Being a patient is sometimes stressful. Sometimes, that stress manifests as “bad behavior.” Raising one’s voice at office staff. Sending a nasty email. A sarcastic remark.
If it’s an isolated event – a one-off – most practices just shrug it off. Anyone can have a bad day.
If one bad day is now many bad days, then it’s no longer a one-off. It’s a pattern that can turn into a bigger problem. No one volunteers to be a human pinata. Left unresolved, employee morale will plummet. Some employees might leave. Employees can even sue for their employer tolerating a hostile and abusive work environment.
The simplest thing to do is to just tell the patient you won’t tolerate behavior X, and if they cannot control their volatility, they will need to seek care elsewhere. Some patients have limited insight as to how they are perceived by others. Merely communicating how their behavior affected others might be enough to trigger an epiphany, achieving détente.
Sometimes it helps to tap into assistance from the patient’s loved ones. This needs to be addressed delicately. There are HIPAA considerations. But, having a trusted spouse, parent, child, or friend in proximity might ease tensions and control behavior.
Recently, one practice struggled with how to manage a specific patient. She was in her mid-30s and had a history of cancer. In the game of life, she had received a tough hand. She alternated between hot and cold. Sometimes she loved the doctor and staff. Sometimes she despised the doctor and staff. Every day was different. Also, she was a great referral source for the practice. Still, there were times when employees were driven to tears.
It turned out the patient had a mental health condition and was seeing a psychiatrist. The plan going forward was to seek permission to bring the psychiatrist into the discussion related to in-office behavior.
All practices should have, at a minimum, a relationship with some provider who can answer questions about patients of yours with potential or actual mental health challenges. Put these psychiatrists/therapists on speed dial. Take them out to lunch. When you need them, you need them now. In any event, they are skilled in diagnosing and treating conditions our patients have, whether you recognize those conditions or not.
If your patient had a cardiac condition, you’d refer them to a cardiologist. If your patient had a kidney stone, you’d refer them to a urologist.
If your patient has a behavioral or mental health condition, you can and should consider referring to a mental health professional.
Not all patients with bad behavior need to be shown the door. Relationships can be repaired. And behavior can be softened.
That said, if you believe a patient’s behavior might devolve into violence, that’s another matter. Discerning whether a patient is just being difficult or is inches away from violence should be run by a trained mental health professional and/or even law enforcement.
What do you think?
Jeff,
I have a close friend who works at a FQHC, so he sees all of the Dx’es at a glace.
When he sees a bipolar, he makes a point to do what is necessary and then works to
move him on to a new practice.
Maybe he is conflicted, I don’t know. But, he does believe that his life ( and career ) is short,
and he does not want the drama or grief that certain patients bring.
Looking at these issues at 30,000 feet, it might be an excellent idea to identify those patients who you just do not want to take care of for whatever reason, usually a very good one. Physicians think by way of their gift of persuasion that they can make patients like them or make them happy. Well, sometimes, and sometimes not.
This might not be a popular statement, but, perhaps the patient is not a good fit, and she can do better elsewhere. This would be best for everyone. Do it with abundant loving kindness.
I welcome other opinions and debate. And, I welcome those who think that my comments are woo. LOL
Richard Willner
The Center for Peer Review Justice.
When I was first in practice in one location, I picked up some answering machine messages on Friday afternoon’s when the staff had gone home for the day.
It was the father of a patient, that we had not gotten insurance pre approval to treat.
We had called the patient earlier that morning to tell him we could not treat him since workman’s comp had not approved.
The father who left the message was polite on the answering machine message.
I called the father back and explained the circumstances.
He stated that his son (also his employee) had good insurance!
I then explained that since this was a workman’s comp injury, I could not treat him without their approval for the procedure that I was contemplating.
He reiterated that they had good insurance.
I pointed out that we could just do the procedure and bill it to the wrong insurance company. I pointed out that if the claim was denied, they could have a big out of pocket expense.
Then the father of the patient became belligerent and stated that he was coming down to the office to kill me!
I had never been threatened like that.
I did not know what to do.
I turned off the lights in the office.
I closed the blinds.
I called my attorney who as 120 miles away to see what he thought I should do.
He did not have any advice for me.
I then called the nursing supervisor at the hospital, next door, and asked if she knew this father, (the son was 30 years old). She did. She stated that the father’s “bark was worse than his bite”.
She said she knew him, and he would not be coming down to shoot me.
I finished up my office work and went home.
I never heard from the father of the patient again.
Workman’s Comp never approved treatment.
Dear Doctor,
Killing doctors is no longer a rare occurrence. I recall an OB was killed years back. And an urologist was killed along with his secretary, nurse and another patient. I recall that the shooter then went to a fast food place and calmly ate a meal until the police found him.
No one can predict future behavior based on “knowing” him. That “his bark is worse than his bite”.
Well, this new situation is different. And, nobody knows his current emotional balance as well as his level of impulsivity.
In short, if someone threatens me, I take him at his word. I won’t waste my energy to “understand” him.
