Consult Skills 2: When Agendas Collide or “Physician Know Thyself”

This is part 2 of Consult Skills.  Check out part 1 here if you haven’t yet.  Part 1 was all about trying to be better at our day-to-day consults – and it was pretty ‘touchy feely’.  This post is not so nice, this is about dealing with the dark side of medicine.  Think of the most unpleasant consult you can remember – this post is all about that conversation!

On my first day as an intern I received this sagely advice from an elder of the ED:  “You will hate 10% of the patients, and 10% of them will not like you!  Oh, and they aren’t the same 10%….”  Now, a dozen or so years later I reckon 10% is a bit too high, but the principle is certain.  We are human and donning a white coat / scrubs and a stethoscope does not cure this.  Part 1 of this series looked at how to communicate with patients who we like and follow the same social rules that we do, however, there are some people who do not follow our ‘rules’.

You know the patients I am talking about – they are the ones you wish you could avoid, their chart seems to hang in the rack. For example: chronic pain, “lost my script”, angry for no good reason, “google doctor says I need a CT…” , non-compliant but still complaining, drunk again….. basically any consult where your goal is not close to where the patient is trying to get.  Agendas collide!

We all have our least favourites.  It is different for each doctor, some days they don’t get under your skin, some days they do.  So why is this?  Instead of looking at what makes these patients infuriating – I am going to look at us – doctors, nurses etc.  In order to do difficult interpersonal dynamics well – you must understand your own make up – your idiosyncracies, weaknesses and character.  Hence the title: Physician Know Thyself [WARNING: the following is gross oversimplification and conjecture ]  So, what sort of people are we?

  • Intelligent, well educated, proud, high-achieving, “teacher’s pet”
  • Highly motivated, a strong internal ‘locus of control’, responsible
  • We tend to like-to-be-liked, avoid conflict, keep things safe / conservative
  • We seek and appreciate the approval of our peers and superiors / power figures
  • Caring, generous and charitable

These are all fine traits to find in your doctor / nurse / carer – and most folk recognise this and appreciate it – our stereotype is what makes us trustworthy, reliable and compassionate – which is what you want when you are a patient going into a clinic or hospital and putting your health and safety in a stranger’s hands. BUT, there is always a but….

If the patient is playing a different sport, is trying to manipulate or derive some ‘secondary gain’ or even suffering a somatoform disorder THEN we have a problem.   The interaction of the stereotype I outlined above with the type of person who presents here leads to a strained relationship, some seriously maladaptive behaviour and possibly poor outcomes.  So who are these people, and how can we pick them?

  • Anyone with a cluster B personality disorder – antisocial, borderline, narcissistic, histrionic
  • Anyone with cluster B traits, who is under stress or having a really bad day!
  • People exhibiting criminal, self-destructive or reckless behaviour
  • People who are consciously trying to con you – lying, stealing and manipulating.

The stats suggest about 2% of the people presenting to a doctor fit this description.  And we do not like them – they represent the antithesis or our ‘moral code’, and worse yet – they are better at the game than we are.  This is a career for some folks – they don’t care if you like them, they revel in conflict, they are able to blame anyone for anything that goes wrong, they abhor power figures (ie. you) and they are more than happy to take your charity and spend it on the street.

Ok, so if you are still with me – now we get to the practical part.  How should you approach these consult?

It is hard to learn this – partly it is experience, partly it is a fundamental human skill – being able to detect when you feel that little bit uncomfortable.  In Australia we call it a ‘bullshit detector’ – but sometimes it can be subtle.It might be something the patient says (eg. “none of the other doctors understand me like you do…”), oppressive or invasive body language. Often you just recognise the scenario – it is in the “presenting complaint” – you can walk into the room prepared if you take a moment to think and change the strategy.

Once you realise that you are “not in Kansas anymore” you need to start thinking fast – put on the poker face, but behind that you need to be analysing and planning carefully every word that comes out of your mouth.

On the bright side – this is the same as my “shut up and listen” approach that I made in part 1. So if you have not realised that you are in an abnormal conversation at “hello” then you have a minute to make your realisation and adjust.

The patient has a story, let them tell it.  The difference here is that the story might be a complete fabrication, full of cringe-worthy statements or just plain bizzare.  But still – interrupting will do 2 things (1) give you less ‘think time’ and (2) start an argument before you are prepared.

