Hi everyone, I'm very happy to be back and providing this presentation. So managing the challenging patient, I think all of us have a patient that comes to mind or two when we use this term challenging patient. And this is my previous disclosure. Okay, so polling question number one. What is the most common reason for patient dissatisfaction? Is it A, feeling that they are not being heard, waiting too long in the examination room, delay in scheduling procedures, or not returning a phone call? Absolutely correct. The feeling that they're not being heard. Although all the other options are important as well, but that's what the most common one. So what strategy can you use to communicate to the patient you are listening? Is it called affect label, interrupt the patient to clarify symptoms, avoid eye contact, or enter information into electronic medical record the entire visit? Excellent. So it's affect labeling, and you'll hear a little bit more about that term, which means to identify the label to the patient, the emotion that they're having. So I'd like to go over common reasons for patient dissatisfaction, review some strategies to deescalate an angry patient, review best practices to avoid that dissatisfied patient, and discuss the importance of reflective listening. So there are three major components that contribute to dissatisfaction. And some of these components we don't have control over. I'm going to go over systems, it's ourselves, providers, and our patients, and their response to stress or anxiety. So in the system, we have long waiting times, much more longer than ever I've experienced in my career, and especially since COVID-19. Lack of time that we feel that we can spend with our patients, because now they're coming in with multiple problems. It's not uncommon that I'll have a patient in my office for a new consultation. And what we're addressing is someone who is 60 years old, and I'm addressing change in bowel habits, rectal bleeding, esophageal reflux disease, mild dysphagia, and fatty liver disease with mild elevated liver enzymes. And the pressure on ourselves as an advanced practice provider is to provide service. The patient's expectation is that all of these conditions are going to be addressed at one time. And it's very appropriate that we communicate to the patients that we may not be able to address everything today, or sometimes I'll even say, you're going to be a part one, part two, or you're going to be a part A, part B next time. I'd like to come back in and make sure we've addressed everything. So providers, feeling personal feelings, lack of communication skills, lack of listening to patients, and disruptions. With our electronic medical record system, we use Epic too, just like Sarah does at University of Rochester. We have a function called Secure Chat, and then we also use an external messaging system called Tiger Text. And when these messages come in, as soft as they are, it's still alert, and they take your attention away from the patient. And I will have to, I purposely now, if my attention is distracted from them, I will tell my patient what distracted me, because they can see it. They can see my speech pattern change. They can see me lose focus. They can see me, just even if it's a millisecond, you can see how you get distracted. And what hearkens that is that I'll never forget, I was with a patient and she was concerned about blood work that had been done previously. And I was going to tell her that I was looking in the computer and I was going to be reviewing that and going over that with her. And she sees a look on my face that I was kind of squinting or concerned. Her interpretation was that I was concerned and that what I was looking at her lab results was, it was bad, there's something worrisome. And she asked me about that. And I said, oh no, I said, and I moved the screen towards her and my screen showed an error and I wasn't even able to log on. So be mindful of, of your physical gestures, your body language, just like Dr. Vicari was saying about her, you know, crossing your arms, meaning that you're not open. Patients are watching her every move and also a patient's expectations. What are their expectations for that visit that day? And a lot of times I'll actually ask that question for my patient, you know, especially that someone's coming in, in their, say, late twenties, they've had a change of bowel habits. They're having some rectal bleeding and wiping. I want to, I'll ask my patients, you know, did you do some reading before you came in? Was your expectation to, to do an endoscopic evaluation, to have a colonoscopy? You know, I want to try to read the room because sometimes when I come in the room and I can feel that the patient's extremely anxious, they may not want to do an invasive procedure right away. They may want, you know, to just talk about what the potential options are or what the next steps would be, or some patients don't want everything to be done in that first visit. So definitely reading the patient and picking up on their cues as well. And we certainly can pick up those cues when we walk in the room. I sense a patient's energy. I can, I can see if they're upset. And then a lot of times our medical staff will prep us for that. Oh, that