Consultation Skills - How to deal with manipulative patients

Dr Kamilla Porter offers some pointers for helping patients who challenge your consulting skills.

Photograph: Dialogue models
Photograph: Dialogue models

Case Study
Mrs S is a frequent attender and repeatedly complains of feeling off-balance and dizzy. She has been extensively investigated in secondary care and no physical cause can be found. Despite attempts at reassurance she continues to make emergency appointments and phone for advice. It is a busy morning at the surgery and Mrs S has telephoned demanding an urgent visit as she is feeling anxious and dizzy, despite the fact she was seen the day before with the same complaint. You are now feeling exasperated and manipulated by this patient.

Doctors may feel manipulated by patients in a variety of ways. A common scenario, as exemplified above, is the frequent attender who takes up a considerable amount of time and appears to have limitless needs.

Other examples include patients who try to influence their doctor unscrupulously to obtain sick notes or prescriptions that are not medically indicated.

Patients may be manipulative through flattery, friendly gestures or even by inducing feelings of guilt. Managing such patients can be a fraught experience.

One approach is to take a step back from your interaction. Consider not only the patient's agenda and driving force behind the patient's behaviour, but your own agenda and why the patient is evoking such feelings.

Consider circumstances
Consider the patient's social circumstances. There may be an overly anxious relative encouraging them to attend, or unhappiness at work may be fuelling the patient to see a doctor.

For an isolated patient a visit to the GP may be the only regular point of social contact. Patients' cultural and educational backgrounds can profoundly influence expectations about how a doctor can help them.

A patient may feel he or she has not been understood properly in the past and may just want some acknowledgement that they have been listened to. A recent life event may have caused the patient to struggle.

The patient's behaviour may reflect underlying anxiety or depression, which needs to be explored and treated appropriately.

Addressing many of these issues is not possible in a 10-minute consultation. Inform the patient from the start what can be realistically achieved to prevent incessant demands on your time.

A routine appointment that takes half an hour is likely to exhaust the practitioner, frustrate other waiting patients and may set a precedent for the patient.

However, it is imperative to ensure that nothing serious is missed and to prioritise the patient's medical needs with effective safety netting. Explain that other patients are waiting and that a further appointment can be made.

Create a management plan
Remain polite but firm with the aim of trying to help the patient in a contained manner with appropriate boundaries.

Rather than just leaving the patient with an open appointment, it may help to offer regular follow-up appointments or even phone contact. Active follow up can reassure the patient and prevent inappropriate appointments and visits.

It is especially important in more complex cases to write clear notes so other colleagues are aware of and stick to the management plan, for example recording that you have told a patient that if he loses his diazepam prescription again, no further scrips will be issued this month.

A further strategy to consider is a verbal or written contract between patient and doctor or for the practice to clarify what has been agreed.

Ask yourself whether your response may be due to your own stresses or preoccupations and find out if colleagues feel the same way about the patient. If you have been the main point of contact for a difficult patient and are feeling at a loss, discuss this with a colleague and consider whether a second GP opinion would benefit the patient.

Ideally, to preserve continuity of care and to avoid 'shopping around' the practice, encourage the patient to stick to one or two named doctors.

Demanding patients
Some patients or their relatives may demand certain investigations, drugs or referrals which may go against your medical judgment. As outlined in the GMC's Good Medical Practice, aim to share decision making and involve the patient wherever possible in their management plan.

Try to diffuse any confrontation and avoid complaints but explain the risks that further treatment and investigation can entail and that your recommendations are based on wanting to avoid unnecessary harm. Be honest and pragmatic with the patient about what can be achieved.

Difficult consultations can be emotionally draining so ensure you are in the right mindset before calling in the next patient.

If you feel uncomfortable because of a patient's manner, for example if he or she is persistently flirtatious, consider contacting your medical defence organisation for advice.

Summary
Identifying a patient as manipulative is highly emotive and requires careful and non-judgmental handling. Good consultation skills will come to your aid.

Do not be afraid to seek help and guidance from other members of your practice team.

  • Dr Porter is a sessional GP in Leigh-on-Sea, Essex

Learning points

1. Employ good listening skills.

2. Consider the patient's agenda and prioritise the patient's needs.

3. Set boundaries and use a safety net to protect both patient and doctor.

4. Maintain good record keeping; consider a verbal or written contract with patient.

5. Reflect on your agenda and any personal shortcomings, and remember to look after yourself as well.

6. Remember your duties and responsibilities to other patients.

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