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Problem patient? Use the three Ps


You can win cooperation on the spot by following these simple steps.

Problem patient? Use the three Ps

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Choose article section...Pause: Get your emotions under control Probe: Find out what the patient really wants Persuade: Show the patient how your plan meets his goals Want to learn more?

You can win cooperation on the spot by following these simple steps.

By Susan Harrington Preston
Senior Editor

You know those patients: The one with a sheaf of Web printouts and a list of brand-name drugs who wants to argue over treatment. The brusque one who snarls at receptionists when appointments run late. The one who demands a second opinion as if you're trying to cheat her out of an expensive treatment.

They're the patients from hell. But you can deal with them by mastering a few techniques for persuasion. The key is finding out what the patient really wants—and providing it, but in a way that's okay by you. Best of all, you needn't take more than a few additional minutes to get yourself and the patient on the same side. It's no more time than you'd spend alienating that patient with an argument.

We've summarized the steps as pause, probe, and persuade.

Pause: Get your emotions under control

"When I was a young doctor and thought I knew everything, a patient asking for a second opinion was an affront," says internist William Park McGehee of Opelika, AL. "The patient would see my reaction and would get resentful and say something like 'Well, maybe I'll go somewhere else.'"

Orthopedist Barry C. Dorn was even more impatient: "I'd tell them, 'If you go to a chiropractor, don't come back.' " Dorn, who practices in Winchester, MA, has mellowed since; he now teaches negotiation in the continuing professional education program at the Harvard School of Public Health. (And he says he likes chiropractors.)

Even if your ego isn't quite as well developed as the young McGehee's and Dorn's were, you may well react angrily when a patient comes in with suspicion on his face and a chip on his shoulder. Having read something with a title like "What your doctor won't tell you," he thinks you're out to wreck his life.

Indignation smacks of identity conflict, says Rajamalliga N. "Lee" Sharma, an ob/gyn who runs a conflict-resolution consultancy. Competence and autonomy are at the core of doctors' professional identity, she says, so a challenge to either is apt to provoke anger.

In fact, though, a patient may have no clue that he is challenging you. "Often the patient wants the opinion of someone he or she respects," says Sharma, who, like McGehee, practices in Opelika, AL. "It has nothing to do with a perceived lack of confidence in the physician's body of knowledge."

McGehee's patients were simply following a requirement imposed by insurance companies. "Every elective surgery had to have a second opinion," he says.

You don't know what your patient is thinking. When your hackles rise, then, step aside emotionally. Pause.

Probe: Find out what the patient really wants

Say a patient wants to go to an herbalist, try an inappropriate drug, or have an irrelevant test. What you need to know is why. In negotiation lingo, you need to stop talking about positions and start talking about interests, so you don't waste time and temper butting heads over incompatible plans.

To put it another way, you and the patient share the goal of making him as healthy as possible, but you're arguing about which bridge to take from here to there. For instance, the patient with old news from the Internet is simply pointing out some bridges that are new to him, if not to you. Unlike you, of course, he may not know that a bridge is weak, out-of-the-way, or dangerous.

By asking the patient why he wants what he's asking for, you map the landscape he pictures on the other side of the bridge. Often, you'll need to ask several questions. But once you understand where the patient wants to go, you can point out how your route will get him there faster and more safely than the one he thinks he wants. At least, you can help him travel safely across the bridge he prefers. Either way, he crosses the river, you both stay on good terms, and neither of you loses any sleep.

The process has become second nature to Barry Dorn. "I get a lot of patients with back pain," he says. "I ask them, 'How are things going for you these days?' or 'What would you like to have happen?' The answer may be, 'I want to go to a chiropractor because my best friend went to one and he felt completely better.' Then you have to go forward and say, 'Tell me about your best friend and what happened.' You have to pull the story out of the patient.

"You ask, 'What do you like to do in the course of your day?'" Dorn continues. "The patient may answer, 'I like to go running, I like to swim.' Whatever. And I'll say, 'Does this condition affect your activities?' and they say 'No, not really,' or 'Yes, I can't drive my car to work.'

