forced to seek medical advice, not because they want it. Sometimes they do not want to visit the doctor but could be brought to a hospital by a member of their family or friend.
We must remember that all our patients are special, each one with a huge range of psychological and personality traits, as well as the current emotional state.
Even before a meeting with a doctor, the patient may be under the stress influence and stay on the brink of his emotional state. And staying in a health facility adds more stress and worries to the patient due to loss of time, health and associated costs .
In order to cope with the patient's emotions, the doctor needs a lot of communication skills. This is necessary to calm the patient and engage him in effective communication . We cannot solve all patient problems, but we can try to find what disturbs him physically and psychologically, and provide the most effective help. So we need to possess not only professional knowledge, but also masterly use our communication skills .
However, this task is not easy. Most of us already have certain communication skills, which he learned during his life . But unfortunately they are not always perfect.
Communication skills are an important part of medical education and doctor’s life in general. The study revealed that social efficiency, and the ability to solve interpersonal problems directly depends on communicative skills . So, good communication needs to be studied .
Objective Structured Clinical Examination (OSCE) is a modern clinical exam used to assess the skills and professionalism of health professionals in most developed countries. The purpose of the exam is to evaluate such important competencies of the future physician as communication skills, involving the patient in medical process, medical knowledge, clinical examination, observance of ethical norms, appointment and interpretation of diagnostic tests, the appointment of therapy, techniques for the implementation of invasive interventions and the correct filling of medical records. OSCE's task is also to train medical professionals to communicate with complicated patients [7, 8].
So it is very important to learn the specific communication techniques to solve difficult situations in real life .
There are many complicated situations in doctor- patient relationship. Interaction with them causes doctors insecurity and even the fear, which leads to refusal from contact with the patient .
A complicated patient experiences strong emotions and demonstrates behavior that interferes with effective communication. As a rule, such emotions and behavior cause negative feelings at the doctor. For example, an angry patient can irritate the doctor so much, that it can lead to conflict, avoidance of contact with the patient, or treatment denial. In addition, such negative patients emotions as fear, depression, anger can complicate the provision of medical care [11,12].
This article presents the main clinical and interpersonal approaches for solving these difficult situations. Such approaches promote effective medical care, as well as deprive the patient and doctor of unpleasant moments in communication.
Patients are invariably emotionally and behaviorally react to their illness, and doctors must respond to these reactions . Most doctors respond effectively to such changes intuitively. However, certain emotional reactions or patients behavior often outweigh the doctors expectations. When such unexpected situations occur, doctors understand that they have to deal with a complicated patient. And it is very important to remember at such a moment that you communicate with a person who experiences physical or psychological suffering [14, 15].
We often ask the patient: "What happened?" Or "Why are you so anxious (angry, confused)?" Sometimes it can help and be effective. But preferably is not to ask the patient about his emotional state, but to use the statement. For example: "You look like sad (angry, anxious)." In this way, we avoid confrontation or obsession with the patient, and we demonstrate that we are ready to see and to hear him.
Despite the facing with the difficult situation, the need to collect clinically important information remains crucial, even though overcoming the patient's strong emotions and behavior.
In this article, we also want to focus on overcoming patient’s emotional reactions and solving difficult situations in doctor-patient interaction. Very often behavior reflects the emotional state. So by overcoming emotional reactions, we can, indirectly, change patient’s behavior, which can interfere with the medical process.
In overcoming the difficult situations in the relationship between doctor and patient, it is important to use the following techniques :
- Empathetic attitude
- Normalization of emotions
- Building partnerships
An empathic attitude
An empathic attitude is the ability to recognize emotional reactions of others and to report on your understanding of these reactions in a timely manner. It is very important while communicating with the patient to pay attention to what the patient says, how he says, and what at the same time says the language of his body. Good communication requires an active listening from doctor. An active and empathetic hearing gives the doctor a time to understand the patient’s emotions or respond to their change . For example: Consider the situation of a doctor who sees a patient who is suffering from high blood pressure. When doctor asks about a private life, the patient says that everything is good. And yet, something in the language of his body, maybe a biased view, bothered the doctor. At this point, it's important to slow down precisely at this stage in history and gather more information.
