When a GP feels manipulated

Deal with your response to demanding patients before managing the consultation, says Dr Peter Havelock

Doctors can be manipulated by patients — this may be subtle or it may be clearly obvious. With both these situations the doctor can have strong feelings of frustration, loss of control or even anger. Behaviour that one doctor might find difficult another might find to be simply challenging or even endearing.

Manipulative is defined as skilful in influencing or controlling others to your own advantage and when used in health can also be a pejorative term. We all have patients who fit this definition and selfishly use their skills to try to get what they want.

There are other patients to whom this term is applied in a judgmental way because they make the doctor feel used or out of control. Examples of this might be the well-informed patient who has clear ideas of the treatment or the referral that they want and put those wishes plainly to the doctor.

Manipulation techniques
Patient techniques that make the doctor feel manipulated can manifest in a number of ways but they create similar feelings in the doctor. I am sure that you can easily recall phrases or situations that have made you feel manipulated.

Some examples include: ‘I want to see you because I have heard that you are a wonderful, caring doctor.’

‘It is only the blue sleeping pills that work — temaze-something.’

‘Ordinary painkillers don’t work on me. I have to have…’

‘I get on so well with your senior partner and he would give me…’

‘The pain is really, really, really terrible, doctor.’

‘I have bought everything from the chemist so I need…’

‘If you don’t do this for me I will harm myself.’

‘I have this rare illness and my specialist says that I need… urgently.’

The situations when you can feel manipulated are also very familiar. For example, the urgent appointment for a lost prescription of analgesics or benzodiazepines; ‘hysterical’ behaviour because the patient’s wishes are refused; the story with inconsistencies within it; the bully; the patient who applies guilt or transference from the patient.

For further examples of many of these techniques from people and ways of managing them read the book Games People Play by Dr Eric Berne.

How to manage your response
The first and most important aspect is to recognise those feelings that the relationship creates within you, for example anger or insecurity and seek in your own mind the causes for these feelings.

This needs careful listening, an understanding of your own reaction and trying to disassociate the emotion from the thoughts.

Ask yourself ‘Why am I feeling in this way about this patient?’

Your own anger or irritation will get in the way of the logical process of a consultation.

How to manage the patient
When you are clear about the reasons why you feel manipulated, the consultation then needs managing to maintain the relationship and to produce the best outcome for the patient and doctor. There are some things that you will need to be assertive about and be clear in your behaviour, for example, prescribing of painkillers or an inappropriate referral.

But there will be some things that might not be important, such as a non-evidence-based antibiotic or an inexpensive investigation. It is important that if you are going to make a stand it is made in the patient’s best interests.

Some of the presentations by these patients also might need skilful and assertive management, for example, very frequent attenders or inappropriate use of the services.

Adult-to-adult discussion and explanation can be the basis for getting your point across in a non-judgmental way.

You will need to be clear in your negotiation and sometimes a written contract and clear plan can form the basis of the ongoing relationship.

Some of the basic skills of cognitive behavioural therapy (CBT) can be used in day-to-day consultations and are well described in Dr Lee David’s book Using CBT in General Practice.

Dr Havelock is a GP trainer in Wooburn, Buckinghamshire 

Case study: Drug misuser

Sally had had a number of issues with drugs in the past. She had been excluded from school for smoking cannabis and was now finishing a methadone withdrawal programme for her heroin addiction. She had been put on diazepam for anxiety and for difficulty in sleeping. She kept losing her prescription or running out and coming to see the emergency doctor. She was difficult for all of us.

In an attempt to resolve the situation I called her in and shared with her the difficulties of looking after her in this way. Together we negotiated a contract that covered the following: she would only see two of the doctors in the surgery for her diazepam. She would come to a booked appointment. She would limit her use of the tablets to an agreed amount. I would prescribe for her but in a slowly diminishing amount. I would arrange some counselling and CBT for her to help with her issues.

She is now off all medication — I think. 

Learning points
How best to deal with manipulation 

  • Understand how the feeling of being manipulated can be brought on by different patients. Realise that different doctors feel manipulated by different types of presentation by patients so find out what makes you feel manipulated. 
  • Always remember that behind a demanding patient might be a real anxiety or concern. 
  • When you feel manipulated be clear where your feelings come from and reduce the anger/frustration that they engender.
  • Managing the manipulative or demanding patient needs gentle assertive behaviour to seek a win/win for both you and the patient.

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