How do you deal with difficult patients?? [moved from LTI]

LegacyUser

How do the rest of ye deal with difficult patients?
They come in and expext you to hand them over an RX for an antibiotic or for something completely unnecessary such as sleepers and the patient gives out hell for you not giving them what they want.
I'm not being arrogant here but we're the one's thats gone through years of med school, and have learned proper diagostics for our patients..we are there to care and do our best for them don't you agree??

What about prescribing anti-depressants to a patient that won't seek or even let you sourse further help for them?

All hypothetically speaking of course!!

tatli_lokma

howtodeal wrote: »

How do the rest of ye deal with difficult patients?
They come in and expext you to hand them over an RX for an antibiotic or for something completely unnecessary such as sleepers and the patient gives out hell for you not giving them what they want.
I'm not being arrogant here but we're the one's thats gone through years of med school, and have learned proper diagostics for our patients..we are there to care and do our best for them don't you agree??

What about prescribing anti-depressants to a patient that won't seek or even let you sourse further help for them?

All hypothetically speaking of course!!

for someone who spent so many years in education your turn of phrase and grammar are not so hot! :rolleyes:

me thinks, perhaps a troll?

or maybe you just chose the wrong audience??

as a former 'difficult' patient, who had to demand medication for something which was later proved, and having had many docs tell me I was 'fine' to 'get over it', 'have some anti-d's becuase you're clearly depressed', I have little sympathy for your complaint!
(what's it feel like to be on the receiving end?? :P)

GER12

howtodeal wrote: »

How do the rest of ye deal with difficult patients?
They come in and expext you to hand them over an RX for an antibiotic or for something completely unnecessary such as sleepers and the patient gives out hell for you not giving them what they want.
I'm not being arrogant here but we're the one's thats gone through years of med school, and have learned proper diagostics for our patients..we are there to care and do our best for them don't you agree??

What about prescribing anti-depressants to a patient that won't seek or even let you sourse further help for them?

All hypothetically speaking of course!!

#

Maybe, it should all come down to self-evaluating basic communication - how do you communicate - is it open - do you listen? Patients today have greater rights around autonomy and self-determination....they want full info on all meds, side affects etc.... and in seeing both sides I would be of the persuasion like you if your patient doesnt require antidepressants of sedatives/sleeping tablets tell them and explain you dont feel its the most appropriate course of treatment that there are other avenues available and explain them (which obviously you did). If you feel they are addicted - ask them whether they are experiencing the symptoms and then explain that taking those meds is creating a form of addition that will have to be dealt with - and not to mention the affects of meds on the body. If you offer further avenues of treatment and they still refuse - well that's their choice - once they are in the presence of their full faculties and more importantly are not any danger to themselves, other's or society from not taking the drug - then the mental health act could kick in.

Where I trained they were called non-compliant patients - some chose to exercise autonomy and doc's should respect those informed choices - and remember medicine cannot always cure.

tallaght01

It's a difficult one.

It can all get very messy. I'm an antibiotic nazi. I just won't give them for the vast majority of cases.

But people get mad as hell about that, no matter how nice you are. I always try and pair it up with some info about viral illnesses etc. Some people are fine, but others literally storm out.

Same when you're on the ward and every time you walk past the junkies they're shouting at you for painkillers etc.

I find it tough to handle, especially when it happens repeatedly and sequentially. But I don't have it as bad as the GPs have it. I have a mate who's a GP, and he told me he just gives antibiotics out like smarties now, because he can't face the daily fight. Apparently, during the winter, he'd be seeing 4 people an hour with viral URTIs who've all come saying things like "It's gone to my chest/I'm bringing up green stuff/It's not getting any better" as justification for wanting antibiotics.

I genuinely don't think I would still be an antibiotic nazi if I was a GP.

DrIndy

I think a balance of tough love, honesty and respect works well most of the time.

Patients have genuine fears, they have cyberchondria and they are determined to get something out of a €100 ED charge and a 6 hour wait.

When you sense a discussion starting to not go smoothly, I often will often bluntly ask what is going on and why are you worried.

An example is a young man, perfectly healthy with one tiny raised lymph node who googled this and found he had a nasty lymphoma. He gave the game away by saying he though this tiny thing got more sore when he drank alcohol and I openly and immediately asked him if he had been googling. Upon admitting this I took 5 more minutes to explain the problem with self diagnosis-via-internet and then explained concisely why this was extremely unlikely cancer and gave him the option of going to his GP with a letter from me if it did not resolve.

