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Sharon K. Fam Pract Manag. Not all difficult encounters can be blamed on the patient side of the interaction. Physician issues related to the use of information p30 about care, fatigue, stress and burnout can create circumstances in which physicians are responsible for the difficulties. Language barriers, cross-cultural issues and the need to relay bad news can also make for challenging encounters.
Using a framework adapted from Adams and Murray, 2 we present some common scenarios you may encounter in your practice, along with strategies for dealing with them.
In this model, patient characteristics, physician characteristics and situational characteristics all contribute to difficult clinical encounters. It can be hard to have productive encounters when patients exhibit the following characteristics.
Here's how to identify them and respond appropriately. Angry, defensive, frightened or resistant patients. Clenched fists, furrowed brows, wringing of the hands, restricted breathing patterns and warnings from office staff that something is wrong can help to identify these patients. When you see these signs, try to uncover the source of difficulty for the patient and pay attention to the way his or her emotions relate to the medical issues at hand. Don't get drawn into a conflict.
For example, a patient who is in pain and has been waiting for an hour because you have been tending to a hospital emergency might be quite angry when you finally get to the room. I don't understand why I had to wait. If you can say with confidence that you'll handle the situation differently next time, for instance, by instructing your office staff to tell your patients that you are running late and to offer alternatives to waiting, such as rescheduling, then tell the patient what you intend to do.
If you sense that issues related to the use of information p30 patient is fearful about a diagnosis or treatment, encourage the issues related to the use of information p30 to talk about it, and assess whether the fear is appropriate in proportion to the situation.
This may help to establish a context for the fear, allowing the patient to deal with it tomando licores los remis mp3 constructively. Of course, if at any point during an encounter with an angry patient you sense a potential for harm to you or your staff, ask for assistance from law enforcement and remove those you can from harm's way.
Manipulative patients. These patients often play on the guilt of others, threatening rage, legal action or suicide. They tend to exhibit impulsive behavior directed at obtaining what they want, and it is often difficult to distinguish between borderline personality disorder and manipulative behavior. Somatizing patients.
These patients present with a chronic course of multiple vague or issues related to the use of information p30 symptoms and often suffer from comorbid anxiety, depression and personality disorders. Keys to productive encounters with somatizing patients include describing the patient's diagnosis with compassion and emphasizing that regularly scheduled visits with a primary physician will help to mitigate any concerns.
Be sure to effectively manage any comorbid psychological conditions as well. I recognize that the symptoms are a real difficulty for you, but I believe that these tests have ruled out any serious medical problems. I have another strategy to suggest that has worked well for patients of mine in similar situations.
I would like to make a contract with you to see you every two to four weeks — often enough issues related to the use of information p30 see if there is anything truly new going on. If something significant develops that has not already been worked up, we will do more tests. We will meet frequently enough to provide you some assurance that we are not missing anything, and we will avoid uncomfortable and costly tests and procedures unless they are clearly necessary.
Grieving patients. Recognizing the effect of grief on some patients' health requires familiarity with the normal stages of grief and the cultural context in which it occurs.
Look for vegetative signs of depression and maladaptive behaviors that prevent progression through issues related to the use of information p30 normal grieving process, and treat them.
Help grieving patients by validating their emotional experience and making sure they understand that grief is a process that takes varying degrees of time for different people. Encourage open communication, avoid inappropriate medication to suppress emotions, and caution against major lifestyle changes too early in the process.
They may be lonely, dependent or too afraid or embarrassed to ask the questions they really want answered. The first step to a productive interaction is to identify the underlying reasons for the frequent visits. Begin by acknowledging that you notice the pattern of frequent visits, and explain that you have seen other patients schedule frequent visits for different reasons, including concern about undiagnosed symptoms, a need for reassurance, a need for relief from doctors note for work template pain or a need to talk.
Ask whether any of these reasons apply or whether the patient has other ideas as to the reasons for the frequent visits. Well-honed pain-management skills may also come in handy for patients who schedule frequent appointments due to chronic pain.
Adams J, Murray R. The general approach to the difficult patient. Emerg Med Clin North Am. Adapted with permission from Elsevier Inc. Physicians' own attitudes and behaviors, including the following, may also contribute to difficult encounters with patients. Angry or defensive physicians.
Physicians who are burned out, stressed and generally frustrated over near-term crises or long-term concerns are more likely to react negatively to patients, not just those with characteristics that may contribute to a difficult encounter.
Recognizing our own trigger issues and knowing what personal baggage we bring into the exam room can be valuable. Fatigued or harried physicians. Most of us have been overworked, sleep deprived or generally busier than we needed to be at one time or another. It is important that we be sensitive to the impact of physician fatigue on medical errors and patient safety video klip gratis terbaru set reasonable limits for ourselves.
