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At the heart of general practice since 1960

Coping with patients' unreasonable demands

An unreasonable demand

usually comes as an unnecessary request for a home visit, inappropriate referral or unwarranted investigation. First ascertain the patient's needs.

Frequently, patients express the conclusion they have arrived at ('I need this test') rather than how they arrived there. What is the patient's underlying concern? Has the patient received an adequate explanation for the medical problem? Is the diagnosis understood by the patient? Is more patient education necessary?

Get the full story

Listen carefully. Allow the patient to tell their story, try not to interrupt. Ask for details: 'I understand you are here because you want a PSA; I'd like to understand how you reached that decision.'

When the patient seems to be telling you what to do, or using you as a secretary for a private referral, it is easy to feel irritated. If you start to recognise these feelings, take a deep breath and slow down: give your patient more time. Draw them out and attempt to understand their values and preferred mode of communication. Once they finish ask more specific questions to try to clarify the situation.

Summarise the patient's story and concerns aloud. This gives the patient a chance to correct or amplify. It allows the patient the experience of being heard and understood. You then might share your strategy about the particular complaint. Include at what point you would test or refer. Give the opportunity to ask questions.

Try to empathise: 'It must be very frustrating to be laid up with back pain for over a month' or 'You sound like you are afraid there might be a problem with your prostate.'

If the patient feels you relate to their problem they are more likely to view you as a credible doctor and listen to your suggestions.

You may not be able or willing to accede to a patient's wishes. When this is the case, your style of saying 'no' needs to be tactful. Try to develop an appropriate introduction, you could say: 'I know this is something you were really hoping I could help you with' or 'This is really difficult for me to say but...'. Then give your rationale for the decision.

Increasingly in modern general practice we are advised to involve the patient in management decisions. Not all GPs desire this 'doctor-patient partnership', but in this information age, better informed and more demanding patients are the norm. As family doctors we will have to accept this.

Responding to anger

Angry patients or relatives can be particularly annoying and frustrating. Be careful, never lose your temper and always listen to what they have to say. People often get angry for a good reason and you need to make sure all clinical needs are dealt with carefully and quickly. Once this has been done you will probably find the patient or relative grateful.

If unreasonable behaviour or demands continue you will have to try a different approach. Some patients are unaware relatives are behaving inappropriately; having a direct chat with the patient may help. Make it clear what is acceptable and what is not.

If patients themselves are causing problems it is reasonable to ask them to see another GP in the same practice or even change practices. The mere mention of this often works and can get some patients to start acting more reasonably.

Trivial pursuits

Frequent attenders with trivial complaints and lists of problems can be demanding. Setting a 'contract' with them (a limit of one weekly, 10-minute consultation only) may work well for doctor and patient. For patients who demand an instant referral why not agree and refer them...to another partner? By the time they return to you they might have recovered.

For the young anxious mother who is always bringing her child in to see you, be patient ­ explain to her exactly why and what you are doing when you examine her child.

Many people keep telephoning or calling the surgery simply because their problem has not been dealt with. Instead of trying to guess or assume what they want, why not just ask them? Put yourself in their shoes: is the demand still unreasonable?

If you do not deal with the patient's ideas, concerns, expectations (ICE) they will come back until they are addressed.

Someone once said heartsink GPs get heartsink patients.

If lots of your patients seem to be making unreasonable demands, try stepping back and looking into the mirror. Could you be overworked and under stress? How long has it been since you had a holiday?

Lastly, sharing your demanding patients by talking to your colleagues will help. You're able to let off tension, seek advice and at the same time warn them about specific patients.

Someone said heartsink GPs get heartsink patients ­ how long is it since you had a holiday?~

Key points

 · Listen to what the patient is saying with tact and empathy

 · Avoid arguments with angry patients or relatives

 · Explain your reasoning carefully

 · Say 'no' tactfully

 · If all else fails, breathe deeply and start again

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