Challenging patients – what options are available?

While the majority of our patients are appreciative and have realistic expectations there will always be a small number of patients who take up a disproportionate of time and energy for reasons outside disease management.

Whether it is frequent complaints, misuse of the system, unrealistic expectations leading to inappropriate demands, unwanted attention/stalking or even aggressive or violent behaviour these situations have significant impact on our members’ patience, morale, ability to focus and sometimes their wellbeing and safety.

There is no single solution that can fix this but I hope to offer some guidance to doctors and practice managers on navigating these tricky situations.

Frequent complaints

Getting it right first time can be helpful in closing down a complaint early on; Medical Protection offers advice and support in identifying the elements of the complaint and assisting with wording comprehensive responses. In the event that a complainant remains dissatisfied with the response we can help review the case and advise on whether the complainant should be reminded of their right to approach the Ombudsman.

If you have satisfactorily responded to every issue, you are not required to continue correspondence with a complainant. We can help you decide when that threshold has been reached and when it is time to be comfortable in the complainant referring the case to the Ombudsman.

We can help members tease out the elements of what is, or has become, a vexatious complaint and when a complaint requires further consideration and response.

Unrealistic expectations

A common theme we come across is the patient with the ‘shopping list’ of issues that they want to explore in a single consultation.

We would caution against a blanket ‘one concern per consultation’ approach and advise members from the outset to explore a patient’s expectations and concerns so that they can then best manage these early on in the consultation. Asking “is there anything else you want to discuss?” after the opening conversation can be a simple but useful tool.

If a patient comes with a shopping list, after consideration of any issues that require urgent attention (such as chest pain), asking “which of these is the most important one to look into today” and then gently suggesting that a further appointment is made for the other concerns can help. This way patients feel heard and feel that you are in a position of wanting to assist within the timeframes given.  

Medical Protection’s two-hour virtual presentation, Reducing Medicolegal Risk, will cover these situations in more detail. I would advocate our members to attend one if they are feeling frustrated by unrealistic expectations, as this workshop offers some practical solutions to these situations in a professional, robust and still patient-focused way. This presentation is available to book on our online learning hub.

Unacceptable behaviour

Everyone has a different threshold for what they personally deem to be unacceptable; for example, some people may be more tolerant than others when patients swear or become angry – but what matters is the effect the behaviour is having on the staff member, and the safety of you and your staff should be paramount.

When faced with unacceptable behaviour, and if your personal safety allows, we suggest the next consideration would be “is this behaviour a manifestation of an illness” – being sworn at or pinched by an elderly person with dementia or delirium may be unpleasant but not necessarily a threat to our wellbeing: we can understand that this is an often frail person acting out of character and their behaviour is a manifestation of an illness.

Being sworn at or threatened by a person who is obviously responding to external auditory hallucinations may also be very distressing and, depending on the physical power of the patient presenting these symptoms, may be a real threat to our safety. In both situations there may be a different level of risk to the practitioner but also a need to ultimately ensure the patient gets the right treatment. The bottom line is your and your staff safety comes first. If you feel personal or staff wellbeing is at risk, call the police. The care and treatment of the patient then takes priority once safety of the situation is established.

There will be patients we encounter who display unacceptable behaviour that is not a manifestation of a treatable physical or mental health illness.

If it is deemed that the unacceptable behaviour is not the manifestation of an illness the following options are open to you:

1. Ignore it – this is a personal choice and different practitioners will have different thresholds for what they feel is tolerable
2. Try to de-escalate the situation – unacceptable behaviour is often a result of unmet needs. If we can ascertain what these needs are, and we can realistically meet them, that may defuse the situation
3. Write a warning letter – warning letters should clearly describe the behaviour that was unacceptable and the impact it had on the staff member(s) concerned. For example, rather than saying “you were very rude on the phone and it is not acceptable” a description may be: “You raised your voice and talked over the member of staff who was trying to explain the situation to you and used language which the staff member found offensive. This led to the staff member feeling intimidated.”
4. Consider a behavioural agreement that outlines what the patient can expect from the practice and vice versa – there are good examples of warning letters and behavioural agreements in the NHS Protect document Unacceptable behaviour: Guidance on warning letters and other written communications
5. Remove the patient from the practice list – in the absence of the patient having committed a crime against the practice this should be considered an action of last resort after warning letters or behaviour agreements have been explored. The GMC offers some guidance on this.¹

Stalking

Some of our members are subject to unprompted and unwanted attention, either in the form of negative attention or inappropriate declarations of feelings from patients. This is a very particular type of behaviour that warrants a robust approach. Again it is important to consider if the behaviour is a manifestation of an illness and consider if the patient needs referral to mental health services.

In addition to this the RCPsych has produced some helpful guidance on how to deal with stalking.² In essence this involves telling the patient clearly what behaviour they have demonstrated, that this is unacceptable, describing the effect this has had on the recipient and a statement that if the behaviour does not stop there will be consequences, such as removal from the practice or eventual referral to the police, depending on the severity of the behaviour.

Summary

The references below are helpful resources to help our members navigate through some challenging situations. If you are struggling to manage a challenging patient, we are here to help with some practical guidance and support.