We need to talk – managing tough discussions with patients

We need to talk – managing tough discussions with patients

For many, difficult interactions with patients remain an unattractive occupational hazard and one which can challenge even the most experienced of practitioners. In this article, Dr George Wright, deputy dental director at Dental Protection, explores some of the factors that contribute to a difficult interaction and some basic strategies for handling such situations.

Dental Protection regularly receives calls from members seeking advice on preparing for an expected difficult interaction or dealing with the fallout from one.

It will come as no surprise that the way in which a difficult interaction is handled can prove pivotal in how the patient responds. A well-managed interaction, even from a place of at times significant disagreement or conflict, can strengthen the professional relationship.

However, without careful navigation, a difficult interaction can easily escalate and precipitate a patient complaint whilst also increasing the risk to the dental professional of aggression or violence from the patient.

In doing so, it is important to recognise that with all the will in the world, some dentist-patient relationships may break down irrevocably and will require careful management to ensure a transition of care that is in the patient’s best interests.

What makes an interaction ‘difficult’?

The literature and our own experiences tell us that generally, the source of any difficulty lies in one or more of four interrelating domains – the patient, the dental professional, the patient’s condition and the systems in which we work.

On any normal day, we may be able to take difficulties arising in one or even two of these domains within our stride. But the more domains that come into play, the more difficult it is to manage the interaction effectively – partly because we may have fewer positive factors to draw on to provide a counterbalance.

Consider, for example, the ‘perfect storm’ of having a high-treatment need patient, presenting with dental anxiety twenty minutes late, for a thirty minute new patient examination on a day when you are short-staffed, the computers are malfunctioning and you didn’t sleep well the previous night as your young child was unwell.

Taken in isolation, many of us would be able to work unaffected by any one of these factors however the cumulative effect of these when they all come in to play can create an entirely different context for the patient’s appointment.

1. Patient factors

Patient factors can include unrealistic expectations, differing interpretations of the same situation, extreme emotion (for example, dental phobia) or the patient’s inflexibility in relation to alternative treatment options.

I recall from my own clinical practice a patient presenting with a number of missing anterior teeth and severe periodontal disease wishing to have their teeth replaced with a 7 unit bridge.

Careful discussion with the patient yielded nothing in terms of their acceptance of the situation or what in my view were the available options (none of which were a lengthy bridge supported by two grade 3 mobile premolars).

2. Condition

A patient’s clinical presentation and condition can also add a layer of unwelcome complexity which might leave us feeling uncomfortable. Anecdotally at least, dentists report difficulty interacting with patients for whom they feel the patient’s pain is non-dental in origin or, for example, those patients with complex medical histories taking multiple medications.

3. System factors

System factors play a significant role in modern healthcare and are a source of frustration to many. Unfortunately, many of these factors sit outside of our immediate sphere of influence and it is important to focus on those factors which can be controlled.

Research has shown in medicine that doctors are often less empathic with patients when there are system factors causing difficulties rather than other factors (Weingarten et al 2009). In fact, studies on human factors in other industries such as aviation have also reached similar conclusions.

For those working within NHS practice, there are additional systems and process considerations that can further challenge even the most resilient practitioner.

Members contacting Dental Protection for advice following a difficult interaction with a patient will often refer to systems and process factors as contributing to why an interaction evolved as it did. These might include factors such as time pressures, interruptions, availability of resources and equipment issues.

4. Dental professional

It is interesting to note that, although all dentists recognise difficult patients, individual dentists are likely to vary as to which patients they would identify as such, or the degree to which they would rate them as difficult. So identifying and rating the difficulty is not objective, and as dentists, we ourselves form part of the equation.

An interesting study conducted in Australia identified that, when asked, dentists believe that they are practising good patient-centred consultations ‘all the time’. Any failure or difficulty in the consultation ‘is thus seen as an external or an ‘other’-related problem rather than it being directly dentist related’ (Asimakopoulou K, 2014).

Dentists had no difficulty in identifying barriers to patient-centred care that arise due to systems or processes. What was less obvious to them were the behavioural factors in themselves, the patients and/or the dental team that could also give rise to difficult interactions.