Normalization of emotions
Once the doctor has demonstrated his empathy and understanding of the patient's emotions, it is often useful to express some normalization or a sense of emotional comprehensiveness. For example: "I see that you are upset, and this is normal in your situation, because everyone who is in your current state will feel the same ..."
This expression of understanding and normalizing emotion is extremely reassures the patient. In addition, this approach helps to create some trust and establish sufficient interconnections to develop a specific strategy with the patient for further treatment.
Doctors, as a rule, offer the emotional support to their patients through intuitive skills. For example: "I want you to know that, I will do my best to help you to resolve your problem." It is very important that doctors always remember how important this to patient.
There are many studies that suggest that partner relationships between doctor and patient are more effective than authoritarian relationships . For example: "We will work together to overcome your problem. When doctors involve patients in the decision-making process, patients are generally more satisfied, and are more likely to follow doctor's advice. "So I can offer you several options for treating your disease, but you need to choose more acceptable for yourself. You can think about this for several days and then tell me your decision"
Respect is the basis of a good relationship between doctor and patient. Again, some doctors respect their patients unconditionally. However, in difficult situations doctors do not always remember this. The doctor may feel angry and irritated. However, it is important for the doctor to realize this and find the strength to overcome these negative emotions.
So how to cope with patient's emotions?
- Show that you have paid attention on patient’s emotional state.
For example: You look worried!
- Name the possible causes of patient’s emotions.
For example: This is understandable in your situation, you just learned a lot today and you are worried about the state of your health.
- Ask the patient if there is anything else that makes him angry or worried.
Recommendation: Never say to an angry patient: "I understand you!
- Do not offend and do not conflict with the patient. Remember that strong emotional reactions can be caused by the patient’s physical or psychological state.
- Regardless of the patient's anger, be restrained; use a calm, balanced language of communication.
- Do not interrupt the onset of anger. Give the patient the opportunity to speak.
- Communicate with a frustrated and sad person in a calm setting, preferably in silence.
How to respond to verbal and nonverbal signals?
- Show that you have heard the patient using non-verbal patterns of behavior (eye contact, head movements, facial expressions).
- Show compassion (empathy). Use the empathetic expressions.
For example: "I see that you are upset," "It's normal for a person in your condition"
- Explore the contents of the problem on which the patient reacts violently.
For example: "Would you not mind if I ask you more about this ......"."If you do not want to answer this question now, we can come back to it later"
- Only respond to the patient's request, try to solve the problem. Do not try to respond emotionally .
How to communicate with patient in difficult situations?
Angry or hostile patient
Tense, rugged eyebrows, squeezed fists, crossed arms, limited breathing.
- Internal - Mental problems: personality (borderline) disorder, manic or depressive irritability, psychotic disorders.
- Internal - Physical problems: acute or chronic pain syndrome.
- External problems.
- When you see these signs, try to reveal the source of the problem for the patient and look at how his emotions relate to the somatic state or healing process.
- Do not conflict! Instead, define your limits and understand when a conflict situation with the patient can affect you, this will help to change your reaction to the situation on time and allow empathizing to the patient.
- What to do when the patient is unpleasant to you? Remember that you are dealing with a person who may experience mental or physical suffering.
- If the situation has already "hurt" you use reflexive statements.
For example: "I can understand why I felt these emotions in relation to the patient, I'm just a person, and I also have feelings..."
For example: Situation when patient waits for a doctor, while the doctor is late. Long waiting can be the cause of anger manifestation. The patient can say: "I do not understand why I had to wait?"
A feeling of angry can cause the same reaction at doctor, but it’s just necessary to take a deep breath and apologies for the delay. It will be more constructive than express the anger.