"It does take a few minutes," Dorn concedes. "However, if you get into an adversarial relationship, you probably spend just as long in subliminal sparring. Drawing the patient out is a lot more rewarding, and the patient perceives that you're interested in him as a human being.

"As a physician, you're the patient's advocate," he notes. "Half of this business is really the emotional response to illness. You have to be able to deal with that."

Persuade: Show the patient how your plan meets his goals

Lee Sharma tells of one patient, already in labor, who came to the hospital for some medicine and insisted on going back home to deliver her baby. With difficulty, the staff persuaded her to stay until Sharma came.

When Sharma arrived, she'd had time to prepare herself emotionally for dealing with a stubborn patient—the "pause" step. Her first action was to probe for reasons why the woman would be so adamant about going home for delivery. "I spent about a half-hour talking with her," Sharma says. The mother wanted to recover quickly so she could return to her work as a missionary. A prior delivery had ended with a cesarean and a long recovery. This time, the mother was determined to control the process. The patient's "bridge" was a rickety one: Deliver at home.

Next, Sharma pitched her treatment recommendation. Both Sharma and the mother wanted a healthy baby and a quick recovery. Sharma agreed to try for a vaginal delivery. However, using plain language that made sense to the patient, she pointed out the risk of uterine rupture. To be prepared in case that happened, Sharma needed to monitor the baby's heartbeat and start an IV. Was that okay with the mother? It was. Her non-negotiable demand for a home delivery evaporated when she saw that her position wouldn't serve her interests.

Here are some tips for making the three-step process work:

• Restate your common goals. This assures the patient that you know her concerns and share them. It also lets you check that you've understood her; she can tell you if you're wrong. In addition, it helps to get your patient into a Yes frame of mind. It sounds hokey, but salespeople and negotiators will tell you it works.

• Link the plan to the goals. Sharma picked a plan she and her patient could both live with—a trial of vaginal delivery—and told the patient the steps she'd have to take to avoid problems.

• Stick to the positive. Sharma didn't argue over the patient's wish to deliver at home, let alone disparage the idea. The treatment plan made it obvious that home delivery wasn't feasible, so Sharma didn't mention it at all. Similarly, when a patient confronts McGehee with a pile of Web printouts, he doesn't scold the patient about trusting the Internet for advice. Instead, he suggests a couple of reliable Web sites and says, "If you see something I need to know, print a copy for me." When the patient brings in an article, McGehee takes it and thanks him.

• Be prepared to parley. If your first explanation of a treatment plan is compatible with what the patient wants, fine. If you need to do a little horse trading, however, offer options that don't go head-to-head with what the patient says she wants. For instance, besides agreeing to try a vaginal delivery, Sharma also told the patient she could wear clothes from home instead of a hospital gown. If the patient still equivocated, Sharma might have sought out a labor and delivery room with homelike furnishings.

• Accept the patient's decision gracefully. If the patient is set on doing things his way, help him do them safely. When someone is determined to see a chiropractor, for example, make sure he goes to a reputable one. McGehee even makes a point of suggesting a second opinion if the patient seems unsure. "I say, 'Why don't we send you over to Dr. So-and-So and see what he thinks? And let me put copies of your pertinent records in a folder to take with you.' That way, I've empowered the patient," McGehee explains. "Everybody's comfortable and happy, and the patient trusts me. It's a win-win scenario."

Want to learn more?

Our sources suggested these books:

Getting Past No: Negotiating Your Way From Confrontation to Cooperation,
by William Ury (Bantam, 1993).  

Getting to Yes: Negotiating Agreement Without Giving In,
by Roger Fisher et al (Penguin, 1999).  

Difficult Conversations: How to Discuss What Matters Most,
by Douglas Stone et al (Viking, 1999).  

Renegotiating Health Care: Resolving Conflict to Build Collaboration,
by Leonard J. Marcus et al (Jossey-Bass, 1995).  

Resolving Conflicts at Work: A Complete Guide for Everyone on the Job,
by Kenneth Cloke et al (Jossey-Bass, 2000).


Sue Preston. Problem patient? Use the three Ps. Medical Economics 2001;11:57.

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