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What should you do if a patient steps over the line? Dr Stefan Cembrowicz advises

What should you do if a patient steps over the line? Dr Stefan Cembrowicz advises

How to deal with difficult encounters

Most patients stay within reasonable social boundaries with us; but a few step dramatically over the line. You are able to remove patients from the practice list when the working relationship has irrevocably broken down.

This could be after an aggressive outburst, such as verbal abuse that cannot be resolved by a quiet talk and an apology. And those who demonstrate real violence can now be obliged to attend violent patient units for their GP care.

More difficult perhaps is knowing how to handle patients who are demanding, rude, aggressive, manipulative but do not quite step over the mark. Today's hard-pressed NHS is widely publicised as being under threat of cuts and rationing. Patients' behaviour may be caused by anxiety, frustration at delays in treatment, the effects of their illness, and the belief that it is necessary to express oneself aggressively to get one's 'rights'.

Most complaints arise in a background of poor communication; keeping patients informed about waiting times, delays in treatment and availability of services prevents many upsets. Well-cared-for waiting areas show that patients' comfort is important. Other service industries take pains with their 'clients'; so should we.

Grievance procedure

Some practices use a grievance procedure for difficult incidents. The patient is invited to a meeting with the practice manager to resolve the situation, at which the practice's point of view is clearly expressed, and the possibility of removal mentioned.

This also enables receptionists to see that their feelings are taken into consideration. Patients may be appallingly rude to receptionists, yet butter may not melt in their mouths when they see their doctor.

Most staff recognise the difference between someone who is 'het up' by the need for treatment, and those who are deliberately abusive, threatening or frightening. Some patients lack the verbal skills to assert themselves without sounding aggressive; some cultures express themselves louder than others.

Once you know what your limits are, dealing with difficult patients becomes easier. Ejecting irritating patients from the list, while gratifying, may merely lead to reallocation later. In my experience patients who have been allocated do find this a salutary experience; suddenly the all encompassing welfare state, so long taken for granted, has been removed!

Ideally, once difficulties have been resolved, you are left with a positive working relationship which will be sustainable in the future.

In the real world it is wise to accept that a peaceful agreement may only be reached by some compromise on both sides, and that abandoning a rigid stance on matters of principle (eg graciously overlooking a certain amount of rudeness) may be the diplomatic way to settle matters.

One solution for difficult patients is to show them behind the scenes to meet your reception staff. Their perceptions of receptionists as mere obstacles to care may be revised in this way. Another solution may be a formally worded letter: a powerful tool in the right circumstances.

Finally – never act in anger.

Stefan Cembrowicz is a GP trainer in Bristol

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