I am glad that you are alive and you only have an interesting story to tell
Richard Willner
The Center for Peer Review Justice
Mixed mood disorders are often overlooked or misdiagnosed. The hot and cold may become warm with lithium carbonate or lamotrigine. Since finding psychiatric care is nearly impossible if none exists, careful screening at the consultation es muy importante. Capiche? Thank you.
Dr Easy E,
We all know that patients in general are, at best, only partially compliant. Perhaps it is because we tend to speak too quickly and we do not have the time or take the time to really communicate. And, in general, if one has 20 patients a day, taking only an extra 5 minutes per patient means another two hours of clinic time. And documentation and providing “evidence” is certainly very important if one expects to be able to survive an audit or a med mal claim.
But, I think the biggest problem is that those with bipolar really enjoy the manic state. Certainly compared to the state of depression. So, these folks will simply not take their mood stabilizers.
And, some of them have consulted Dr Google and if taking Lithium, don’t want to eventually burn out their kidneys.
As I have written earlier, the “hot and colds” or the Bipolars are tough to treat and if uncomfortable, it may be best to refer them out.
Richard Willner
The Center for Peer Review Justice
When I practiced in a down-town Seattle location, I had a very, very strange young male patient appeared in my office complaining of tingling in his feet. He explained that he wanted me to turn this into Worker’s Comp for an injury. I asked for a description of an injury and the date. He could not provide any. In the meantime, he started walking around my office wordlessly distributing fragments of plants on the desks, chairs and various locations. He walked unbidden into my private office and did the same. He did not appear violent, but rather than confront him, I decided it best to just say nothing.
I explained to him that I would do the “best I could” to get him a claim number. I did turn in the claim and of course it was denied. He appeared again a month later. I was not sure what to say to him but decided a strategy of “blaming” Worker’s Comp was the best. In the meantime, he continued to install fragments of plants all over my office.
I created “fake tears” telling him how awful that Worker’s Comp treated him and that no matter what I did, I could not convince them to give him a claim number. He seemed “satisfied” with my explanation. He again walked into my private office to install fragments of plants he had in a small basket. I wished him well and told him I could not see him because of how “awful” Worker’s Comp was. I hope he did not develop a fixation on Worker’s Comp due to my comments. But I figured they had better “protection facilities” in place than I had.
I (fortunately) never saw him again. Sometimes “confrontation” is not the best approach. If you can show a form of “identification” with a crazy person, you may have a better chance of survival. This may or may not be in their best interest, but it appears to be in yours.
Michael M. Rosenblatt, DPM
Mike,
Your patient was weird. No question. And, when one is in solo in a private practice, the doctor is very vulnerable to attack. There will be no one coming fast enough to help you and your staffers.
Safety is a huge issue today. We don’t vet those patients who call for an appointment. We accept and treat everyone who comes thru that door. And, in reality, we don’t have a clue as to what is going on in their heads.
You instinctively knew what to do for survival.
Richard Willner
The Center for Peer Review Justice
Those with a Bipolar I Dx would be very disheartened and a bit shocked to read your bias toward them as patients. Some endure decades of hard work and trials to arrive at a “cocktail” of off-label meds that finally leaves them free from the deadly and wild symptoms. How many doctors avoid those with mental health Dx by doing “what is necessary and working to move (them) on to a new practice?” Just knowing that there is one out there with your prejudice, Mr. Willner, is sinister.
We are judged as a society by how we treat those weaker than ourselves.
I believe Dr. Segal’s message was intended to urge providers to be proactive and to have a partner in these situations and, ideally, always. To have a Psych consult on call – down the hall, a friend, a colleague that owes you one. Don’t be fearful: Be prepared.
Dear Anonymous:
I disagree your opinion concerning Dr. Willner that being “fearful” of potentially dangerous patients is “sinister.” Many of us have families in need of our support. If they are disabled or murdered by a patient, they will no longer be in a position to support them. I was a surgically trained DPM who actually owned my own Medicare Certified Surgical Center.
My family was in need of my financial and “head of the family” support. Yes, I had life insurance but that is not a substitute for me or my earning ability. Apparently, Medicare and Washington State believed I actually had the qualifications to own and operate a REAL ASC, despite the fact that I was not an MD. I successfully operated this facility and sold it to retire. Despite that I am not an MD, I invented a statistical format to audit medical/surgical charts that caused me to be hired by attorneys for this invention.
I understand that prejudice exists against people with behaviorally/developmentally disabled people. It even exists among medical license boards who routinely act against providers if they ADMIT to a psychiatric treatment history!
One of these ironies is that state medical practice boards are more willing to allow doctors with a prison record or substance abuse problem back to work than a person who admits to a psychiatric history! So, if you want to blame Dr. Willner for his fear of some patients and attempt to try to find another source for their care, you have to also blame medical practice boards for THEIR prejudice against their licensees.
Finally, not every provider is a psychiatrist. We cannot “pretend” we have skills to manage deeply disturbed patients. That was NOT within the bounds of my particular limited medical license. I was qualified to re-attach your ruptured Achilles tendon. But not to treat a psychiatric patient.
Michael M. Rosenblatt, DPM