We all encounter problem patients. If we react emotionally or say the wrong things, we can easily escalate a difficult situation. While I was waiting in a busy medical clinic to see my own physician this week here in Florida, a frustrated older man came to the front window, a few feet away from the waiting area.The man was frustrated because the pharmacist down the street had not agreed to fill a prescription that he needed and that had been prescribed by a doctor in the clinic. He was a large man, a bit unsteady on his feet, unkempt and poorly dressed. With his deep frustration driving his behavior, he was acting aggressively. The medical receptionist was not patient in her response to his rather taunting challenge. He then became argumentative, raising his voice, questioning her competence. All of us who were waiting were becoming a bit intimidated by the unfolding scene.
"Do you want me to call the police?" The receptionist almost shouted.
"Yes, go right ahead! You call the police! You call them right now!" he responded.
Fortunately another calmer person who worked in the clinic came to the rescue of the now-infuriated receptionist and was able to quiet things down. Before we left that day, the elderly gentleman was finally satisfied the clinic personnel would help him, and he laid out his sad story. It was one anyone would feel sorry about; a commentary on the difficult times so many are facing with the recession.
Many patients present challenges when it comes to interacting with them, let alone obtaining the most meaningful medical history. Dealing with old people can be difficult. The percentage of elderly patients coming to medical clinics is increasing dramatically as our population ages. There are now more than 50,000 Americans over 100 years of age, and the number is increasing rapidly. In a few years, half of all patients seen in medical clinics will be over 65. We also have increasing numbers of those with dementia, autism and concentration problems such as attention deficit/hyperactivity disorders.
Posttraumatic stress disorder is common in adults, along with panic disorders, anxiety states and clinical depression. A few people may break down emotionally under the stress of an intensive medical interview and start sobbing or hyperventilating. This is particularly likely if they are anticipating bad news during the medical visit.
Here are a few suggestions for some of these special situations that you may encounter, especially with obtaining the medical history, which comes first in our encounter with them. We must each decide how best to handle any unusual situation as it occurs, but here are some thoughts about some of the more common challenges.
This is a good time to remember the saying first applied to good salesmanship: "The customer is always right!" We need to be infinitely patient with loud and aggressive people, listening to their complaints and concerns, and continually reflecting back our desire to be helpful to that person. Remember that this type of behavior is a common manifestation of dementias of various sorts, especially Alzheimer's disease, and is common as a result of living and struggling to get ahead in our crowded, depersonalized modern society. We can never take it personally. I do feel that those who practice Oriental medicine are good at this approach to patients. A few times in my medical practice, I did have to call the police or a security guard. At such times. I was grateful for these individuals who are there to protect us.
Confusion is common in elderly patients when taken out of their own familiar environment. Try to determine early on if you will need a family member to help obtain an accurate history. In general, go slowly with elderly patients if they have difficulty hearing or if they seem confused. Speak clearly, and simplify your questions. Skill in working with these people is acquired with time. They are often the ones who need our help the most.
We no long use the term "deaf" when referring to these individuals, and must remember that many of them do not feel they have a disability. They consider that they live in a different world than we do, with differing skills and talents. Written questionnaires are of special importance with these patients. As you move through the history, you may have to write out questions. This may take more time than you would like but can be essential. When we are working with hearing-challenged people, time must take a back seat. Sensory dimensions become different than we are accustomed to.
Keep your voice low-pitched as these tones are easier for a hearing-challenged patient to hear. Almost all hearing-challenged individuals have some skill at reading lips. Do not cover your mouth, look directly at the person, and enunciate clearly. If you use a translator fluent at American Sign Language, listen to what they tell you the patient is saying, but do not look at and speak to the translator when you respond. Look at the patient and speak to them directly, even though they cannot hear you. Otherwise, they will feel ignored and sidelined. This is tricky but, if you do it well, you will make the hearing-challenged person your friend.
Teenagers may seem disdainful, sarcastic or non-communicative to adults. This is frustrating, but you must not show your frustration. One secret in breaking through this mismatch is for you to avoid discussing feelings, which make many teenagers uncomfortable. Focus especially on their activities and interests, which they will gladly talk about. Then move to your medical questions. They will tell you about their health if you are matter-of-fact in receiving the information and do not convey judgmental attitudes. Your radar may tell you it is unwise to ask them how they feel about their problems or what it all means, as such mature reflection may actually be beyond their developmental level. Meeting teenagers on their own turf is a learnable skill and brings great rewards. Their enthusiasm for life is infectious.
Go toward anticipated or actual emotional responses. Do not convey discomfort. You are there to provide support. If you feel a patient is about to cry, do not try to discourage it; this person needs to cry. Any attempt by a practitioner to stifle an upwelling of emotion can induce fear, for example, that you are afraid of what the patient is talking about or afraid of what they are feeling. Always have facial tissue handy. Do not indicate you are distressed. After all, you understand why this person might need to cry and they will control the crying shortly so that the interview can continue. Be supportive and empathetic without being sympathetic. Never say, "I feel so sorry for you." Help this person find a way out of the problem if you can, or at least a way to cope with it and move forward in some positive direction.
Your professional boundaries must be solidly in place. It seems unnecessary to mention this obvious fact, but some practitioners make mistakes in this regard and infractions in this powder-keg area do occur, more often than we might realize. Certain casual comments to patients may be interpreted by them as flirting, even when you never intended it. Sooner or later a patient may come on to you and make a romantic or overtly sexual approach of some sort. This can happen even if you are a paragon of professional virtue. You will need to say something that places your relationship with this person solidly back on the right track. Don't ignore such comments because you feel uncomfortable. Address the situation promptly and firmly without anger or reproach.
Those who are socially or intellectually challenged (or both) can present special problems. However, by focusing on this person and being patient, you can learn a great deal about their medical history in many cases. It is surprising how much such people are able to reveal to an empathetic questioner. In cases of advanced dementia or when an autistic patient is mute, a loved one or a professional aid will usually be present to help out. Particularly in the case of autistic children, the assistance of their primary care person will be of tremendous value.
In our multicultural society today, language barriers are obviously common. In my own practice, I often wished I spoke Spanish better. As an educator, I have worked with students from more than 20 foreign countries. The range in their level of skill with speaking and understanding English has been wide. Some of your patients may not speak English well and it may be better to defer a medical history until you have a translator so you don't miss essential aspects of the history.
In writing this article, I know I am "preaching to the choir." Empathy and compassion are the hallmarks of those who practice Oriental medicine. In fact, when the patients who come to see you need referral to a Western physician, it is often difficult to get them to agree to go to an MD. They will insist that you take care of it, because they feel so comfortable with you. I am hopeful and confident you will continue your skillful ways and perhaps even enhance them as time goes on.
Click here for previous articles by Bruce H. Robinson, MD, FACS, MSOM (Hon).