For example, the phrase "I can understand why you are upset, and I appreciate the fact that you waited for me" - softens the patient's dissatisfaction. It is also necessary to warn the staff to inform the patient about possible delays due to certain circumstances. Alternatively, you can propose to postpone the visit.
- Sometimes, depression may be masked under the irritation. Often this can be observed at patients suffering from chronic pain syndrome.
- For example: "I see that you are irritated, but it seems to me that sadness hides behind this feeling. You can be angry even on me, but I would like to do my best to help you."
- If you feel that the patient is afraid of a diagnosis or treatment, urge him to talk about it and assess whether the fear is appropriate to the situation. This can help to determine the cause of fear, and will allow the patient to fight it more effectively.
- Of course, if at any time during a meeting with an angry patient you feel a potential harm for yourself or staff, ask for help!
Characteristic: Looks like as «lost» or nervous. He may exhibit physical signs of anxiety: (sweating, trembling), speak quickly uncontrollably; it may seem that he requires excessive attention from you, especially as regards conviction. Or it might seem that he does not hear you and does not remember what you are talking about.
Possible causes of anxiety.
- This may be his usual behavior, it may be an anxious personality, or may be suffering from anxiety disorder.
- This may be his reaction to illness and medical aid. Most patients feel some anxiety degree in such circumstances. Anxiety about what can happen to us in the future.
- A concern may be related to other problems in the patient's life.
If you understand that the patient is worried about the diagnosis or treatment, encourage the patient to talk about it and assess whether this fear is appropriate. This can help determine the cause of fear, and will allow the patient to look at it more constructively.
Recommendations for communication:
- Be calm and ready to give the patient time.
- Explain that most patients may have anxiety and this is normal.
- If the patient says too much, try to manage the conversation using closed questions, and summarize what he has told you, explaining what additional information you need and why. For example: "I see how important this topic is for you, but we can come back to it a little bit later."
- Be persistent on what you want from the patient during, and after consultation.
- If the patient presses on you and wants to know the cause of his symptoms and seeks assurances, explain it with insufficient information and the need for clarification. For example: "Yes, I understand that you already want to know about your diagnosis today, but we need to wait for research results."
Characteristics: Such patients may complain of a variety of chronic diseases with fuzzy or exaggerated symptoms, and often suffer from concomitant anxiety, depression and personality disorders. He often addresses many doctors, has a history of multiple diagnosis, and many laboratory tests.
Possible causes: personality type, psycho-traumatic situations, environmental factors, other diseases.
During communication with the hypochondriac patient, express empathy and emphasize the need for regular scheduled visits to the doctor. This will help reduce the concern of such a patient.
For example: "I noticed that you have already visited several doctors and conducted many studies (tests) to try to reveal the cause of your symptoms. I recognize that the symptoms are really heavy for you, but I believe that these tests have already rejected any serious medical problems. I have another method of treatment for you, which has already helped other patients with symptoms like you. I would like to draw up a plan with you according to which we can meet every two or four weeks, often enough, to see if something really new is happening in your state. If something important will develop, we will do additional tests. Our meetings will be quite frequent so that you can be sure that we do not miss anything. And we will avoid inconvenient and expensive tests and procedures unless they are clearly needed".
Depressed or Sad patient
Characteristic: Looks sad, not happy, has less modulated facial expressions, does not smile, may cry and may show by avoiding behavior and not being interested in the surroundings.
Possible cause: severe loss, injury, mental illness, congenital or personality shyness, reaction to the disease, previous disease treating negative experience, waiting for the hidden truth, fear of the consequences of the disease.
- If the patient is sad and depressed, try to give him first good news.
- Give the patient time to think.
- If necessary, support the patient (the patient may cry and be ashamed of it). Tell the patient that it's okay to cry. Tears relieve mental pain. If the patient wishes, you can leave him alone.
- Repeat some of the questions you have already asked, which may help you to gather more information.
- Provide or clarify unwanted information for the patient dosed.
- For example: "I can only guess who worries you, or I cannot say anything about your diagnosis until I have a confirmation ..."
