Who is Your Patient?
This series explores how both innate and acquired elements of identity manifest in the clinic:
A few years ago, optometrist Ian Whipple of Ogden, UT, examined a patient with the most advanced keratoconus he had ever seen. Dr. Whipple managed to quickly convince the patient that specialty contact lenses would be the best solution after sharing that many of his other advanced keratoconus patients experienced improved quality of life with specialty lenses.
The process went smoothly until a staff member tried to authorize the patient’s insurance coverage and it was denied. Hearing the bad news, the patient marched over to Dr. Whipple’s billing manager and launched into a tirade.
“The patient wasn’t ready to pay for the lenses out of pocket, so he took his frustration out on my staff,” Dr. Whipple recounts.
Whether you’ve been in practice for one year or 40, every optometrist will face a difficult patient at some point in their career. In fact, it’s estimated that 15% of patient encounters are on the more challenging side.1
In today’s world, where feelings of isolation are common due to the pandemic and opinions differ strongly on how COVID-19 protocols should be handled, emotions may be more heightened, which can lead to an environment that’s ripe for difficult patient encounters, says Patricia Poma, OD, of Bloomfield, MI.
“Difficult patients are a part of doing business,” adds Highland, CA, optometrist Pamela Miller. “You need to recognize the fact that people can be difficult, and you don’t know what’s going on in a patient’s life.”
|At Dr. Whipple’s practice, a staff member discusses costs with each patient before their eye exam. Photo: Ian Whipple, OD. Click to enlarge.|
The Cost-Triggered Patient
When a patient is disgruntled, education and communication are essential, Dr. Poma says. For example, if a patient is upset because the office billed their exam as a medical visit instead of billing their vision plan, it’s not appropriate to say, “Your insurance deductible wasn’t met, and that’s how the doctor decided to bill your exam, so therefore you owe us money,” she adds.
Instead, she suggests the conversation should take an informative angle and sound something like this, “The doctor noticed that you have some spots near your macula and therefore spent a little more time examining your eyes. To make sure your condition won’t progress, further testing was done with the latest technology the field offers, which we use to provide the best outcomes for our patients. Unfortunately, this isn’t covered by your vision insurance, but we will work with you to ensure optimal vision and create a plan for the resulting finances moving forward.”
When Dr. Whipple’s advanced keratoconus patient became furious after insurance wouldn’t cover the cost of the specialty lenses, Dr. Whipple changed course and imagined what it would be like to be in the other man’s shoes.
“It was an intense situation,” he notes. “The patient couldn’t see, and we had a solution for him, but insurance wouldn’t cover it. If I were him, I’d be frustrated too. When I recognized that, I could feel empathy.”
In this case, the empathetic approach worked. The patient returned a few days later and was fit in a specialty lens, which he paid for out of pocket. “He’s been on his best behavior ever since, and today, he’s the nicest guy and a great patient,” Dr. Whipple says. “And he’s since gotten insurance that covers the cost of his specialty lenses.”
Transparency is key in defusing angry patient encounters, Dr. Whipple suggests. At his practice, each patient is briefed by a staff member about pricing and insurance coverage before they ever step foot in the exam room.
|Transparency among all the staff of a practice is key in reducing the chances of a difficult patient encounter. Photo: Ian Whipple, OD. Click to enlarge.|
The Denial Patient
Vincent Zingaro, OD, of Chester Springs, PA, recently diagnosed a patient with macular degeneration. The woman, however, kept insisting she just needed a new pair of glasses to improve her vision.
“I explained there wasn’t a change in her glasses prescription and that she needed treatment from a retina specialist for wet macular degeneration. She became angry and told me there wasn’t anything the specialist could do,” Dr. Zingaro recalls. “I explained the treatment options, and I was frustrated too since she didn’t accept my findings or take my advice.”
After a somewhat argumentative conversation, the patient demanded her prescription and left the office, declining Dr. Zingaro’s offer to schedule the referral appointment for her.
