All right, and I think we're trying to catch up some time here, so I'm going to do my best. You'll have the content, and you'll be able to review that after. I know there's some questions coming in, so we'll try to get through those later. So I went over my disclosures. So this presentation is on managing challenging patients in the office, and you're going to interestingly see how it dovetails with our other speakers. So we're going to look at some common reasons for patient dissatisfaction, review strategies to de-escalate an angry patient, look at those best practices to avoid dissatisfied patients, and discuss the importance of reflective listening and ways to reduce burnout. So contributing factors are the system that we work within. It's providers, either ourselves or colleagues, and our patients. So we all work together. The system, we have long waiting times, lack of time with our patients, overstretched system, documentation challenges. Providers, sometimes our personalities or feelings or other colleagues aren't working well that day. Some physicians may not spend as much time with patients. Sometimes I find myself in a situation where I'm seeing a patient to kind of go over their plan because there wasn't enough time or else smooth out things that maybe there was some misunderstandings. This lack of communication, lack of listening to patients, disruptions. Dr. Tawani said, stop talking. Once we introduce ourselves to patients, stop talking. And that's when patients want to feel like that they're heard. Excuse me. And disruptions, we are constantly disrupted. You know, my practice has significantly transitioned from over 15 years ago to today with our new EMR system. So I work with Inepic and I can be having my visit with my patient, typing in some key notes for them, turning and looking at them. And then, you know, I can look at Epic screen and I can see at the top that all of a sudden there's a red phone, which a cue to me is that a patient called and it's an urgent visit and they need me right away. Or there's an Epic secure chat. I could say radiologist called, there's an abnormal radiology patient has a pancreatic mass. The daughter saw it in the EMR system and she's calling to ask you what to do. So the amount of information, I want you all to appreciate the amount of stress and information that we have to process. At one time, we haven't been in this situation before. And our brains are like computers and we have too many windows open sometimes that we can't process it at the same time. So be mindful to yourself. And if you find that you're getting too many interruptions from your staff, you can start creating more barriers and borders so that you, that time with your patient is going to be more sacred and uninterrupted. Because I know I can think better when I'm not interrupted as much. Patients expectations and personalities, feeling anger, and that sometimes that lack of untreatable diagnosis. First thing I think of is, is functional dyspepsia or non-ulcer dyspepsia. So these are the diagnoses. I'll see a patient that I've seen for providers and, and they'll have every test that they've done and they don't understand, you know, why can't you find something wrong with me? You can't, you don't know what's wrong with me. And those are the patients that those patients take a long visits because I'm actually pulling up up to date and sharing with them, you know, this is what we've done. This is what we ruled out. This is what we're doing. And these would be the next steps. I actually walked through a patient with the Rome IV criteria showing them, you know, the, the symptomatic criteria for functional dyspepsia, and then the next alternative strategies for the TCAs. So burnout's real. Sarah mentioned that. In fact, she even found a study that showed that APPs are even higher at over a 40 to 50%. There are studies to look at physician burnout and I, and, you know, we're, we're here to support our physician colleagues, especially in a specialty area. You know, we don't, we don't work in isolation. But I think a lot of the, the way difficult patients sometimes have been shifted to the APPs. So, so times have changed that we're being treated as, or sometimes the same template as our physician colleagues. So I'm not going to list out every one of these, but healthcare executives have challenges. And, and, you know, Dr. Carl said that, you know, money makes a difference. Organizations need to make money, but there's, there's a problem with them making money. Increasing price competition, narrowing insurance networks, declining reimbursement rates, and increasing mergers and contracts. And, you know, and there's more effort or more focus on us because we need to now meet quality metrics. There's public report cards, there's patient satisfaction, there's press Ganey scores. And it's, it's different. Interesting when you hear Dr. Twain say, you know, there's a difference between patient experience and patient satisfaction. And sometimes that patient experience, we don't have control over. So make sure that you're making the most out of that patient visit that you have that quality time with during that face-to-face time. So these key drivers for burnout, it's going to be workload, efficiency, meaning at work, cultural, organizational cultures, values, social support, that work life integration that, that Sarah mentioned that I think, you know, any of us that went into a specialty area, we are striving to know as much as a gastroenterologist. And that puts a lot of pressure on us internally, because we want to make sure