How I manage difficult encounters

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In ”Challenging cases: How can we better manage difficult patient encounters?” (which begins on page 414), Dr. Teo and his colleagues offer excellent advice. Based on my 38 years in family practice, their 3-principle approach to difficult patient encounters (focus on the relationship between doctor and patient, incorporate the patient’s emotional experience, and let the patient’s perspective be your guide) rings true.

The practical strategies Teo et al recommend should be standard tools in every pri- mary care physician’s medical bag. I especially like the BATHE mnemonic, a reminder to engage patients emotionally by addressing:

Background (What has been going on in your life?);
Affect (How do you feel about that?);
Trouble (What troubles you the most about this situation?);
Handling (How are you handling this?) and
Empathy (That must be difficult).

As a young physician, I judged my success by my patients’ success in “getting well.” After a decade in practice, I realized that patients change at their own pace, not mine. There is no therapeutic substitute for providing a setting in which patients are encouraged to tell their life stories. This insight helped me to relax and avoid becoming frustrated when my patients did not adhere to their medication regimen or failed to overcome their depression, anxiety, chronic fatigue, substance abuse, or you-name-the-condition. I have also learned that there is no therapeutic substitute for providing a setting in which patients are encouraged to tell their life stories.

And finally, I am keenly aware that we must develop—and cultivate—a deep knowledge of the difficult conditions we confront daily as family physicians. I used to groan when the third patient of the day with low back pain walked in. Not anymore. That’s because I have thoroughly studied the excellent body of research on low back pain. I now know the natural history of low back pain, and I know what to do and what not to do for my patients. The same is true of my approach to depression, anxiety, substance abuse, and patients with a “positive review of systems.”

As family physicians, we must be experts in the diagnosis and management of chronic conditions, which are present (to some degree) in nearly 50% of the patients we care for. The art of medicine is essential, but not sufficient. Art plus science equals optimal outcomes for patients and physicians.

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