We were both happy. Other times I confront aggressive and demanding patients similarily by reiterating they have never met me before and why should they take an aggressive tone with me right from the start. This causes a pause and the chance of a second start where you can deal with people fairly and openly.

Some people are completely unreasonable and clearly seeking drugs - they get frogmarched out and I make very detailed notes as to why they were removed. They are by far and away a minority and most people are just afraid.

I do confess to giving out antibiotics probably more than I should but from an ED perspective - it is hard at times not to in ireland as we will not see them again unless they return very unwell and should they not improve, will need to shell out extra bucks to see a GP and I don't like adding to this financial burden.

ZYX

tallaght01 wrote: »

I find it tough to handle, especially when it happens repeatedly and sequentially. But I don't have it as bad as the GPs have it. I have a mate who's a GP, and he told me he just gives antibiotics out like smarties now, because he can't face the daily fight. Apparently, during the winter, he'd be seeing 4 people an hour with viral URTIs who've all come saying things like "It's gone to my chest/I'm bringing up green stuff/It's not getting any better" as justification for wanting antibiotics.

I genuinely don't think I would still be an antibiotic nazi if I was a GP.

To be honest it is no different as a GP really. The big thing is to stick to your principles. If you feel person will not benefit from an antibiotic do not give it. Offer explainations, offer to see person again the next day (for Free) if necessary etc but never give the antibiotic. Also never, never, never give parents a prescription for an antibiotic to be used "if child gets worse" unless patient has a chronic condition that requires regular antibiotics. This is simply a cop out. If you cannot make the decision about the antibiotic after at least 10 years college and post grad experience how can you expect parent to decide.

Some patients will think you are a rubbish doctor and never see you again. So what, get over it. You are not going to please everyone. Most patients will come around and see that they do get better without antibiotics.

Finally, if you are wrong and patient comes back and now may actually benefit from an antibiotic, make sure you apologise but don't let this cloud your judgement in the future.

metrovelvet

I do think the public are antibiotic crazy though and do expect to come out with something that will make them feel better even if it does have a placebo effect.

<General non-related rant about GPs edited out. It's nothing to do with this thread, and it's just going to rile the good bunch of GPs who use this forum>

tallaght01

I think it's different as a GP from the perspective of the amount of times it happens. It's something those of us who are hospital docs don't confront as much as you guys) possibly with the exception of the A+E guys.

There's no difference in the principal, but I think the sheer repetition would break me.

Even family members have complained to me that they've gone to see the GP "I paid him 50euro and he didn't even give me an antibiotic". Our family GP in dublin gives them out to everyone.

LOL at the oul "just in case prescription". That's my pet hate :P

bleh1234

Drives me demented I'm a complete a/b Nazi, really annoys me though when the intern on call is asked to review bloods & treat elevated WBC's please read the notes we know the WBC's are elevated, have looked for a source of inf haven't found one, the patient is well treat them not their bloods in isolation.

That and generic prescribing though that prob comes from knowing as an intern if I didn't write my kardex's generically they'd be returned for rewriting by my consultant.

locum-motion

tallaght01 wrote: »

LOL at the oul "just in case prescription". That's my pet hate :P

The JIC A/B Rx annoys the hell outta me too.

As a pharmacist, though, what makes it even more annoying is when you do up the child's antibiotic and then the parent tells you afterwards that they wanted it "dry".

I just wish I could say "Well, thanks a fcuking bunch, ya pr1ck, now who TF is gonna pay me for the bottle of perfectly good medicine that I'm now gonna have to throw away, and which you didn't fcuking need in the first place anyway?"

Sometimes I just despair!

tallaght01

I'm pretty sure a lot of people don't know you guys make up some of the Abx.

I reckon a lot just think you pluck them off a shelf.

locum-motion

tallaght01 wrote: »

I'm pretty sure a lot of people don't know you guys make up some of the Abx.

I reckon a lot just think you pluck them off a shelf.

Oh, yeah, absolutely. That's part of the reason why we can't say what we'd like to!

MrCreosote

ZYX wrote: »

Also never, never, never give parents a prescription for an antibiotic to be used "if child gets worse" unless patient has a chronic condition that requires regular antibiotics. This is simply a cop out.

