Managing Patients With Behavioral Challenges in an Outpatient Setting

In this video, W. Clay Jackson, MD, DipTH, provides tips for managing patients with behavioral challenges, including setting boundaries with a patient, and how and when to seek guidance from a trusted leader or mentor. 

W. Clay Jackson, MD, DipTh, is an assistant professor of clinical psychiatry and family medicine at the University of Tennessee.

TRANSCRIPT:

Dr W. Clay Jackson: Hi guys, Clay Jackson, here from Memphis, Tennessee and I want to discuss something that probably we've all dealt with from time to time, but we may not talk about that much. I'm in an outpatient setting in general medicine in Memphis, Tennessee. I see lots of patients with mood disorders and see patients from all spectrums of life in terms of age and disease condition, etc.

Something we don't spend a lot of time discussing is, how do we handle difficult patients? Specifically, today, I'd like to talk about what we do when difficulty actually becomes untenable. When patient language or behaviors exceeds the boundaries of what is appropriate in a professional setting to give both them the good care that they deserve, but also for staff and other patients. How we can maintain a safe and professional environment?

Let's talk about those four choices and what we might do. Number one, just ignore the problem, allow it to continue on. I would urge you not to do this, for a number of reasons, there may be challenges to the practice and to the patient.

Also one of the challenges that we may not be as cognitive of in the past, but now we're beginning to realize is that continuing to allow situations that put people outside the professional boundaries can constitute moral injury and can undermine morale. It can lead people to not feel fulfilled in their work or safe in their work. We don't want anybody to be in there.

It's not fair to staff and to other patients to place in a situation that you might tolerate, but it's actually inappropriate for them, so ignoring the problem, probably not the best answer. Let's go to the other extreme, and that is saying, "We're not dealing with this anymore, we're not going to communicate about it, we're not going to offer a second or third or 37th opportunity, you're out the door."

In most cases, if you decide to dismiss a patient from the practice, there is a window in which that patient needs emergent care. Otherwise, it's called patient [inaudible 02:17] and I would ask you to consult with your state board, or your state insurance carrier, or your malpractice carrier, about what the exigencies are for your state. In our state is 30 days for the patient.

What situations might arise in which this would be appropriate? Imminent threat to staff, imminent threat to other patients, these types of circumstances, unless there's a an inpatient consultation with a radical change in medication that could give you hope that these behaviors will never be repeated. Imminent threat, obviously, constitutes a reason to move forward with potential dismissal without an opportunity to change those neighbors, if it's threat, isn't it?

Let's talk about those middle two choices. That would be where you communicate with the patient in an attempt to salvage the therapeutic relationship, if the behaviors can be changed.

We want to communicate with the patient. Set the boundaries first before that conversation starts. Know what you're going to say. Outline very specifically, what the behaviors are that are intolerable. Then what the consequences would be if they aren't changed, and what the consequences will be if they are changed.

Communicate with that patient, I recommend communicating verbally, after you've already determined those boundaries, and maybe you go ahead and write that out so that you can follow a script in the conversation. It's very clear which way the conversation is going.

Try to avoid emotional language or subjective language, you want to be very objective and be very calm. If possible, focus a conversation about the patient's well‑being and why these behaviors are undermining the therapeutic relationship that would offer the patient high‑quality care.

Obviously, if the patient changes the behaviors after such a conversation, then that's wonderful. The therapeutic relationship may actually be stronger because of that conversation, and moving through that conflict.

Unfortunately, not all patients and clinicians can keep it together, so what do we do if they don't agree to move forward under the new Conditions of Participation, or if they do agree to move forward, but they violate the agreement that has been made?

It's appropriate to refer the patient to another clinician for continued care. Again, we talked about that not abandoning the patient to allowing them in our case, a 30 day window to return to the practice if there is an emergency.

You want to communicate with the patient trying to end on a positive note if you can, and in addition to the verbal communication again, remember we said communication documentation two different things.

A written letter to the patient outlining the plan is very important. I would recommend that you send that through certified mail, in order that there's no question as to whether the patient has received it.

Hopefully, we can all handle conflicts with patients in a professional manner, and can offer our patients the best chance to move forward in a positive way. We can certainly protect our staff and other patients from inappropriate behaviors that may be happening in the clinical space.

We want to always keep in mind that we want to, first, do no harm. That doesn't just mean the patient, it also means to our staff or other patients, and ourselves. Balancing all that can be quite a challenge. Reaching out to trusted colleagues. Protecting patient confidentiality all the while, of course, is a valued strategy to help you negotiate these challenging issues with patients.

I promise you, once the issue is resolved, and the conflict is handled, you probably feel a lot better about the situation and realize that you might have been carrying a weight of unresolved conflict that may actually free you once that's finished to provide better care. Hopefully, for that patient, his behavior changes but certainly for the rest of your clinical panel as well.

You'll move forward in a better way to provide the best care that you can. I hope this helps today and good luck with treating your patients.