we're not missing something and knowing all that information, communication and skill deficiencies. Sometimes we rush patients through decision-making. Sometimes we don't feel that way, but it may just be in, in our speech pattern, say, if we're worried about a patient, say, this is what I think you need to do. I, we're going to talk about different procedures that are options for you. But I'm really concerned, you know, your hemoglobin is 8.2. You're having some rectal bleeding. And sometimes in our efficiency, sometimes it's too fast for patients. We just have to be mindful of that and take a step back, make sure that we're providing them the time that they need. So interrupting patients, I've actually done studies to show that we do not let patients speak for very long before we have to jump in and get a question answered because they haven't given us a key piece of information that's going to trigger our medical decision making. So they found that Switzerland study 335 patients, actually this, they timed how long the patients speak. So 78% of patients didn't speak for more than two minutes. And then 50% of patients spoke less than one minute. So I challenge you when you go back to your work on Monday, see how long you let patients speak before you interrupt, because it's a habit and it can happen very easily. So angry patients, you know, it happens in our offices. And there's this continuum. The continuum is that they're calm, but they're frustrated. Then they become verbally agitated, and then verbally hostile, and then threatening and physically threatening, and then violence. And unfortunately, my career, I guess, if you've been a nurse practitioner PA long enough, you're going to encounter patients like this in your office. So I'm going to give you some tips on how you can help navigate through that. Part of it is improve listening and understanding. If a patient's coming to you, and they're upset, you want to summarize that patient's chief concern. And you want to validate to them that you hear them. So what I hear that you're saying, you know, did I get this right? If you want to improve the partnership with your patient, discuss the fact that offer ways that you can you can improve care. Sometimes they call this service recovery. So how do you feel about the care that you're receiving for me? It seems that sometimes we don't work so well. I mean, sometimes the way that I've couched this is that, say, if a patient wants to really expected to see a gastroenterologist the day of our appointment, and they thought, Oh, I want to see the gastroenterologist. I didn't know I was going to see you. No, I guess you'll be fine. And so by the end of the visit, you win them over. But I still offer let me make sure your follow up visit is with with the gastroenterologist you wanted. And sometimes they go, Oh, no, no, no, Jill, you're fine. No, I really, I really enjoyed being with you. Let's just stay with you. And I'm like, No, let's go ahead. And you want to go above and beyond to provide that extra service for the patient because you want to give them the service you want to you want to wow them you want to go above and beyond what they expected from you. So you're already doing a service recovery. They walked in the room, they didn't anticipate to see you, you're an advanced practice provider, their their expectation was that they're going to see a physician. So do that. But then you won them over during the visit. But then during that service recovery, wow them and say no, next visit, I'll have you see the gastroenterologist. And then after that, you can come back with me. So I set that expectation up with my patients that there's a lot of sharing with our with our with our team members. Make sure that we're empathetic. Yeah, you know, you seem upset. Could there be something else that I can talk to you that misunderstanding, and then again, negotiate that process of care. These are practice management strategies, we want to make sure that we have adequate community resources and follow up and scheduling appropriately. Our patients do not leave the office unless they have a follow visit. Because of the impact of care, they can't get back in again, a lot of times for six or nine months. So make sure that you're showing that continuing of care and then following up. These are strategies that you can review about how to access community resources, how to make sure you're having adequate follow up. If my schedule is so packed, and I'm seeing an elderly patient that I've started a therapy on, I really want to make sure that they're responding to it in the next next, you know, seven to 10 days, then I'll add on a telephone visit, say at 12 o'clock at my lunchtime. So, you know, I have less time to do my catch up work to have lunch, but it's, it's, it's good care, good service that you're providing to your patients. Because at the end of the day, we do care about our patients, and we do worry about them. And I think that they feel that and we're illustrating that to them as well. So organizational themes and strategies that can help support this unity between our departments. Approach to patients. So think of the patient's behavior, if they're upset, they're angry, they're frustrated. We don't know why that's where that's coming from. It doesn't mean it's being directed to us. It could mean another reason. So explore that just the way that they're communicating. Look at the way that you can acknowledge and allow and affirm and follow through. And there are two tactics. One is called mirroring and labeling. When you have a patient, you want