A few weeks later, the patient returned with a new pair of glasses that she had purchased at a different office. In the middle of the crowded reception area, the woman began yelling at Dr. Zingaro’s optician, complaining that she couldn’t see out of her new glasses.
Dr. Zingaro immediately escorted the woman away from his other patients and took her to an open exam room, where he calmly told her that the problem wasn’t with the glasses but instead with her retina, and that she needed to see a specialist.
“I made the mistake of dismissing the patient initially when she didn’t accept my diagnosis. I think it’s important for doctors to have empathy for the patient. We don’t always know what each patient is going through in their life, and it’s easy to want to rush through to the next patient when our schedules are busy. Stepping back and acknowledging the patient’s fears can go a long way in minimizing unpleasant patient interactions,” he says.
This time, the woman accepted her diagnosis from Dr. Zingaro, who scheduled the specialist appointment for her.
When dealing with a patient in denial, sometimes a doctor may have to think outside of the box. Dr. Whipple recently diagnosed a new patient with moderate glaucoma, and the woman was not only upset about the news, but also wouldn’t accept it.
“The patient was familiar with the Harry Potter series, so I used the example of the character Voldemort, who is known in the books as, ‘He who must not be named,’” Dr. Whipple says. “I asked her, ‘How can we know what to fight if we can’t even name it?’ We need to talk about it and come up with a treatment plan. I know it’s disappointing news, but what’s even worse is having a condition and not doing anything about it. Your glaucoma is only moderate now, but it could get worse if we don’t treat it.”
Tips to Turn Down the Heat
When a patient loses their cool, it’s critical for the doctor to keep theirs intact, Dr. Miller says. She offers several suggestions on how to turn a negative patient encounter around:
The Fretful Patient
It’s always important to be open and honest about the diagnosis and long-term impacts of a severe or threatening eye condition, even though it may be a difficult conversation to have with the patient, Dr. Poma says.
The staff and doctor need to be very confident and compassionate with patients who are worried, she adds. “The goal is to ensure that we are capable and caring. Eye contact is especially crucial, along with words of encouragement and a smile. I sometimes will make casual conversation with the patient while I’m working so that they’re distracted from what I’m doing.”
When breaking the news about a potentially troubling diagnosis, doctors should keep the initial information simple and avoid using technical, medical language that might be confusing, a study suggests.2
Optometrist Andrew Fischer of Jasper, IN, adopts the “KISS” mindset when he describes a new or changing diagnosis to a patient and keeps his explanation simple.
“Explaining a medical condition can be both intimidating and confusing to a patient,” Dr. Fischer says. “I clearly and briefly explain the diagnosis and whenever possible, use photos, imaging or other visuals to help the patient understand what exactly I’m seeing.”
Dr. Fischer also takes the time to describe the potential visual, systemic and lifestyle impacts the condition could have, and then he reviews the plan to mitigate any progression of the condition, all of which can help ease a worried patient’s concerns.
|Clinics have adapted protocols to ensure safety during COVID. Photo: Ian Whipple, OD. Click to enlarge.|
The Busy Patient
Dr. Fischer recently treated a two-year-old who had recurrent styes. At first, Dr. Fischer prescribed at-home treatments, but the issue persisted. A subsequent dose of oral antibiotics cleared the lid; however, a few months later, the mother brought the toddler back to the practice with a large chalazion. After discussing his findings with the mother and breaking the news that the child would need the chalazion surgically removed, Dr. Fischer referred the patient to the only pediatric specialist who accepted the family’s insurance. The problem was that the specialist was located about 2.5 hours away.
A few weeks later, the patient’s father showed up at Dr. Fischer’s practice, irate and frustrated with the front desk staff. The father was yelling so loudly that Dr. Fischer could hear him from the other side of the office. Dr. Fischer, who was in the middle of an eye exam with a patient, excused himself to escort the father to an empty room where he could vent.
