A practical approach for managing problem patients

  The detailed plan described in the next few paragraphs might seem like too much work, but past experience has shown that it will save time, money, and stress in the long run. Because every situation is different, doctors have to be flexible. However, this way of working usually helps patients get better results.

1. Know when you're doing something wrong. A regular patient may keep coming back with symptoms that aren't clear, change, or cause other problems, or a new patient may have a lot of complaints that point to a behavioral cause. In either case, the doctor should know that a comprehensive approach to care is needed.

2. Find out what the patient thinks. It's easy to want to cut a patient's "organ recital" short and get the meeting over with as quickly as possible. At a patient's first visit, this is sometimes the only solution that will work. If so, tell the patient that you need more time to evaluate him or her and have your staff set up a follow-up appointment.

In some way, the patient must be able to tell his or her story, with the help of the clinician, who should guide and ask good questions. Ask the person about their illness and what they think should be done. Talk about what treatments have been given in the past and how they turned out. Ask the patient what he or she thinks caused the illness, what the prognosis is, and what he or she thinks might stop them from getting better.

3. Get an organized history. This includes a general health history and a review of the person's psychosocial systems. The second is meant to find out about the patient's life stressors and how they deal with them, as well as what resources they have. Ask for the names of the patient's previous doctors, as well as the dates and reasons for any previous hospital stays. The fact that a patient doesn't want to give access to these reports may be important information in and of itself.

4. Get a regular physical exam and lab tests to check for health problems. This will help you find any medical problems that are happening at the same time and show the patient that you care enough to do a thorough evaluation. Make sure you touch what hurts. Most of the time, it is not a good idea to start by doing a "megawork-up" to rule out every possible disease.

5. Do any tests that are asked of you as soon as possible. Try not to get into the habit of ordering new tests and procedures every time the patient tells you something new.

6. Tell the patient as soon as possible what you think and what you plan to do. Say that the patient's symptoms are important and that you're willing to work with him or her in the long run. Assure them (when you know for sure) that the results do not mean they will be disabled or that they are a threat to their lives. Listen to make sure the patient gets what you are saying and agrees with it.

7. Make your goals specific. Having symptoms may be an important part of a patient's life, and trying hard to get rid of them can lead to bad things like depression, angry denial, hostile behavior toward doctors or other people, self-destructive actions, or just going to a different doctor. This risk will be lessened with a more gradual approach, which may also help patients give up the role of sick person over time.

8. Plan to see them often. At first, you may need to set up appointments as often as once a week, but over time, the time between them should get longer, maybe to once a month. If a patient misses an appointment, they should be called and asked to make a new one. The following goals will be met by regular patient visits:

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They help people feel like they are cared for and understood.

They deal with small problems before they become too much for the patient to handle.

They may slowly (but surely) help the person think in a more mature way.

They cut down on or get rid of phone calls, tests, consultations, hospital stays, and trips to the emergency room that aren't needed.

9. Visits should be short and to the point. Encourage your patients who are giving you trouble to write down their health worries and bring the list with them to each appointment. Have them put an asterisk next to the one or two things that are most important to them. Take care of these, and if none of the others seem important, leave them for another day. The average length of a visit shouldn't be more than 10 minutes.

10. Talk to the person. Start the meeting by shaking hands. Even if you've done it a dozen times before, give your heart and lungs a quick check. Finish the visit by giving the patient a pat on the back and telling them that you want to see them again at the next scheduled time.

11. Find something for the person to do. Give them something to do regularly, even if it's just a 20-minute walk every day. You might want to suggest vitamins and changes to the way they eat. You should try to get your patient involved in things like hobbies, religious activities, group trips, and other similar things. Some hands-on therapies, like chiropractic or massage therapy, can be tried, but there isn't much evidence that they do anything more than make the patient feel better.

People who don't have many friends can benefit from having a pet. A pet gives you an emotional connection and a reason to live. A dog might be a good choice for people who are healthy, smart, and have enough money. A cat is quieter than a dog and needs less care, so it may be better for some people. Smaller pets like gerbils, fish, and birds don't live as long and give you less time to get attached to them. You might want to tell your patient to talk to a vet about choosing an animal with the right size and personality.

12. Choose which medicines to take. Most of the time, pharmacotherapy is not the most important part of treating a patient with a problem, and it shouldn't be. However, medication is often needed when depression, panic disorder, or other conditions are present.

13. Put your family and friends to work. Ask the patient's family and friends what they think is going on. Listen for genuine worry that can be put to good use with some coaching. Listen for destructive attitudes that can make you feel like you're not good enough, make you feel dependent, or make you feel shame. Before you talk to the patient's family, you should always ask the patient's permission, and you shouldn't do anything that could be seen as going behind the patient's back.

14. Work with the people you work with. Make sure they know what you stand for and agree with your plan. They don't have to agree to everything the patient wants, but they should be nice and call the patient by name. Don't let people in your practice use insulting words that can make people feel bad about patients. Listen to what your team members have to say about what they've learned from your patients. They might notice something you've missed. Let them help with giving emotional support and enjoy the feeling of satisfaction that comes when good care leads to healthier behavior. Lastly, make sure they know that they have an absolute duty to protect the privacy of these patients and do so.