to repeat that back those words, exactly how they stated, and labeling, you actually label their, their emotion that they're that they're, that you're feeling from them or expressing, I can see that you're frustrated, I realize that your time, your time is valuable. So make sure that we have our patients that are that are that they know that we're hearing them. So a cultivate community at work. This is to dovetail on what Sarah said, identify specific areas in the department to meet, coordinate and attend those monthly department meetings, and be intentional, discuss and share those cases and management plan. Yeah. Sometimes we don't have the luxury to meet down with our with our collaborating providers once a week, but at least once a month or every two months. And sometimes we we are go along our way very independent, we're communicating via secure chat tasks, you know, communicating our notes with our with our collaborators, but we miss that face to face, we need to still sit down and have that community because that's going to give us more satisfaction as well. Reflective listening, we addressed on that talk about mirroring and labeling our patients emotions. And there are the next step is how to promote resilience with ourselves. This is that work life balance, we exercising, are we caring for ourselves? Are we spiritually caring for ourselves? You know, we need to fill our cup back up again. So then when we come back to work, when we're we're providing care for our patients, a new paradigm that I've been doing some research on is called self compassion. And I find this fascinating. If you want to look at this, there's a website that has a five minute break, that you can teach yourself how to be self compassionate to yourself. So what you do is you start off acknowledging the fact that there's suffering in the world. And at that moment in time that we're experiencing it, and it's happening right now. So say if a patient was upset with us, say if we we miss something, you know, patients calling, you know, you order stool studies, you're like, I didn't order the stool studies. You know, instead of beating ourselves up, remember that there's there be compassionate to ourselves, acknowledge that they're suffering, remind ourselves that this is part of the human experience, you know, we're not perfect. And then you can comfort yourself using a soft tone, just like you would have family member or your patient, like, Jill, that's okay, people forget, you know, it wasn't catastrophic. It wasn't life threatening. It's okay. You know, you'll remember to order the labs next time when you see the patient. And you let you let it go, you really, we have to learn how to stop carrying these, the self talk with us, because we are our own worst critic. And, again, that website will give you a self guided tour on how you can be compassionate to yourself. So what are you going to do on Monday, how can you take this information and go away and, and change your practice. So some of the strategies that I've learned and talked to other colleagues that they review their scout their schedule from a high level perspective over the next two weeks, to see if there's a patient that may need extra time. You know, sometimes we get surprised, you may have a patient, this is post hospitalization, it says melanoma. And you may want to be able to look back at that and said, Okay, was the patient just discharged two weeks ago? Or they discharged two months ago? And have they not had a recent CBC? Well, that patient, I'm going to order a CBC before even see the patient and then ask my staff to call the patient to ask them if they're having any symptoms. Look at your schedule the day before the clinic. So you've got the high level overview, and then you've got that that fresh that next day clinic look. And then one of my colleagues, actually, she told me that the day of her clinic, she's seeing patients, she'll finish her 8am patient, then she'll go over to the next day and look at tomorrow's 8am patient to try to make some some crib notes on it to keep track of them. And then look at your schedule, try to anticipate who's going to need most of that care. Or when you're looking at those visits, is it going to be the 25 year old that that new diagnosis of non ulcerative dyspepsia that I mentioned earlier? Or is it the 99 year old who has dementia and chronic constipation? So try to anticipate what you need ahead of time. And that's going to also help you with your with your best practice. So in summary, look at affect labeling to deescalate your angry patients, improve patient satisfaction, which will also help your patient's experience. We're all being scored now we're all being we're all being looked at. And so this is important that we also know what our patients are saying. So routinely, go on your website with your organization and look to see what the what the patient comments are and see if there's anything that we can do to do better or else celebrate the successes. I had a patient the other day who wrote a comment that told me I was a rock star. And I'm like, yes, you know, celebrate those successes and and realize that you are doing a good job or great job. Listening techniques, summarize that chief complaint, interrupt less and provide self compassion and self healing strategies. And here's a list of my references I encourage you to review and thank you very much for being here today. One of my favorite courses to present it so thank you again.

patient satisfaction

healthcare communication

provider burnout

de-escalation strategies

self-compassion