“He was very upset that his son’s appointment was so far away that he had to take time off work,” Dr. Fischer says. “When he’d said his piece, he did calm down enough for us to discuss why I referred his son.”
Dr. Fisher explained to the father that other offices in their area that accept the family’s insurance don’t treat pediatric patients.
“I also made sure he understood that I appreciated the strain the appointment put on his work schedule. I really didn’t do anything more than listen to him, but sometimes that’s all it takes to resolve a difficult situation,” Dr. Fischer says. “I think it is important to remember to approach any situation where a patient is difficult or upset with empathy. Give the patient time to address their concerns, make it clear that you hear them and understand the situation and then do everything that is within reason to rectify the situation.”
The Language Barrier Patient
Sometimes difficult patient encounters may be the result of limited English proficiency.
Dr. Fischer has a large population of Spanish-speaking patients in his community, which he says can create an opportunity for a difficult exam. “I know and understand a fair amount of Spanish—enough to get through an exam easily—until there is a medical condition to explain,” he says. In these cases, he relies on five of his staff members who are fluent or nearly fluent in Spanish.
Additionally, if a deaf patient comes in for an office visit, he will contract with an American Sign Language interpreter. “Otherwise, in these cases, we will write back and forth on a pad of paper, which is slower but also works very well,” he says.
In the case of a patient who has limited English proficiency, Dr. Whipple will ask the individual to bring someone they know who speaks English to interpret during the office visit. “If we’re having a hard time understanding each other on the phone, we ask the patient to bring an interpreter.”
When a translator accompanies a patient to the exam, Dr. Miller will pull her chair back and address both individuals, making a point not to focus all her attention on the translator, which could make the patient feel devalued.
While hiring a translator may be a costly prospect, remote interpreting services are available. When she finds herself in a pinch, Dr. Poma will sometimes resort to Google Translate.
COVID-19 Mandate Frustrations
We would be remiss to not take into account how COVID has heightened patient tensions. Depending on how the virus has affected your region, mask mandates may vary. Almost two years into the pandemic, mask wear and other COVID-related safety restrictions remain a flashpoint for some.
In fact, the American Psychiatric Association’s recent Stress in America report found that eight out of 10 Americans said the pandemic has created significant stress in their life.3
So, how should an OD dial down the tension when a patient is fired up about masking up?
Dr. Zingaro’s practice implemented a mask mandate, regardless of vaccination status, based on recommendations from his state’s optometric association.
“On occasion, we get a patient who refuses to wear a mask, and we just tell them that we can’t see them without one,” Dr. Zingaro says. “They typically turn around and leave without saying anything. Luckily, this is rare and has only happened five or six times in the last 18 months or so. I think it’s hard to find a healthcare facility at the moment that will allow you to go in unmasked. This will change eventually, but this is our current reality.”
Drawing a line in the sand about mask wear is essential for practices, Dr. Zingaro suggests. “I feel if we let that slide, it could get ugly pretty quick,” he adds.
During the onset and height of the pandemic, Dr. Fischer asked all his patients to wear a mask during the exam, and the policy had minimal pushback, he says.
Over the course of the pandemic, mask guidelines changed, and Dr. Fischer’s office followed suit. Currently, vaccinated patients aren’t required to wear a mask during their exam. However, when mask mandates were in full effect, if a patient refused wear, Dr. Fischer asked them to reschedule to a later date, in hopes that the guidelines would eventually change.
During the early days of the pandemic, his practice also adjusted its schedule to include fewer patient appointments throughout the day. This new approach limited contact between patients, gave staff the opportunity to deep clean rooms between exams and provided patients ample space in the optical for frame selection, Dr. Fischer explains.
Dr. Poma has experienced both ends of the spectrum of COVID-19 protocols, and she’s found that on many occasions, it’s difficult to make either side happy.
“We decided to have a discussion among the doctors and made protocols and procedures based on OSHA, CDC and local health department recommendations,” Dr. Poma says.
