By Sharon McGee, MD, PhD

It doesn’t always happen, but today you’re on top of things, and decide to review tomorrow’s clinic in advance. Some familiar names jump from the screen—the ones with whom the encounter always seems to leave you delayed or deflated. A pit rapidly develops in your stomach in anticipation of a difficult day. You berate yourself for looking as you’ve just ruined your night, and vow that going forward it’s best to just not know. Forewarned is not always forearmed.

What Contributes to a Challenging Clinical Encounter?

Although prominent in our minds, challenging clinical encounters are overall an infrequent occurrence, with surveys of health care workers typically estimating the frequency of difficult encounters at 15% to 20%.^1-3 Certain subspecialties, however, face them more often, including our colleagues in frontline services such as emergency and family medicine, where they serve as the gatekeepers to our hospitals. Oncologists are equally at risk given the emotionally charged nature of our speciality. Some physicians may also be more likely to have difficult encounters, particularly those working in overtaxed or underserved environments. The same is true for physicians at the start of their career as they learn to practice the art of medicine.

What constitutes a difficult clinical encounter? One approach to understanding these situations better is to think of the contributing factors as they relate to the disease, the patient, the system, and the doctor.⁴

The Disease

There are many factors related to the specific disease or cancer that can make a case challenging. As we go on in our clinical practice, we realise that more and more our patients typically fall just outside the selection criteria of a study or are not directly addressed in the clinical guidelines. Furthermore, the ever-increasing list of comorbidities and the extremes of age at which patients now present create further challenges. However, I think most physicians would acknowledge that the clinical component is typically the least difficult piece of the puzzle.

The Patient

Dr. William Osler was certainly correct when he said, “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” Socioeconomic factors frequently complicate care, including access to treatments and availability of supportive services. Co-existing mental health conditions, including depression and anxiety, can also be challenging. Patient behaviours can further complicate care, with patients exhibiting angry, demanding, intransigent, or dependent behaviours frequently acknowledged as being difficult to manage.⁵ Unrealistic patient expectations can also play an important role, despite our best efforts to temper them. These challenging behaviours and expectations do not always stem from the patient, but rather their families, which can be even more difficult as we may not have had the opportunity to develop a good rapport with them.

The System and Surroundings

A cramped clinic space with short appointment times and a temperamental computer system can also add to the difficulty of clinical encounters, but is unfortunately a common reality as our medical systems struggle to meet increasing demands with limited resources and finances. The increasing role and presence of technology in the patient-physician relationship can also be challenging, particularly when it becomes wedged inappropriately in the middle, making it hard to truly connect with our patients. Finally, the hospital environment can also be very distressing for some patients, for personal, cultural, or religious reasons, and may lie at the root of some of the maladaptive behaviours we encounter.

The Doctor

As doctors we don’t always make things easy for ourselves and can cause, or contribute to, a lot of the difficulties we encounter. Disregard of self-care can be a common theme amongst physicians and can take many guises; forgoing lunch to “catch up” frequently contributes to the difficulty of an afternoon clinic by adding hypoglycemia and exhaustion to the mix. Our perception and approach to challenging clinical encounters can also be unhelpful, particularly when that approach is one of dread and avoidance. In our defense, physicians often have little training on how to manage these situations more effectively, due in part to a tendency for trainees to be kept away from challenging patients or situations to avoid further problems.⁶ Sometimes it’s more complex, though, and even feels personal: certain patients can get under our skin and stop us from practicing that objective detachment we’ve been perfecting since medical school. It may be because we are of the same age or phase in life, but for whatever reason we empathize rather than sympathize, which can lead to a very emotionally challenging encounter.

Finally, sometimes it’s not always the patient or case—an increasing frequency of difficult encounters may be an important sign of burnout that we should recognise in ourselves, and in our colleagues.

How Can We Better Manage Challenging Clinical Encounters?

Whatever the factors contributing to a difficult encounter, it is important that we try to identify and tackle them, not only because they can lead to physician dissatisfaction and burnout, but most importantly because they can compromise patient care. Furthermore, they frequently lead to increased use of limited health care time and resources.

The Disease

Of all the factors contributing to a difficult clinical encounter, I think the greatest supports available relate to the disease itself, as at least here we have practice guidelines to reference and multidisciplinary tumour boards at which we can present the case and get input from our colleagues. Subspecialty fields such as geriatric oncology and cardio-oncology continue to grow and provide guidance on these challenging patient populations. Overall, we need to maintain our communication and collaboration with other specialities if we are to effectively manage our patients’ increasing comorbidities, or indeed the sequalae of our successes in extending life expectancy in the setting of advanced, metastatic disease.

The Patient

Critical to addressing patient factors is knowing the patient and this can take time. Try to identify other people or services that can help you better support your patient. These may include family members, nurses, social workers, the family doctor, or mental health services. When faced with maladaptive behaviours, try to understand the drivers behind them and see things from the patient’s perspective. At the same time, it is equally important that you set clear boundaries and expectations with the patient, whether this be around punctuality for appointments, use of inappropriate language, or clinical issues, such as prescribing drugs for indications outside your expertise or with no evidence base.⁴

The System and Surroundings

Challenging patients can certainly take more time and creating this additional time can be difficult. However, one strategy can be to move them to an appointment slot where you might have more time to spend with them, or energy to give them. If the patient is uneasy in the hospital setting then explore how you can improve this by having a family member, friend, or social worker attend appointments. If your electronic medical record requires you to complete documentation during the encounter, try to make sure to step or look away from it for part of the interaction, so you can really engage with the patient.

The Doctor

First things first: “Physician, heal thyself!” You need to look after yourself so that you can look after your patients. Remember the popular psychology acronym HALT, as things are always more difficult if you are hungry, angry, lonely or tired. However, sometimes things can be more serious, and we all need to be on the watch for burnout in ourselves and our colleagues.

Our communication skills can always be improved, particularly in difficult clinical encounters, including both our verbal and body language. One approach can be to acknowledge and verbalise the impasse and focus on finding a common ground with the patient, for example, “We are both concerned about this issue but have very different views on it. Do you agree?”⁴ It is important to recognise when to stop an encounter and return to the issue on a separate visit, or when to refer the patient to another physician if you feel the therapeutic relationship has been significantly impaired.

Finally, as physicians we need to be more open about these encounters and share our experiences with our colleagues, trainees, and students, so that we can all learn from one another.

Conclusion: Reframe Your Perceptions and Avoid Blame

Despite my claims at the start, I do believe that forewarned is forearmed. If you anticipate a challenging encounter, take steps in advance to prepare, and hopefully the reflections here are of use to you in this regard.

I hope this piece has challenged your perception of difficult clinical encounters by demonstrating that there is in fact much that can be learned from them.⁷ We have come a long way from Dr. James E. Groves’ first description of the “hateful patient” in a 1978 edition of the New England Journal of Medicine, where such individuals were characterised as belonging to one of four groups: clingers, demanders, help-rejecters, and self-destructive deniers.^8,9 However, there is still significant negativity in labelling patients as difficult, or challenging, which places the blame more on the patient and serves to justify our feelings of dread or avoidance.¹⁰ We need instead to see these encounters as opportunities to improve our clinical and communication skills, as well as our teamwork and support services, which will help to ensure that all our patients get the care they deserve.

Acknowledgments: Thanks to my patients, colleagues, and mentors.

References

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