To be fair, using the old Back Pocket/Just in Case prescription is recommended for a few things like otitis media and conjunctivitis. Reduces antibiotic use, representations and improves patient satisfaction apparently. I'd never use it for cough, undifferentiated fever though which is done.

I find it way easier to steer people away from antibiotics if it's a kid that's sick. Adults know what they want already- you're not going to change most people's expectations in one ten minute consultation. And anyway are you SURE you didn't hear some creps at the left base without a CXR and bloods?!

ZYX

MrCreosote wrote: »

To be fair, using the old Back Pocket/Just in Case prescription is recommended for a few things like otitis media and conjunctivitis. Reduces antibiotic use, representations and improves patient satisfaction apparently. I'd never use it for cough, undifferentiated fever though which is done.

Don't get me started on conjunctivitis. Hugely overdaignosed and over treated.

MrCreosote wrote: »

I find it way easier to steer people away from antibiotics if it's a kid that's sick. Adults know what they want already- you're not going to change most people's expectations in one ten minute consultation.

It is not about changing their expectations in 10 min consultation. They may have expected an antibiotic. That does not mean you should mistreat them by giving one. By giving the antibiotic you reinforce their expectations. They leave surgery thinking "it was a good job I went to doctor, he/she said I needed an antibiotic. Next time I feel this way I will go to GP again". Next time they will be certain they need an antibiotic as they feel exactly the same way they did the last time when doctor felt they needed an antibiotic. And you have created a vicious cycle.

It is the same with benzos. Doctor has a huge argument with patient about benzos then eventually gives in and writes prescription. Patient now knows they have to have a huge row every time they want benzos. Then doctor complains about all his difficult patients.

MrCreosote wrote: »

And anyway are you SURE you didn't hear some creps at the left base without a CXR and bloods?!

Well as bleh1234 was saying, treat the entire patient, and if you need extra diagnostic tests then do them. Of course you will be wrong sometimes. You will give antibiotics where in hindsight they were not needed. The point is, only give when you feel they are needed.

MrCreosote

ZYX wrote: »

It is not about changing their expectations in 10 min consultation. They may have expected an antibiotic. That does not mean you should mistreat them by giving one. By giving the antibiotic you reinforce their expectations. They leave surgery thinking "it was a good job I went to doctor, he/she said I needed an antibiotic. Next time I feel this way I will go to GP again". Next time they will be certain they need an antibiotic as they feel exactly the same way they did the last time when doctor felt they needed an antibiotic. And you have created a vicious cycle.

Fair enough point. And I'd agree that antibiotics are hugely overprescribed. But it's not like you're the first or only doctor a patient will have seen. They'll come with years of getting antibiotics for colds and so on. Refuse (and I mostly do!) and they'll just move on to another doctor who will give them what they want. Far better to try and keep them on board and slowly change their way of thinking.

An in GP-land things are rarely cut and dried pneumonia/cellulitis or whatever. Doing investigations on every person who walks in the door isn't realistic either...

kelle

I only visit my GP when necessary. My youngest child was sick 2 years ago. I made 4 visits in total and this totalled €200! She was getting worse and worse, and the doctors (a different locum each time) wouldn't prescribe an antibiotic, even though I promised I wouldn't give it unless she got really bad. She eventually got one on the 4th visit, and only then did she start to get better. BTW, that was her first antibiotic! I was on unpaid leave from work and I could not afford this kind of money.

metrovelvet

tallaght01 wrote: »

I think it's different as a GP from the perspective of the amount of times it happens. It's something those of us who are hospital docs don't confront as much as you guys) possibly with the exception of the A+E guys.

There's no difference in the principal, but I think the sheer repetition would break me.

Members have complained to me that they've gone to see the GP "I paid him 50euro and he didn't even give me an antibiotic". Our family GP in dublin gives them out to everyone.

LOL at the oul "just in case prescription". That's my pet hate :P

Why? antibiotics are often given as the just in case. I had an iv of cipro before any diagnosis was made.

tallaght01

ZYX wrote: »

Don't get me started on conjunctivitis. Hugely overdaignosed and over treated.



