When patients are challenging, try to understand

Take a deep breath and put yourself in their shoes

Regardless of the healthcare setting in which they work, case managers are likely to encounter challenging patients and family members — those who are irate, provocative, depressed, or just plain ornery.

“Dealing with difficult patients and family members simply comes with the territory. It’s totally predictable that sooner or later case managers will work with unhappy patients, those who are angry, frustrated, or who suffer from mental illness or a personality disorder,” says John Banja, PhD, professor of rehabilitation medicine, medical ethicist at Emory University’s Center for Ethics and director of the Section on Ethics in Research at Emory’s Atlanta Clinical and Translational Science Institute.

It doesn’t matter if you see patients in the hospital, follow them by telephone after a hospital stay or when they have a chronic illness, coordinate care in a physician’s office, or help a workers’ compensation patient get back to work — they are likely to be sick, in pain, under stress, and/or fearful about their situation.

Banja points out that most challenging patients don’t think they are being difficult. They’re feeling overwhelmed, helpless, and depressed because of their situation and they project their feelings to those around them, he says.

When you encounter people who are uncooperative or grouchy, avoid the tendency to diagnose their personality flaws and put a label on them, cautions Tammy Lenski, EdD, chief executive officer of Tammy Lenski, LLC, a conflict resolution and negotiation consulting firm based in Peterborough, NH. “There’s a huge difference between difficult people and people acting in difficult ways because of difficult circumstances. When case managers label them as difficult, they start treating them that way,” she says.

The minute you start to think of someone as unfriendly or uncooperative, stop and think that you could be wrong about the person, she adds.

When you deal with a patient who is obviously distressed, the empathetic approach works better than ignoring it or being dismissive. Begin by validating the patient’s feelings by saying, “You appear to be angry [or sad, or upset]. Could you talk about it? I would like to know what it’s like to be you right now,” Banja advises. Don’t make the mistake of dominating the conversation rather than stopping to listen. Don’t talk, except to make comments like “I hear you,” or “That sounds like an important point. Tell me more.”

For instance, workers compensation patients may not feel as if anyone but their lawyers is on their side. “When a healthcare professional asks patients what it’s like for them, it usually elicits a positive response,” Banja says.

Present yourself as a supporter and encourage the patients to share their frustration, disappointment and pain. “The biggest mistake we make is emotionally reacting to patients instead of trying to understand why they are acting that way,” Lenski says.

Take the time to really understand and talk to your patients. “People in healthcare are asked to multi-task and they often don’t take time to listen to their patients. You can save a lot of time on the back end by putting in time on the front end to find out what really is going on with patients and how they are feeling about their situation,” Lenski adds.

One of the mistakes that case managers make in trying to get patients to be cooperative is assuming that if they are giving the client logical information, the patients are buying into it, she says.

When patients won’t cooperate, stop giving them more and more information, Lenski advises. Instead, try to understand why they aren’t cooperating and why they think your plan won’t work. Don’t interrogate the patient. Instead, say, “The discharge plan calls for X, Y, and Z but you won’t do Z. What about Z isn’t working in your life? Help me understand.”

Resist the temptation to run or to fight when you encounter grumpy or combative patients. “Leaving the room or arguing with patients tends to escalate the situation and that will only make it worse in the future,” she says.

If the situation escalates, Lenski advises taking a break. Tell the patient you think the conversation got off on the wrong foot and you’re going to come back in 30 minutes and start over, she says.

If all else fails, consider firing your client, particularly if he or she is threatening or uses profane language, Banja suggests. “There are many legitimate reasons for case managers to tell their client that the relationship is not in their best interest or the client’s. It should be a last resort, but it’s nevertheless an option,” he says.

But before it gets to that point, discuss the problem with the client. You might say, “I want to help you, but it’s difficult when you are screaming at me or using that language.” Or say, “I can’t help you if you are going to threaten me.”

It’s very important to say it in a calm, non-threatening, non-judgmental, and respectful way, he says. Don’t get angry or upset back at them.

When you document the conversation, be objective rather than judgmental. Don’t say, “the client is unreasonable.” Instead say, “He erupts whenever I mention...”

“It’s very important for case managers to retain their objectivity and not use language in their documentation that someone could interpret as being biased or prejudiced,” Banja says. Not only is it a violation of professional standards, if the client has an attorney it will be very easy for the attorney to show the representation the case manager made in the notes and make that case manager look unprofessional, Banja adds.