You need to listen and make sure you get all the facts.  If you don’t allow all the story to come out then this is what will happen – as soon as the inevitable conflict occurs the patient will cry foul: “you bastard – You don’t even know what happened. ”  And you will feel bad for not being a good doctor / listener and you will cave!

Occasionally it is a complex, rambling, directionless story – you really need to try and NOT interrupt this one.  This patient may be here simply to tell the story – they may not want you to ‘fix’ anything, just listen and acknowledge it.  If you interrupt it they will almost certainly just start from the beginning again!

Often when talking to somebody who has an agenda that is not acceptable to yourself (opiates, unwarranted medical certificate, triangulating you into a dispute with another party, unnecessary admission…) the conversation can degenerate into an uncomfortable negotiation.  Why is this?

Well – we are nice folk, and don’t like to say “no” or disappoint our patient.  We try to avoid the conflict that standing our ground will create. We also have a sense of boundaries – and this stuff usually makes us want to get out of the room ASAP – so agreeing is easier / faster, yet we are uncomfortable with it.

Here is my advice – toughen up!  How?  You need an inner mantra – something like:  “I do not want to make friends with this patient!”  or something more specific like:  “I will not write a script for this guy.”  Now keep repeating it over and over in your mind as you try to decide what to do next, or at your first inclination to ‘cave’.

I have a 2 year old who loves to do silly things which seem likely to end with a trip to the ED. Saying “no” is always countered with a “why”. So you gotta have a better tactic or else you end up in a spiral of negotiation with somebody who is better at negotiating, more determined and has all day to debate the point!

Don’t come out and ask what they want – they will not tell you what they want, they will allude to it and talk around it but not give you the chance to say “No.”

So use your think time to decide on 2 or 3 outcomes that are acceptable to you – one of them may be “sorry , can’t help you, here’s the door”.  Then once you have listened and assured yourself that you have all the facts – lay out your options in no uncertain terms and ask the patient to choose one.  DO Negotiate, keep it simple – “option A, B or C.”

I have a colleague who actually writes his “pain scripts” and puts them in his pocket before he enters the “opiate seeking” consult.  That way he has set his decision, drugs, doses etc before the “negotiation” begins – no matter how hard they bargain – his “hands are tied” by the pre-written script!

If you have messed up and have entered into an ugly negotiation that you can’t back out of – then tag out and get a colleague to start over (pre-warned) – this resets the dynamic to some extent. One of the hallmarks of the borderline / difficult is to try and ‘split’ the world into wholly good and bad people. If you have been labelled ‘bad’ then there is little point in trying to continue the conversation as you will just escalate it into an emotive argument. This is a good time to tag out and get a colleague to enter as the “good cop” and explain the options in clear terms.

Sometimes you are really stuck. You have tried all the above and you have reached an impasse, or the patient has become frankly inappropriate. What now?

This is not the time to negotiate, or even talk about the specifics of the problem at hand (the content). This IS the time to talk about the process – this is when it helps to have a frank discussion about how the ‘normal’ consult runs and the roles and responsibilities of the doctor and the patient. Some patients will do anything to place the burden of responsibility on the Doc – this needs to be corrected in unequivocal terms.  You need to make it clear what you expect of the patient in terms of acceptable behaviour, compliance etc.  Do not give “special favours” in order to appease the difficult person – you will invite another demand, then another….

Physical assault of doctors and nurses often occurs in the context of a strained relationship where the patient with poor coping mechanisms feels frustrated and resorts to the oldest / simplest expression of this – a punch or a slap etc.  The rate of violence in the workplace in my ED is high – usually it involves alcohol, disinhibition and a sudden deterioration in the staff-patient relationship – often when we say “no” to an unreasonable request / demand.

So be aware that there will come a time when you are going to have to disappoint a patient, and it could turn ugly.  Watch out for the drunk, previously violent or desperate person!

Luckily you have ‘home ground advantage’ – so only have these chats in places where you can be safe – eg. a mental health room, in the presence of security / police, through te triage window if necessary.  There is no need to be injured

Those are a few tips from yours truly, I would love to hear your pearls – so leave a comment please.  Obviously there are an infinite number of scripts for these consultations so I have tried to outline a few principles.  If you have any other golden rules let me know.



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