(+)JayA.Kaplan,MD,FACEP
Director, Service and Operational Excellence, CEP America, Emeryville, California; Member, Board of Directors, American College of Emergency
Physicians; Immediate Past Chair, Emergency Medicine Foundation
ThePatientWithMultipleComplaints We have all been there. The patient in bed 4 has a chief complaint of “chest pain, headache, vaginal bleeding, and I am out of my Percocet.” How do you maneuver through the maze of complaints your patient has? What exactly should you work up? How do you intelligently ignore certain complaints? The presenter will offer a strategy for dealing with these difficult ED patients.
Objectives:
Describe an approach to the patient with multiple complaints.
Discuss a method of filtering multiple complaints.
Describe a method of deciphering what complaints need to be worked up in the ED.
Date: 4/14/2014
Time: 9:00 AM ‐ 9:30 AM Course Number: MO‐03
April 14‐18
SanDiego,CA
Advanced Practice Provider
Academy
The Patient
With
Multiple Complaints
Jay Kaplan, MD, FACEP Practicing Clinician and Director, Service/Operational Excellence, CEP America
Board of Directors, American College of Emergency Physicians
Provider communication correlates STRONGLY with adherence rates by patients in acute and chronic disease. There are now over 100 observational and 20+ experimental studies published demonstrating the correlation of communication (patient satisfaction) with compliance. Compliance with treatment
regimens has significant influence on quality
measures in chronic disease and outcomes.
Medical Care: August 2009 - Volume 47 - Issue 8 - pp 826
Provider Communication =
Compliance = Quality
What Makes A Patient “Difficult”?
Multiple complaints
Angry
Demanding
Chronic Pain
“I have seen 10 doctors and no one has
helped me.”
What Makes A Patient “Difficult”?
Back again . . . And again . . .
And again . . .
Needs far more resources than
you can offer.
Every Patient Interaction Has a . . .
Beginning Middle End
or seen in another way . . . It’s about . . . Relationship
Task
Relationship
The Construct of the Physician/Patient Visit
The Beginning (A/I)-The first
impression
The Middle (D/E)-Gathering and
explaining information, and the creation of a collaborative plan
The End (T)- Review of information and
Know what you are doing and who you are meeting prior to entering the exam room
Intoduce/Connect
Knock, pause 2 seconds prior to entry Acknowledge everyone in the room
Introduce self-role in care and experience Sit at eye level, facing the patient
Non-medical query
Smile and establish eye contact Use the patient’s name
How Do You Walk Into the Room?
Middle
Acknowledge/Articulate
Let the patient agenda/concerns drive the visit Let the patient speak without interruption
(2 minute rule)
Paraphrase the patient history
Convey physical exam findings while doing the exam
The Middle – Part II
ReviewA clear summary of the diagnostic impression, work-up and time-frame Clarity on what will happen next (Rx’s, Discharge instructions, Follow-up appointments)
Educate/Ensure Understanding
What questions do you have for me? Is there anything you would like for me to go over again?
Tell me what your understanding is.
Multiple Complaints
Let me go over what the nurse has written so you don’t have to repeat yourself all over again.
What is the one most important issue that brought you to us today?
What is one thing we need to do for you to make this ED visit an excellent one?
Excuse me . . . Let’s take your concerns one at a time.
Angry
Acknowledge the anger – I can feel that you are upset and angry.
Are you upset at me or at the situation?
Okay, I understand. We have not met before. So be upset at the situation, just don’t be
angry at me. I am here to make it right for you.
Demanding
What are you most worried about this being? What do you think you need?
Let’s discuss what you want.
What you want will not give you the answer you desire.
This is not the best time to do that test or to give you that medicine.
Here are the potential costs ($, exposure, future consequences).
Chronic Pain
Do not walk into the room
with judgment.
Chronic Pain
Review the medical history Print copies of previous records
Review the state database; Call local pharmacy chains
Consistency amongst practitioners is crucial. Here are my findings. Here is my plan.
What questions do you have for me?
“I have seen 10 doctors . . . “
Review the history you have, if any. Replace frustration with fascination. Consider yourself Sherlock Holmes.
Is there anything that has missed the careful eye? Connect with body language and tone (rather than words)
Suggest alternative and complementary medicine alternatives (diet, acupuncture, yoga, etc.)
Back Again . . .
Get Social Services involved.
Create a special needs patient file.
Talk with hospital administration regarding the cost of caring for such patients and the ROI of creating a program to dal with them. Can you make an appointment for him/her at the FQHC?
Others
What other types of patients are difficult for you?
Do you want to role-play some interactions?
Summary
Know what you are doing when you walk in the room.
Do not walk in with judgment. Be systematic.
Resist jumping to conclusions.
Thanking you . . .
Jay Kaplan, M.D., FACEP [email protected]
