The Difficult Patient

Defusing challenging patient encounters requires the right balance of sensitivity and assertion.

The Difficult Patient, ACR Bulletin

It was late at night when a mother took her child to Boston Children’s Hospital (BCH) with severe abdominal pain and abnormal stool. An ultrasound revealed that the child was suffering from an ileo-colonic intussusception and needed an emergency air enema.

With no time to waste, Stephen D. Brown, MD, pediatric and obstetric radiologist at BCH and assistant professor of radiology at Harvard Medical School, described the procedure to the patient’s mother, detailed the risks, benefits, and alternatives, and obtained her consent to proceed immediately. The mother contacted the child’s father to alert him of the situation, but it was unclear when he might arrive at the hospital. In the meantime, Brown and his team prepped the child and prepared to begin the procedure before the intussusception caused extensive damage. That’s when the child’s father, visibly intoxicated and angry, entered the room and demanded that the procedure stop. “Automatically, as soon as that father walked into the room, we had a very difficult situation,” Brown says.

While the situation that Brown and his team faced might be uncommon, difficult patient encounters are not. Radiology practices see all types of patients, and myriad factors can make those interactions challenging. Radiologists must know how to resolve those situations, particularly as they begin to interact more directly with patients — a hallmark of the ACR’s Imaging 3.0™ initiative. “Lately, we all have been talking about communicating more with patients, and difficult patients are a subset of that,” says C. Douglas Phillips, MD, FACR, professor of radiology and attending physician at New York-Presbyterian Hospital. “But how do you do that? It’s not something we have traditionally done.”

The Challenging Encounter

The phrase “difficult patient” puts the onus on the patient, but most encounters in which the patient becomes angry about the level of service provided are actually the result of a system breakdown. Perhaps a scheduling error occurred or the patient didn’t know the copay would be so high or the procedure took longer than the patient expected or the procedure took less time than the patient expected or the scanner wasn’t available at the scheduled time. “Anything that goes wrong from registration to the performance of the exam to the patient leaving the suite can result in a difficult patient,” Phillips says.

The root cause in most difficult patient encounters is communication failure. For example, Linda R. Poznauskis, director of radiologic technology at BCH, says she recently encountered a family that complained to the hospital’s patient relations group that the radiology department had performed the wrong exam and, as a result, overexposed their child to radiation. Once Poznauskis learned about the complaint, she called the family and conferenced in the referring physician to talk through the concerns. It turned out that the radiology department had performed the exam as ordered, but the referring physician hadn’t communicated the details of the exam to the family prior to imaging, Poznauskis says. “The family was grateful that they found someone to help them resolve the situation,” she says. “We really do everything we can to prevent families from leaving here angry. Because if they do, that means they don’t trust us, which impacts their whole health care visit and possibly even their trust in their referring physician.”

“Anything that goes wrong from registration to the performance of the exam to the patient leaving the suite can result in a difficult patient.”
—C. Douglas Phillips, MD, FACR 

Other difficult patient encounters are caused by things outside of the radiology practice’s control. The intoxicated father who Brown encountered is one example, but most situations are less dramatic. Maybe the patient got stuck in traffic on the way to the office or the patient has other responsibilities that are causing stress. Or perhaps the patient has psychological or language challenges that require additional resources. Poznauskis says it’s important to recognize that patients often have a lot of external pressures that may cause tension. “We should make the assumption that all families are under stress and attempt to deescalate by listening and acknowledging their situations, without passing judgment,” she says.

The Radiologist’s Role

Each difficult patient encounter requires a different approach for resolving the issue. Many practices encourage the person who is directly involved at the point of the encounter to do their best to resolve the issue. But if that person needs help, he or she is typically instructed to go up the chain of command or bring in the person who can best attend to the issue. “Sometimes the situation can be addressed by simply having another staff member come and validate what the first staff member has said,” Poznauskis says.

If the patient asks to speak with the radiologist or if a staff member thinks the radiologist can help address the patient’s questions, the radiologist should speak with the patient, Phillips says. “For me, the minute someone says that they want to speak to the doctor, I’ll make myself available,” he notes. “I may not even be the right person to address the issue, but if they want to talk to me, I feel as though I ought to be there.” Radiologists who are uncomfortable talking with patients who are angry should ask a member of the practice’s leadership for help. “Radiologists need to know their strengths and limitations,” Brown says. “If the radiologist feels like he or she is not a reasonably good communicator in these situations, then it may be better to find someone else in the practice to step in so as not to inadvertently escalate the situation.”

In some cases, radiologists may speak with a patient without being asked. For instance, if the patient is disrespectful to the technologists or other staff members, the radiologist might need to defuse the situation. “The technologists and nurses sometimes get bullied and disrespected by patients,” Brown says. “There have been a couple of times when I have personally chastised patients or parents and said, ‘You cannot talk to these technologists this way; these are hardworking professionals.’ You have to stand up for the people who are on the front lines.” If the patient goes beyond being rude to putting others at physical or psychological risk, radiologists or practice leaders may need to call security. “I would not hesitate to get help removing patients if I thought they were putting others at risk,” Phillips says. “But that is a really, really rare phenomenon.”

The Extra Mile

The case of the intoxicated father at BCH could have easily escalated into a situation that required security, but Brown eventually calmed the father down and proceeded with the air enema. “I never asked him if he had been drinking because that would have inflamed the situation,” Brown explains. “You just have to take a step back and calmly listen. Let them get their anger out and then discuss what is happening and why time is of the essence. If that doesn’t work, and you feel that the situation is becoming threatening, that’s when you take stronger action, but not before you try to defuse the situation.”

Resolving difficult patient encounters can take a considerable amount of time. Brown says it took him and his team roughly 25 minutes to get the father to agree to proceed with the procedure. Currently, no billing code exists for radiologists to be reimbursed for the time they spend interacting with patients, but they can’t let that deter them. “In any kind of customer-service organization, you’re going to have to interact with people. It’s not always going to generate income, but it lets your customers know that the people at the practice care about them,” Phillips says.

Even as radiology practices do their best to deliver high-quality service and care, difficult patient encounters will continue to happen every day. It’s how physicians handle those situations that counts. “You’re not always going to give people the answer they want. But you must do the best you can to leave patients with the idea that at least you explained the situation and cared about their concerns,” Phillips says. “We’re in a customer-service environment. You have to take care of your customers — and in our case, our customers are patients.”

By Jenny Jones, freelance writer for the ACR Bulletin


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