- Ask about the cause of sadness. For example: "Why are you depressed? What happened to you? "," What thoughts you have at a moment? "
- Provide the opportunity to choose. For example: "I would like you to answer the following questions in more detail, but if you feel uncomfortable, let me know, we'll go over to the next."
- If necessary, ask the patient to attend group therapy with like "severe loss", "domestic violence", and "alcohol addiction".
- Help the patient understand that grief is a process that depends on time and perception. Encourage open communication.
Scattered or Inattentive Patient
Characteristics: Such a patient is allocated through a large part of the "empty" visits to the doctor. He may be lonely, dependent, too timid or embarrassed to ask questions to which he really wants to get an answer. He can ask a large number of rational questions. He worries a lot, or simply is misinformed and needs to be clarified.
Possible causes: mental and somatic disorders.
- The first step towards productive interaction is to identify the main causes of frequent visits. Begin by noticing the nature of frequent patient visits. For example: "I see that you have already visited a doctor three times this week, how can I help you"
- Explain that you have seen other patients who planned frequent visits for various reasons; including anxiety about undiagnosed symptoms, the need to be sure that everything is well, the need to relieve chronic pain, or just need to talk.
- Ask if any of these causes worries the patient, or there are other ideas about the causes of frequent visits. By showing understanding that could cause patient frequent visits, you will contribute to an open problem discussion.
- Make a plan of regular, planned visits with the patient. Provide enough information.
Characteristics: Such a patient often plays on others' feelings, threatens to be angry, lawsuit, or even to make a suicide. He tends to exhibit impulsive behavior aimed to obtain what he wants, and it is often difficult to distinguish such behavior from a borderline personality disorder.
Why does a patient manipulate? He needs: medical time, medical diligence, compassion or mercy.
Being manipulated by patient, the physician improperly distributes working time and pays more attention to the manipulative patient.
Also, the doctor often makes the wrong decisions following the patient's requirements.
For example: just prescribe this drug or make MRI right now.
The main rule in communicating with a manipulative patient is to realize your own emotions and not involve to the patient's emotions (he may actually be smarter, even if his actions speak the opposite). As better you know your weak sides, as faster you realize that you are being manipulated. Sometimes you have to say no!
Patient: "Assign me, please, this…. drug!
Doctor: "This drug is very strong, now you do not need it."
Patient: "No, it is necessary! I cannot be without it! Urgently prescribe it to me! "
Doctor: "But I'm sorry I cannot do it."
Patient: "I know much more about my illness than any doctor, I read a lot of literature, tried a lot of drugs, so I do not know how else you can help me." How to behave with this type of patient? It is not necessary to confront with the patient.
Doctor: "So why did you come to me?" The best thing to do is to get ahead: "I see you are very skillful and experienced, but you still come to me, can I still try to help you?"
A very good defense against manipulation is the gain of time. Any manipulator tries to deprive you of time for reflection, so the easiest way is to say "I need to think" or "could not you put me your request in written form?"
Such patient main feature - is his constant hostility and suspicion during communication. He can constantly suspect you of something. He can both hide and express his suspicious thoughts.
- Remind the patient about the privacy you already talked to him at the beginning of your conversation, or during acquaintance.
- In order to disarm a suspicious patient and reduce his emotional stress - verbalize his suspicion. This may encourage him to more open communication.
For example: When the doctor asks the patient for confidential information.
Doctor: "What do you think, why I ask you all these questions?" Or "What do you think about this?"
Patient: "So I'm really curious about how you will use this information."
Doctor: "Do you remember we talked about the confidentiality of all the information that I receive from you? So it's important for me to clarify these questions. This information is necessary to me for better understanding and trying to help you. "
Patient: "All doctors say this" (The patient may be sarcastic).
Doctor: "Have you heard this already? Then I understand why you are so careful in providing information about yourself ..."
Silent or Closed Patient
Characteristic: Vulnerable, difficult to express their inner feelings. May be ashamed to answer personal questions. Often answers the question "Yes", "no", "I do not know", or at all keep silent.
