As difficult patient interactions continue to rise, here is how to handle them
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At least once a week, Emily L. Weis, MD, MS, says she has a challenging consult or patient interaction in her allergy practice, and she has noticed these situations have been occurring more frequently since the pandemic.
“There are probably two reasons for that,” Weis, assistant professor of clinical medicine and pediatrics and the allergy and immunology clinical director and regional director at University of Rochester Medical Center, told Healio. “One would be the sheer volume of patients coming through the door — both because of early physician retirement and consolidations within the major medical groups — and there are a lot of psychosocial stressors in the community right now.
“There also is a lot of communication via electronics, which lends itself to more miscommunication,” she added.
Difficult situations
Women physicians in particular frequently deal with bias and questioning from patients.
For instance, as part of a survey Blumenthal and colleagues conducted in 2023, women allergists reported being mistaken for a nurse, being touched inappropriately by colleagues and patients, and being “berated by male patients and colleagues.”
Blumenthal and her co-authors also cited data showing that more than half of women faculty and staff and 20% to 50% of women students or trainees report having experienced sexual harassment in academia from colleagues or patients.
Meera R. Gupta, MD, FAAAAI , associate professor in the department of pediatrics and director of the allergy/immunology fellowship training program in the division of immunology, allergy and retrovirology at Texas Children’s Hospital and Baylor College of Medicine, as well as a Healio Women in Allergy Peer Perspective Board Member, recalled an interaction that caught her completely off guard. She was working on a case with one of her fellows, who was a man, involving an older woman patient. Gupta said her trainee explained the treatment plan they came up with to the patient, and then Gupta entered the exam room to reiterate what he had explained and to answer questions.
“The patient cut me off and said, ‘I have already talked about it with the doctor here,’” Gupta said. “I sputtered and stopped and tried to decide what to say. Do I say, ‘But I am his boss, he is just a trainee?’
“At that moment, I decided the best thing I could do was say, ‘OK, great,’’ she added. “And I walked out of the room.”
Now that Gupta works in pediatrics, she has noticed that emotions tend to run higher when dealing with children and their guardians.
“I think it is very difficult to have your heart walking around outside your body and then having to hand them over and trust someone else with the most important person in your life,” Gupta said.
Theresa A. Bingemann, MD, FAAAAI, FACAAI, associate professor of medicine and pediatrics, and allergy and immunology fellowship program director at University of Rochester Medical Center, as well as a Healio Women in Allergy Peer Perspective Board Member, said it is important to make sure everyone in the exam room is prioritizing the child’s health. She described an appointment with a child and their parents, who were both there with their new spouses. She was notified before she even made it out to the waiting room that security had been called due to the adults arguing with each other.
“It sounded like they could not even talk to each other without fighting,” Bingemann said.
She knew that the best way to handle the situation was setting some ground rules at the beginning of the appointment.
“I looked at the parents and said, ‘I hope we can agree that we are here for the benefit of your child, and I know there may be strong feelings here,’” she said. “’But I am going to request that you direct your comments at me. If there is fighting, I will send people out of the room.’ And everyone played by the rules.”
Establishing respectful communication
One of the best ways to prevent and manage difficult patient interactions is through setting up an expectation of mutual respect, Weis said.
“It’s really important that patients know that I respect their wishes, because it’s their health care,” she said. “But then, in order to be able to provide that care, they also need to be respectful of the fact that I have a team that is working very hard from an administrative and nursing care standpoint.”
Gupta establishes an environment of respect in her practice by ensuring all her patients are treated the same.
“It does not matter if they are designated as a VIP, an uninsured patient or a Medicaid patient,” Gupta said. “Every person who comes to my office is treated the same, because once I stop doing that, I am not practicing good medicine anymore.”
Bingemann agreed, stressing that not only do patients deserve respect, but so do physicians and their staff.
Because data show women physicians tend to get more MyChart messages from patients, Bingemann manages electronic conversations by explaining to patients when and how often they will hear from her.
“I usually tell patients, ‘OK, we’re going to do your labs, and things may come in one by one on the electronic health record, but unless there is something urgent I’m not going to send a message until they’re all in.’ Just saying that can be the difference between one conversation and 20 conversations,” she said.
Weis agreed that such asynchronous communication can be a driver for misunderstandings. She encourages her staff to be clear and concise in written messages, but if the conversation keeps going back and forth, she prefers to call the patient on the phone or schedule an in-person visit to make sure the patient’s questions are getting answered.
“Sometimes we find out that the patient may not even be mad, upset or concerned about the thing they were messaging about,” she said. “There may be another issue going on. Listening to what the concern is can often lead to a rapid resolution or solution.”
Setting boundaries
Weis said it is important that physicians take time to understand their own boundaries in areas such as working hours and scope of practice.
“Setting up these boundaries is a skill that we as physicians need to really think about,” she said. “You don’t want to be pushed beyond a boundary that you have in your mind where it may make it difficult for you to do your job. Over time you may realize what your limits are on your hours that you can really be accessible, as well as what disease processes you really feel comfortable with so you aren’t treating outside of your scope of practice.”
Social media can be a useful tool for physicians to connect with their colleagues and patients but is another area where boundaries should be set. Weis prefers not to use social media to speak to patients about medical questions.
“If it is a medical question, that is best handled during business hours or with the on-call provider, because you do your best thinking when you are on, and then you have the necessary resources and documentation,” Weis said.
Boundaries not only ensure the safety of patients, but also physicians’ well-being, Bingemann said. She recommends being thoughtful about how much time visits will take, how long phone calls should last, and how soon patients and colleagues should expect responses to questions.
“I think a lot of us were raised to be the good girl, to please everyone and always say yes,” Bingemann said. “But that is a recipe to really burn you out.”
Setting boundaries is important, but equally important is maintaining those boundaries, Gupta said.
“Once you have crossed that line, then there is an increased risk of perpetuating that behavior,” Gupta said. “If it happened once, they will do it again and again, and the expectations do not go away.”
Be confident in yourself
Being questioned by a patient is not always a bad thing, Weis said.
“I actually welcome that,” she said. “If a patient is questioning me, that may mean my delivery may not have been received and processed.”
In cases where Weis feels like her patient is not following the plan she came up with, she said it helps to ask the patient what their understanding is.
And do not be afraid to ask a colleague for advice, Weis said, because it is possible they have been in the same situation at some point.
It is also important to recognize your part in difficult situations, Bingemann said.
“Sometimes people forget that physicians are human and have emotions too,” she said. “We all have bad days and days we could have handled things better.”
In many cases, a patient may be upset about something that is entirely unrelated to their visit, Weis said. In those cases, it is best to be empathetic and address their concerns when possible.
However, sometimes all you can do is answer their questions and leave the rest up to the patient, Gupta said.
“All you can do in those situations is to be confident in what you know,” Gupta said. “If a patient does not feel you are good enough, all you can do is your best. Be open and honest with the patient, and they are either going to take your advice or not.”
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For more information:
Theresa A. Bingemann, MD, FAAAAI, FACAAI, can be reached at theresa_bingemann@urmc.rochester.edu.
Meera R. Gupta, MD, FAAAAI, can be reached at meera.gupta@bcm.edu.
Emily L. Weis, MD, MS, can be reached at emily_weis@urmc.rochester.edu.