patient's angry. They were really waiting a long time. And sometimes I'll ask my staff, you know, not to, not to bias me with information that I have no awareness of, you know, cause I'm starting off with this patient on a greenfield. So I hadn't met the patient before, but sometimes there is there's, there's, there's turmoil or anxiety that can work up to that visit. And then patient's frustrations, their lack of, or untreatable diagnosis is, you know, there are countless times that we've seen a patient in our office, especially younger patients that have been told that they have irritable bowel syndrome, but then they've felt abandoned at that. No one's helped them with their diagnosis. It's a, it's a, it's a diagnosis of exclusion and they feel like that it's almost a misdiagnosis because no one's been giving them any guidance throughout the way. So communication deficiencies, inappropriate choice of words or phrases, assumptions made health literacy and understanding biology, a lack of plan structure, delivering difficult news, initiating plan, lack of options offered to the patient, not involving the patient in decision-making, rushing patients who agree to a proposed treatment plan, rushing the office visit due to other pressures, and then not referring patients to appropriate services or counseling. You know, we are constantly distracted by additional information or disruptions. So even that knock on the door that there's a patient on the phone that the MA wants to interrupt you for, cause there's a emergency or radiologies on the phone, they had a stat reading that they want to go over with you. This is constant interruptions that our brains are switching back and forth. And this presentation is not going to go into this, but there's a lot of literature that's done on, on task switching. When we are starting to focus on one task and to go through that thought process and complete it, if you're interrupted in that task and you switch away and come back again, it takes longer for you to then reorient yourself to then look at that thought process and then to complete that task. So here's the anger continuum, and you can think about your practice and see where you have been, even in your career and how you're encountering those types of patients. So you have a calm, non-threatening patient that may be frustrated, but fails to show overt signs. You have a verbally agitated patient. A patient may say, this is ridiculous. I can't believe I have been waiting here for 45 minutes. They may be pacing. This is the patient that may be in your waiting room that you're not aware of. Verbally hostile. A patient may shift from offering phrases of discontent or unkind words. The doctor's incompetent and this entire practice is a sham. By the time you have a patient in your office with this type of verbal hostility, then the front office, our front office has instructions that they're going to start to engage management to try to intervene before that patient even comes into your examination room. Because we want to identify what is the problem that the patient had encountered before coming in there. And verbally threatening. A patient may demand an apology, threat to sue, physically threatening, and then physically violence. I personally haven't encountered physically violence or a patient may attempt to injure a provider personally, but our department has. And we actually have an armed guard in our department. I work for a multi-specialty department. We have a seven gastroenterology, gastroenterologist practice. We have three advanced practice providers and it was probably, I'll have to, I'll correct myself. It was last year we had a physical threat against one of the doctors. So we had an armed guard at that time. This was right at the time, probably a year and a half when there was a shooting in a gastroenterologist office. I wanted to say it was in the Midwest. So we had an armed guard and then now we've transitioned to an unarmed guard, but we do have a physical presence. And I think we can all say that our patients are definitely more anxious, more angry and more frustrated with the, with the system that they're involved. So this is a communication technique, goals to show that you're listening and understanding to the patient. What I hear from you is that, did I hear that correct, which is feedback, which is an excellent strategy to use with your patients. You want to improve partnership with the patient. How did you feel about the care that you're receiving from me, improve skills at expressing negative emotion. It's difficult to me to listen to you while you're using this type of language. Sometimes I have to, I have to referee couples that are in my office. So I will use that type of discussion when I want them to stop arguing with each other so I can understand what the concerns are or what the chief complaint is that I need to take care of today. Free sympathy. You seem quite upset. Could you help me understand what you're going through and then negotiate the process? What is your understanding of what I am recommending and how does this fit into your ideas? Reflective listening is simply reflecting and restating words back or that teach back focusing on the words, not the emotions, paraphrasing and, and