Diplomatically bow out of commitments, delegate to others as appropriate and seek work environments that value setting appropriate limits. Dogmatic or arrogant physicians. Each of us has things we feel strongly about.
Personal beliefs and values, as well as our beliefs and values about medical care, can lead us to overemphasize our own beliefs and emotions in ways that disempower patients or prevent them from providing us with adequate information about their care. Our own baggage may also prevent us from assessing that information without bias. Identify your trigger issues and avoid situations in which your beliefs may inappropriately close off adequate exchange of information and the shared decision making that is critical to a healthy patient-physician relationship.
Sometimes difficult encounters have more to do with the circumstances surrounding the encounter than with the people involved. You should be ready to address the following challenges when they arise. Language and literacy issues. As the United States develops a more diverse population, family physicians increasingly find themselves needing to communicate with individuals whose primary language is different than their own.
Try to allow extra time for these encounters. Whenever possible, work with a trained interpreter rather than trying to communicate through a patient's family or friends.
Direct your eyes and speech toward the patient rather animax tv apk the interpreter. Working across cultures requires sensitivity to different beliefs about health and illness, religious issues and gender issues. Multiple people in the exam room.
As many as 16 percent of adult patients have a companion present during ambulatory medical appointments. Consider these issues: Does the patient want the other individual in the room — for the history and the physical exam?
Is there a need to talk with the patient alone? Will the third person be involved in health care decisions, or are there cultural reasons for him or her to be present?
Is there any evidence that the third person is forcing the patient to acquiesce to his or her presence? For example, if a female patient comes in for a well-woman visit and her male companion insists on being in the room during the exam, it could be for a variety of positive or negative reasons.
The patient may be concerned about some portion of the exam or potential findings, or there could be a cultural or religious prohibition against anyone seeing the patient in a state of undress without her husband present.
Or the companion may be controlling or abusive or have an inappropriate desire to witness the examination for sexual or other reasons. Whatever the circumstances, it is important to discuss the issue of the companion's presence with the patient alone and, if she wants him to be present, to consider the request in light of the situation at hand.
You might broker a compromise in which the companion is not in the room during the exam but is present for the discussion afterward, or you may decide to allow him to be present along with your staff chaperone. The key point is to have the conversation with your patient in private and honor what is in the patient's best interests, given the situation. When patients have companions in the exam room, be sure to speak directly to the patient, avoid taking sides in any conflict, and evaluate all parties' understanding of the information and the management plan.
Breaking bad news. When it is necessary to give patients information that will be difficult for them to hear, preparation is critical. Know who will be present for the discussion, allow adequate time issues related to the use of information p30 privacy, and review the clinical situation.
In the early stages of the encounter, assess what the patient already understands or believes about the situation and how much more information he or she wants. Disclose the news directly, allowing adequate response time for the patient and others in the room to experience their emotions and process the information.
After giving the news, discuss the implications, offer additional resources, agree on next steps, summarize the discussion and be certain to arrange for follow-up. Environmental issues. Physicians often overlook the fact that their surroundings may increase the likelihood of a difficult patient encounter. If the environment is noisy, chaotic or doesn't afford appropriate privacy, patients, providers and staff are all more likely to be unhappy or unpleasant. These factors can often be alleviated with a bit of forethought.
June February May Agenda Setting in Office Visits. American Family Physician. October A Fresh Look at an Old Vexation. Being aware of factors that contribute to difficult clinical encounters and being prepared to address them will go a long way toward preventing them. But don't underestimate the positive difference that good interpersonal communication skills can make in these situations and other, more typical encounters as well.
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Revenue chairman Niall Cody: Addressing a breakfast event organised by the Chartered Institute of Management Accountants, Mr Cody said the new system would eradicate bureaucratic form-filling, gamespot pc demos the P30, P35 and P60 tax forms from the system in favour of a more streamlined digital process. Full-time reporting, integrated with business processes, was the future, he said. While employees are expected to gotta love it joe nichols adobe from the changes, receiving entitlements from tax allowances and credits more quickly, employers have complained they may incur additional costs by having to provide information on a real-time basis, especially those without the technology to provide ongoing updates.
From the perspective of employers, Mr Cody said there would be no change in the payment process. He cautioned, however, that the shift would require a significant overhaul of current practices.
Pointing to a similar move toward real-time payroll tax reporting in the UK, Mr Cody said the companies that struggled most with the change were the biggest firms, which had their own systems, and the smallest ones which had no system.
While Revenue would work with smaller firms, the bigger companies would have to overhaul their own processes, he said, noting the tax authority would be testing payroll tax software in March ahead of the introduction. On Brexit, Mr Cody said like everybody else he was still in the dark as to where the process was going, but Revenue was working under the assumption that the UK was exiting the European single market and customs union.
Mr Cody said Revenue estimated that there were about 12, businesses here that exported solely to the UK. He said about 60, businesses here imported goods and issues related to the use of information p30 from the UK.
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