It is not about changing their expectations in 10 min consultation. They may have expected an antibiotic. That does not mean you should mistreat them by giving one. By giving the antibiotic you reinforce their expectations. They leave surgery thinking "it was a good job I went to doctor, he/she said I needed an antibiotic. Next time I feel this way I will go to GP again". Next time they will be certain they need an antibiotic as they feel exactly the same way they did the last time when doctor felt they needed an antibiotic. And you have created a vicious cycle.

It is the same with benzos. Doctor has a huge argument with patient about benzos then eventually gives in and writes prescription. Patient now knows they have to have a huge row every time they want benzos. Then doctor complains about all his difficult patients.



Well as bleh1234 was saying, treat the entire patient, and if you need extra diagnostic tests then do them. Of course you will be wrong sometimes. You will give antibiotics where in hindsight they were not needed. The point is, only give when you feel they are needed.

I agree. Most conjunctivitis is viral, even if it's hanging around for a while. Same with otitis media. Duration of symptoms doesn't correlate with aetiology, as far as I know.

I would imagine the just-in-case scripts reduce re-presentation because people come back for an antibiotic. It's because of this assumption that people need an antibiotic "because I've had this for over a week now".

Certainly within the paeds population, the incidence rate of true bacterial infection is not very high. Even if you hear creps, it doesn't mean there's a bacterial aetiology, either.

It's a tough one. I'd be a weakling as a GP. But one thing I definitely wouldn't do is the just-in-case script. I'm interested that it may reduce antibiotic use...I'd be interested in the actual evidence, and what is eing compared etc etc.

I know it's not a very PC thing to say either, but sometimes you just have to accept that patient satisfaction is a not a good proxy indicator of quality of care. There are all sorts of interventions where there's evidence of patient satisfaction being improved without evidence of there being clinical benefit. But, again, that kid of thinking is a luxury I have as a hospital doc, where I'm not depending on bums on seats to keep my business going.So, I would e very sympathetic to the GP position.

MrCreosote

tallaght01 wrote: »

It's a tough one. I'd be a weakling as a GP. But one thing I definitely wouldn't do is the just-in-case script. I'm interested that it may reduce antibiotic use...I'd be interested in the actual evidence, and what is eing compared etc etc.

Here's a BMJ trial from 2006 about conjunctivitis in GP setting:

http://www.bmj.com/cgi/content/full/333/7563/321?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&title=conjunctivitis&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=date&fdate=1/1/2006&tdate=12/31/2007&resourcetype=HWCIT

tallaght01

MrCreosote wrote: »

Here's a BMJ trial from 2006 about conjunctivitis in GP setting:

http://www.bmj.com/cgi/content/full/333/7563/321?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&title=conjunctivitis&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=date&fdate=1/1/2006&tdate=12/31/2007&resourcetype=HWCIT

That's a nice little study. It shows a reduction of symptoms by about a day and a half if antibiotics are used.
I'd be much more convinced if there was a placebo group, because there severity was measured by patient reports. So, how did all those viral conjunctivitis people get syndromic improvement? I'm suspicious that the result wouldn't be as impressive with a placebo.

The other thing that makes me suspicious, is that you would expect, in a genuine effect, that there would be significant changes within 3 days. Yet the severity score measured at 1-3 days after the consult was no different between the groups.

Also, if antibiotics did work, there should be some kind of a dose response. If they did work, then the immediate antibiotic group should have had the best outcomes.

The bit about perception is interesting, as it shows patients who are given antibiotics have a much higher belief that antibiotics are essential for the treatment of conjunctivitis than those who weren't given them.

I think it's an interesting paper, but for me it's not enough evidence to go with the just-in-case Abx, though.

But I'm no expert paper-reader, so I'd be interested in what others thought.

sam34

kelle wrote: »

I only visit my GP when necessary. My youngest child was sick 2 years ago. I made 4 visits in total and this totalled €200! She was getting worse and worse, and the doctors (a different locum each time) wouldn't prescribe an antibiotic, even though I promised I wouldn't give it unless she got really bad. She eventually got one on the 4th visit, and only then did she start to get better. BTW, that was her first antibiotic! I was on unpaid leave from work and I could not afford this kind of money.

maybe by the fourth visit she was naturally about to turn the corner anyway, and would have improved without the antibiotic?

kelle

sam34 wrote: »

maybe by the fourth visit she was naturally about to turn the corner anyway, and would have improved without the antibiotic?

