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Posted on 4. August 2011

Maybe It's Not the Patient Who Is Difficult

By Kris McFalls

Did you ever see the episode of Seinfeld where Elaine found in her medical chart that she was labeled as a "difficult" patient? The interaction with her doctor went as follows:

DOCTOR: You shouldn't be reading that.

ELAINE: Well, it's, you know, I noticed that somebody wrote in my chart that I was difficult in January of '92, and I have to tell you that I remember that appointment exactly. You see, this nurse asked me to put a gown on, but it was a mole on my shoulder and I specifically wore a tank top so I wouldn't have to put a gown on. You know, they're made of . . . paper.

DOCTOR: Well, that was a long time ago. How about if I just erase it. Now, about that rash—

ELAINE: But it was pen. You fake-erased.

(Annoyed with Elaine, the doctor makes a beeline for the door.)

DOCTOR (on his way out the door): "This doesn't look too serious. You'll be fine."

Studies have revealed that doctors consider one in six patients difficult, but not always for reasons many of us think. In fact, doctors report being most frustrated with patients who fail to show up for appointments, are verbally abusive with office staff or are noncompliant with treatment. As one might expect, patients with multiple complaints, poor functional status and multiple symptoms are also perceived as difficult.

On the professional side of the equation, physician characteristics also play a role in the doctor/patient relationship. Physicians who are younger, less experienced and female, or those doctors who have psychosocial difficulties, are more likely to perceive patient encounters as difficult.

Almost every study reveals that both patient and doctor characteristics contribute to creating difficult encounters. Additionally, most studies conclude that communication skills are key to improving the doctor/patient relationship.

At its most basic level, improving communication starts with both parties being able to speak the same language. To that end, it may be helpful for patients to adopt the "SOAP method" when communicating at a doctor visit. As part of their training, many medical professionals are taught to use the SOAP method to help them organize their thoughts when charting patient information. If patients could prepare for an office visit by organizing their information in the same manner, both sides may find that they will be more effective communicators and, therefore, may be more satisfied with the outcome.

Briefly, the SOAP method is an acronym for:

S Is for Subjective
Start the visit with identifying your chief complaint. Then, explain the complaint by telling the doctor about the symptoms you are experiencing. It's important  to be specific. For instance, if you are having pain, be specific as to where the pain is. Also, describe the pain using such words as dull, throbbing, stabbing or burning. Once you have listed your chief complaint, explain what you hope to accomplish at this visit.

O is for Objective
Again, it is important to give specifics and use identifying characteristics such as colors and numbers. If you have pain, give it a number. Also, make sure to give references for what the bottom, middle and top of your scale represent. For instance, a score of one may mean you have no pain. A score of five many mean that you need pain medication but you can still get your activities done. A score of 10 means you cannot function even with pain medication.

A is for Assessment
Your assessment of how your symptoms and/or treatment have affected your activities of daily living and quality of life will help you and your doctor make adjustments to your treatments. Again, make sure to address how your treatments or chief complaints have affected your ability to function. It is not enough to say "I am worse" or "I am better." What can you do or not do as a result. Give examples.

P is for Plan
Don't leave any office visit without a plan, and don't let visits end with vague comments. How many times has a visit ended with the statement, "Call me if you are not feeling better"? A better statement that creates realistic expectations might be, "If your symptoms have not improved by Monday, please give me a call."

In the end, although it may not be the patient who is difficult, getting the desired result from an office visit is more likely if the patient adopts a method that coincides with the professional's style of communication. Using the SOAP method like doctors do may help patients overcome being misunderstood as the "difficult" patient.
Good communication in healthcare is essential for better health outcomes, especially for patients and doctors dealing with chronic, incurable diseases. Having a chronic disease is difficult. Communication between the patient and the healthcare provider does not have to be.

What have you found that makes communication between doctors and patients more effective?

Download a free SOAP template.

Categories: Need to Know

Comments (1) -

Linda Riley
5:58 PM on Friday, August 05, 2011

I find that today the doctors are preoccupied with the insurance guidelines and they basically are supposed to do the office visit within 15 minutes.  They squeeze too many patients within each hour block of time.  Waiting in the waiting room you get to talk to other patients and when the doctor is late everyone asks what time was your appointment and you will find everytime that there are at least 4 people scheduled with that fifteen minute time frame.  It's very hard to try and fit your concerns, problems or get the result of tests when they are rushing the visit.  You wait 1 1/2 to 2 hours sometimes and then I feel they are rushing you.  I have had many discussions with my primary care doctor and he doesn't like debating issues with me, he will say I can't believe you are debating this with me.  Stop what you are doing and listen to me, I have a problem with you and your staff and I will be heard.  He calmed down a bit so I am very anxious to see how he will be my next visit.

I for one am tired of being labeled difficult.  I will treat them with respect as long as they treat me with respect.  I am tired of chasing them to refill scripts, or call back.  I am not patient #?? I am a real living person whose life depends on them being professional and not treat me like an idiot.  When called on the fact they don't return calls etc. they don't even think it's wrong.   They are like robots, showing no compassion, or emotions.  I'm dealing with several chronic conditions, and I have been through hell the last five years and the last thing I want to do is chase them for the job they are supposed to be doing.  I'm sure I am not the only one who feels this way.  I keep wishing that some of the new doctors out there will be like the old ones who took the time to talk with you, find out what going on in your life etc., you had complete faith in his care.  I don't feel that way today with the majority of doctors I must deal with.  They forgot the basics like "SOAP" evaluation of their patients, and have no bedside manner.  They don't come to see when hospitalized, because each hospital has a staff of doctors who manage your care while in the hospital.  I have a big problem with this because these doctors know nothing about you and it scares me to death whenever I have to go in.  They have mismanaged my meds and they too rush you because they have a whole floor to manage.  This to me is dangerous and as the patient you have to be very, very careful with them.

So until they get there act together I'm afraid we will always be labeled as "difficult" all because we are aware of our condition, treatment and meds and we question them or maybe ask new questions because they are a concern and they don't like that.  They would rather you come in, take a quick listen to the heart, check the ears, etc. and go over your blood work and say you're doing good see you in 4 months but call if you have a problem, and out the door he goes.  Anyway, this is how I feel but don't get me wrong, there are some excellent doctors out there and I have been blessed to have a couple of them, but they are far and few in between and definitely not the majority.

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