She and the other doctors at her practice even role-played different scenarios with staff based on potential issues that might arise among patients due to COVID and her practice’s associated safety requirements.
“Whenever a patient comes in demanding service that is beyond our protocols, we calmly tell them that we aren’t able to accommodate their request but that we would be very sad to lose their business,” Dr. Poma says.
When appropriate, she will remind a patient that it’s her job to follow CDC/OSHA guidelines, even if they don’t want to wear a mask.
On the other hand, she has also dealt with people who demand to be seen when there are no other patients in the office. There are those who have even requested that Dr. Poma and her staff be dressed in hazmat gear.
“We simply tell them that our protocols are well established, ensuring safety. We inform them that we have spent over $10,000 in air scrubbers, but if they aren’t comfortable, we can see them once the COVID numbers decline in our state,” she says.
To tamp down any disgruntled patient encounters due to your practice’s COVID-19 guidelines, experts suggest it’s best to spell out your requirements prior to the visit, which may be communicated during the initial scheduling call, and reinforce them with text or e-mail appointment reminders and signage throughout the office.4
When to Set Boundaries
Dr. Poma and her staff make an effort to help each patient unless the individual becomes irrational, belligerent or threatening. In these cases, the patient is told, “You’re more than welcome to take your happiness elsewhere,” she says. The patient is then sent a letter, stating their relationship with the practice has been terminated, and a short list of other eye care offices in the area.
“We also have a code word within our office that’s a signal for others to call 911. We use a name of a frame line that we don’t carry. It is a security blanket for ‘just in case,’” she says.
To ensure office safety, Dr. Miller has mirrors throughout her clinic and doors are left ajar, even during the exam, so she can remove herself from a situation if one arises and so staff have easy access to her as needed.
While violent patient outbursts might seem rare, workplace violence is most common in the medical setting, and it frequently involves a patient or family member threatening physicians or practice staff.5 In one such incident in 2013, a disgruntled former patient used a fake name to make an appointment and shot to death a Newport Beach, CA, doctor after the doctor entered the exam room.6
Practices need to set boundaries and shouldn’t tolerate certain behaviors, Dr. Whipple explains. “I’ve had to let a handful of patients go through the years for inappropriate behavior, especially when employees felt uncomfortable, including one time when a patient took a photo of a tech when she wasn’t looking. That’s not okay. If a staff member tells me a patient is really difficult and isn’t a right fit for our practice, I’ll trust my staff’s judgement and we’ll remove the patient. You need to stand by your team,” Dr. Whipple says.
When a difficult patient encounter arises, Dr. Poma suggests the best thing to do is to simply listen.
“Most people want to air their grievances and just be heard,” she says. “Stay calm and don’t interrupt. Many times, a patient is just upset about something in their lives, and they take their emotions out on staff or management. When the patient is finished expressing, I simply ask, ‘What can I do to make you happy?’ or, ‘How would you like me to fix this problem?’ Most of the time, they’re speechless and realize they were overreacting.”
1. Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159:1069-75.
2. Hardavella G, Aamli-Gaagnat A, Frille A, et al. Top tips to deal with challenging situations: doctor–patient interactions. Breathe (Sheff). 2017;13(2):129-35.
3. Stress in America 2020. APA. www.apa.org/news/press/releases/stress/2020/report-october. October 2020. Accessed December 15, 2021.
4. Cole J. How to calm patients’ nerves about COVID. www.reviewofoptometry.com/article/how-to-calm-patients-nerves-about-covid. June 3, 2020. Accessed December 15, 2021.
5. Cheng KS. How to prepare for and survive a violent patient encounter. Fam Pract Manag. 2018;25(6):5-10.
6. Fry H. Retired barber who murdered Newport Beach doctor was sane during the 2013 killing, jury finds. Los Angeles Times. www.latimes.com/local/lanow/la-me-newport-murder-20170828-story.html. August 28, 2017. Accessed December 7, 2021.