Don't know - she had developed an ear infection by that stage. But I would not visit a GP willy-nilly, I hate my kids being on antibiotics - yet I knew she needed one. It was a pity I had to part with such a huge amount of money to get that far though, €200 is a lot.

sam34

kelle wrote: »

Don't know - she had developed an ear infection by that stage. But I would not visit a GP willy-nilly, I hate my kids being on antibiotics - yet I knew she needed one. It was a pity I had to part with such a huge amount of money to get that far though, €200 is a lot.

it sure is, and im not underestimating that or dismissing it.

my point is that we dont know and can never know whether or not she would have improved anyway without the antibiotics, which would have happened if the infection was viral.

i dont mean to personalise this to you, or seem like im getting at you.

this is a major reason people have a lot of faith in antibiotics - they have a cold or sore throat for a few days, decide after 2 or 3 days that they cant shake it off themselves, so go to the doc and get antibiotics.. hey presto, by day 5 or so they are improving. now, the likelihood is that the infection was viral in origin and that the improvement was the natural course of teh illness, but people will automatically credit it to the antibiotics. then the next time they have an infection, they want another antibiotic because they firmly believe thats what got them better the last time.

its a vicious circle and hard to break.

Squiggle

sam34 wrote: »

it sure is, and im not underestimating that or dismissing it.

my point is that we dont know and can never know whether or not she would have improved anyway without the antibiotics, which would have happened if the infection was viral.

i dont mean to personalise this to you, or seem like im getting at you.

this is a major reason people have a lot of faith in antibiotics - they have a cold or sore throat for a few days, decide after 2 or 3 days that they cant shake it off themselves, so go to the doc and get antibiotics.. hey presto, by day 5 or so they are improving. now, the likelihood is that the infection was viral in origin and that the improvement was the natural course of teh illness, but people will automatically credit it to the antibiotics. then the next time they have an infection, they want another antibiotic because they firmly believe thats what got them better the last time.

Wow I wouldn't dream of telling my GP what medication I needed and up to recently my GP was my father ! In fact if he did prescribe antibiotics I would ask was there an alternative. Can't believe people seem to be so blasé about taking antibiotics tbh - it would be a last resort for me.

sam34

Squiggle wrote: »

Wow I wouldn't dream of telling my GP what medication I needed and up to recently my GP was my father ! In fact if he did prescribe antibiotics I would ask was there an alternative. Can't believe people seem to be so blasé about taking antibiotics tbh - it would be a last resort for me.

people demand all sorts form docs.

i'm a psychiatrist, and i get people demanding specific benzos or anti-depressants because thats what worked for their relative/neighbour/friend. they dont seem to get that their relative/neighbour/friend may have had a different diagnosis to them, or that they may not be able to take specific meds because of side-effect profile etc.

it can be quite the battle!

angeldelight

locum-motion wrote: »

As a pharmacist, though, what makes it even more annoying is when you do up the child's antibiotic and then the parent tells you afterwards that they wanted it "dry".

I just wish I could say "Well, thanks a fcuking bunch, ya pr1ck, now who TF is gonna pay me for the bottle of perfectly good medicine that I'm now gonna have to throw away, and which you didn't fcuking need in the first place anyway?"

Sometimes I just despair!

Oh God that is so true - I particularly hated it as I was the pre-reg so I felt like everyone thought I was a gob****e and just hadn't listened when taking in the script.

Or when they say they need itdry because they're going away and "just in case" then you ask in general chit chat when they're paying where they're going and it's Wexford or something :rolleyes:

BumblebeeGirl

Can i ask why taking anti-biotics is bad for a patient? No offence intended- just curious

DrIndy

all drugs have side effects and you can have those.

In addition - over-exposure to antibiotics simply breeds resistance to this antibiotic in the bacterial population - so when you genuinely need it - then it doesn't work and you need a potentially powerful and toxic one. MRSA is a classical example of this problem.

Also - why pay for an antibiotic you don't even need?

Squiggle

DrIndy wrote: »

all drugs have side effects and you can have those.

In addition - over-exposure to antibiotics simply breeds resistance to this antibiotic in the bacterial population - so when you genuinely need it - then it doesn't work and you need a potentially powerful and toxic one.

Precisely why I avoid them if at all possible.

Also - why pay for an antibiotic you don't even need?

Lots of people aren't - maybe that's part of the problem !