It is easier to influence the behavioural factors than it is to influence systems and processes, so it is worth focussing on the factors under our control that can be improved to reduce the risk of a complaint or claim.

Sometimes it can be just a personality clash, but often it’s that something in the situation triggers our ‘hot buttons’, which may activate our prejudices, stereotypes and assumptions.

Handling situations

We may also have been profoundly affected in a negative way by our interactions with patients who have presented or behaved in a similar way to the patient before us and this may significantly influence our attitude and ability to handle the interaction.

Examples include the patient who is always cancelling appointments, the patient who does not pay on time or the patient who only uses you in an emergency.

Our degree of training in handling difficult interactions is also a major factor. It is interesting that people in service industries receive a lot of training around handling difficult situations.

Do we, as healthcare professionals, receive the same level of training? Our own resilience can be affected by our own emotional baggage and a patient that might not otherwise have created a problem becomes ‘a difficult’ patient.

This might also explain why difficult patients to one person might be easy-to-manage patients to another. All of this is harder when we are hungry, angry, late, tired, energy depleted, distracted.

Choosing your response

Dental research has shown us that the impact of difficult interactions contributes to stress and this creates long-term physiological and psychological phenomena if not managed correctly (Bodner, 2008). Difficult interactions tend to create a feeling of discomfort.

The original work of Corah and O’Shea on dentists’ perception of problem behaviours in patients listed a number of behaviours that can be very annoying for dentists.

These included patients devaluing, criticising or questioning a dentist’s performance. Because such behaviours are likely to result in feelings of personal assault on the dentist’s part, they are likely to have a deleterious effect on the patient/dentist relationship.

An interesting study by Thierer, Handleman and Black in 2001 assessed the relationship between dentist communication behaviour and their perception of patient attributes such as likeability/manageability and prognosis.

The result suggested that dentists alter their communication behaviour depending on their assessment of various patient qualities.

There are already branches of communication that look specifically at these situations, for example neurolinguistic programming, which recognises that people have different filters through, which they see the same situation which predetermines their reaction.

Is your reaction different when you like or dislike a patient or with someone who fails to attend an appointment? It is an innate human trait that if you don’t like someone, you will often show it!

Effective skills and strategies

One of the most effective strategies in managing a difficult interaction is to recognise our own reaction. Our automatic reaction may be telling us things like ‘this person is a nuisance’ or ‘this person is uninterested in their oral health’.

Such reactions may interfere with our self-control and self-confidence and our ability to demonstrate support skills like asking open ended questions, reflecting content back to the patient, empathy and reframing.

It is possible to be empathetic with a patient even if you disagree with what the patient is saying or find it difficult to be sympathetic to their plight. The beauty of empathy is that it can be applied to situations even where you are uncomfortable. Conveying empathy is a powerful way to increase the feelings of support of patient experiences.

Reframing is a technique used in psychology where a therapist might ask a patient to consider a different explanation for their concern knowing that doing so may well reduce their distress. To consider alternative explanations for a patient’s behaviour or attitude might allow us to approach that patient in a more objective or neutral manner.

Way forward

An example of this is the patient who is quite hostile at your inability to find the source of pain and for you to label the patient simply as a difficult and impatient person. The reality is that by reframing, that patient may be dealing with an anxiety whereby they consider they had a more serious disease but have not been able to articulate this to you.

However, when faced with a patient with whom you anticipate a difficult interaction, the above ‘theory’ can very quickly be forgotten and we can default into ‘defence’ or ‘attack’ mode. A simple step to take towards deescalating conflict is to first acknowledge how the patient is feeling.

By doing so, you are able to demonstrate to the patient that you have actively listened to their concerns and it allows you to check understanding. From here, it may be helpful to inform the patient of your position, clearly stating the reasons and respectfully explaining any boundaries.

Finally, if done effectively, you will be able to move with the patient to discussing a way forward. At this point, it can prove invaluable to empower the patient to propose possible options, albeit with some gentle encouragement.

By taking this approach, patients are more likely to feel they are in control of the situation and are more accepting of the resolution they have jointly reached.

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