mirroring. Practice management strategies that can help facilitate a good visit. As Dr. Vacari mentioned, is, is having access to community resources that we can provide to patients, adequate follow-up, again, that's one of the number one frustrations for patients is they don't feel like they have adequate follow-up and then scheduling appropriately. I'll see, we have open access systems. So patients, if they have non-acute symptoms, they can have open access for upper endoscopies or colonoscopies while they haven't had a consultation. They've had a mini consultation. They met the gastroenterologist that morning, but say if they have multiple polyps or even diverticular disease, patients will say, gee, I just didn't get the follow-up that I expected to. So then they're on my schedule and then you're doing this, this retro consultation. Sometimes I'll even find out other problems that, that warrant, you know, additional workup or additional testing for. Even in practice management. So access to community resources, ensuring adequate follow-up educate patients on appropriate telephone and portal messaging. We all have patients that may overuse the portal system. I think in the very beginning, since we had limited access in our gastroenterology practice, we were encouraging patients to use the portal messaging system. Now I have to give my patients a disclaimer that I can, I do not turn around my portal messages within 72 hours. So I give them that expectation that it is not like email that I'm going to be responding to them directly. And if they have any urgent concerns or questions that they need to call my office and again, scheduling appropriately. Our lengths of visits in Epic are 30 minutes, whether it's a new patient or, or established patient. We just know that our established patients always come in with either an exacerbation of the problem or a worsening problem or of a new problem. So somehow that 30 minutes seems to go by very quickly and patients. We all also know that in the gastroenterology specialty, that our patients, there's a high emotional component to their, their gastroenterology disorders too. We also set firm limits on time, discuss and enforce your policies about abuse to the staff. So this is, I really rely on management to be able to provide that support for us. So what can you do different on Monday? One of the strategies that I've started doing is I review my schedule over the next two weeks to see if there's a patient who is a difficult patient or challenging patient. I don't want to use the word difficult patient or challenging. And these patients think about what we see in our day-to-day practice. We've got anxious 25 year olds with generalized anxiety disorder with a new diagnosis of non-ulcer dyspepsia. And we've got 99 year old patients with dementia with chronic constipation. If there's a way you can look forward in your schedule and see someone that requires additional time, maybe they can be that last patient in the morning. So they can go over into your lunch a little bit, or if you have time at the, at the end of the day. So really taking control of your schedule and, and being proactive on what it looks like throughout your, throughout your week versus those surprises. And this is where, when you do your own prep work, when you're reviewing your notes before the next day, gives you a better sense of what you're going to encounter that next day. So say if your 8am patient is there for their Bravo results, but they just had their Bravo done two days ago and the results had been interpreted, then you know how to start that conversation with your patient versus walking in and then opening up the note and go, Oh, you're here for your Bravo interpretation. Okay, well, let me go ahead and look at it for you. So, so you're, you're better on your game, you're more prepared and the patients perceive that that you're confident and in control. So in summary, affect labeling is a way to deescalate an angry patient because you're, you're expressing to them that you understand what they're going through. I understand you're angry, you're frustrated, you're upset, you're anxious, and they go, you're right, I am anxious. Improving patient satisfaction to ensure adequate follow-up, listening techniques summarize that patient's chief complaint concerns, interrupt less, and empathy by naming that emotion that the patient is feeling. And here's some references that I'd encourage you to follow up on. And as Dr. Vacari had mentioned, patient satisfaction is a, is a marker that we're judged on. It's part of our PRESS-GAINI reports, is also part of the, the five-star metrics for CMS. And ensuring patients are being heard is going to be that number one satisfier for them. And, and don't be shy if a patient had an amazing experience with you and you can tell to ask them when they receive that survey to mention your, you by name and that it was a good experience and that you had, because we all know that it's usually the patient who's upset that is going to make those comments on those surveys. And the N is always small, so you want to get your N as high as you can. So thank you very much.

patient satisfaction

effective communication

listening skills

empathy

practice management strategies