- This can be a closed personality.
- This may be a manifestation of mental illness
- It can be a response to illness and medical aid.
- The emotional system of the patient may not be sufficiently developed.
- Try to show maximum respect and patience.
- It is advisable to start communicating with abstract themes. For example: "What do you like? Do you like music? "
- Questions that can turn a patient to a conversation can be related to interests, friends, and leisure.
- If the patient often answers the question "no" or "I do not know". How to engage him into a dialogue?
Example 1: "If you really do not know anything, that's fine, but if you do not want to tell me something else and then just tell me I do not want to talk to you."
Example 2: Use non-direct questions.
Ask the patient whether there is a friend, familiar or close person who may be in trouble or has a problem "Do you have a friend or familiar person who has a problem? What’s your opinion why he may be worried about?" or "Do you have a friend, sister or brother? What do you think what may happen to him (her) if he (she) has the same mood as you now?" Answering such questions, the patient can describe his behavior and his feelings. In this way, we can overcome the patient's protection and engage him in communication.
Characteristic: talkative, can «jump» from one topic to another, cannot answer questions briefly.
During the communication use more closed questions or questions that require specific choices.
Doctor: "What was your mood like last time?" (Open Question).
Patient: "Oh, it depended on how I spent my time. If I met my friends the mood was good, if a lot of tasks were waiting for me at work, my mood was gone, and my mother, you know, it's very difficult when she starts to make a pressure on me ..., etc."
Doctor: "I would like to ask you again, what was your mood during the last two weeks? In most cases, elevated, depressed or irritated? "(Question with a specific choice of answers).
Patient: "Preferably elevated".
Doctor: "How are you sleeping?" (Open question).
Patient: "Differently. Sometimes I fall asleep badly. It depends on how much I am tired, and even thoughts about the past day do not give rest. Sometimes it seems to me ..."
Doctor: "What time do you usually go to bed? When you wake up? How many hours did you sleep last night? Do you wake up during the night?" (Closed Questions)
Practice a delicate interruption of the patient's monologue.
For example: "I see how important this problem for you, but could we come back to it a little bit later?"
Periodically remind the patient about the necessity to move further in the process of your communication.
Dependent (from a family member or relationship) patient
- In a dependent relationship, a family member reluctantly leaves the patient alone with the doctor.
- When a patient is asked about his or her health, the family member is trying to answer the question firstly, or the patient looks at a family member before answering.
- A patient who has actively communicated during previous visits does not speak in the presence of a family member.
- The patient has signs indicating physical violence (such as bruising).
- Try to speak directly with the patient. Ask the family member to give the patient the opportunity to answer the questions. For example: "I understand that each one of you has an opinion on ..., but I would like to hear the opinion of each one separately."
- After getting acquainted and a few minutes of communication delicately, ask the family member to leave you with the patient alone. For example: "I am very pleased to meet you. But now I would like to talk to ... "or" So you can choose who I will talk to first"
- Emphasize the need for patient physical examination without the relative presence in order to assess the possible signs of physical violence.
- If the results for abuse are positive, the doctor is required to report this to law enforcement agencies or social services, if possible, to hospitalize the patient.
- Ask patients whether there is something that threatens his health. For example: "Is there anything you would not want me to say to your relative? If you do not mind, I will tell him only about ..."
- Ask if there is someone else whom the patient would like to see or who can be contacted instead of a present family member [20, 21, 22, 23].
Consequently, we must recognize the shortcomings of our communication and be prepared for changes. In this way, we can better understand our patients, and sometimes ourselves . We can learn and practice communication skills to better deal with the difficult situations that may occur in our day to day practice. Unfortunately, anger, aggression, sadness and anxiety are inevitable manifestations of any disease. And timely, effective response to the patient emotional states can improve the therapeutic process .
The effectiveness and quality of our interaction with the patient will intensify if we talk with care and create a good impression. Sometimes the patient does not care what we know about his illness, but it is always important to understand that he is being heard and carried by his physician.
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