Dealing with difficult patients

 Why this episode

[00:00:06] Munir Adam: Hi guys. It's Munir Adam here, and this is season two of Primary Care UK, which we bring to you in partnership with Integrated Care Support Services. And in this episode, we continue our time management series, and the topic for today is Difficult Encounters. So thanks again for joining, and I'm here to waste your time... 

Or at least that's how I thought I'd be introducing this episode before I actually did the recording for it. The only reason I even chose to do it is because difficult encounters are definitely one of the commoner reasons for running late, and so a series on time management wouldn't be complete without it.

But these are patients who, if it's the next one you're about to call in, you start thinking to yourself, oh no, and your heart sinks. And in fact, they're often referred to as heart sinks. And you think, why didn't I just become a, I dunno, a plumber or sit outside a train station, you know, with a violin box open. You know you're not going to enjoy that next consultation. You want it to finish quickly, but you know it's gonna end up taking a lot longer. And I wasn't so sure that you can actually do anything about that. That's why they're call heart synks after all. 

In fact, Ed Pooley, who you may remember, was with us a few episodes ago, convinced me and will convince you that there is much that can be done to deal with patients who we see as challenging.

At the end of the episode, you should have a shifted perspective of difficult encounters, awareness of some of the categories of difficult encounters in terms of how they present, and hopefully feel better equipped to deal with a variety of these. And of course there is always Ed Pooley's Facebook group that one can turn to if having challenging situations. So we hope that you find it interesting. 

 [00:01:59] Munir Adam: You work in primary care and patients come to see you. Much of the time, the consultation's fairly straightforward, relatively speaking, or perhaps interesting and enjoyable. You feel quite pleased. At the end of it, you feel you've provided a good quality service and the patient leaves happily.

But then every so often you have a patient that you just either feel very apprehensive about beforehand or during the consultation. And this can take many forms and sometimes these patients are referred to as heart sinks. Is it because no matter what you suggest, it just doesn't seem like a good solution for them? Is it because everything you try is resisted? Or maybe they have a million things they want you to sort out in the short time that you have available with them, or they ask for things that are unreasonable. 

And what are the consequences of such encounters? It can affect your mental wellbeing and it can actually lead to a disservice to those patients because they do have needs that need to be met.

It may lead to repeated appointments because they're never quite getting what they feel they need out of the consultation, and it may even lead to complaints, and of course it affects timekeeping, which is what this series is about. Now, before we join Ed Pooley I wanna add a note in relation to the last consultation episode, which was pleasure in consultations with Professor Roger Neighbour.

You may recall that there was a part in the episode when Dr. Neighbour started to talk about the three parts of the consultation, and since the focus of the episode was something different, we didn't actually cover all three of those parts. So here goes. So the three parts of the consultation are first the patient's part, where you concentrate on getting the patient's version of the problem in their own words. The second is the clinician's part where you make sure you've got all the medical information you need to assess the problem, and then the third is the shared part where you and the patient discuss your way to a management plan that you're both happy with. In fact, Dr. Neighbour's book Consulting in a nutshell goes into much more detail into these three parts.

Okay, so now that's done. Let's join Ed Pooley.

Aligning with the difficult patient?

[00:04:00] Munir Adam: Hi, Ed. I found your last episode that we did together really helpful. shared some great ways of saving time, and I'm sure others will have benefited from it as well. As well as of course, the book and the Facebook group that we briefly talked about last time as well. So I'd like to see myself as being generally a positivist and somebody who believes that things can be improved and changed. And I really enjoy consultations as I think I've mentioned before as well. But difficult patients. I mean, a difficult patient is just a difficult patient, really. That's who they are. There's nothing you can do about it. That's why they're called difficult. . I enjoy consultations, but definitely not the difficult patients.

And by the way, I'm not complaining. Well, at least I don't complain for long after I've had a difficult patient. Because at the end of the day, that's life. You know, you could be working in a restaurant and you're gonna have a difficult customer. You could be a school teacher and you're gonna have a difficult pupil.

So I think it's just part of the job, it's part of life and we just have to get on with it and accept that some patients are gonna be harder than others. Things aren't always gonna go nice and easy for us, and that's it. And get on with it. So, I honestly honestly didn't think a about doing an episode specifically on this, but you said at the end of the last episode you said you've got a passion for this kind of thing.

And I thought, oh my God, how can anyone have a passion for difficult patients? But it's not too late, if you're having second thoughts, we can call it a day. 

[00:05:19] Ed Pooley: Yeah. No I did rather land myself in that, didn't I? And thank you very much for inviting me back to, to talk about why we find some patients difficult and how we might, find some enjoyment in the difficulty. I suppose the first thing to clarify is, to explore why we find patients difficult. General practice is very much focused on what makes consultation easy, what makes consultation difficult. And if we go all the way back to the sort of definition of what we would class as heartsink patients, those patients that elicit, that dysphoric, oh no, not again, sort of reaction.

 The sort of various definitions of what difficulty looks like and what form it takes.

I think for me a really simplified way of looking at it is that difficult patients, or challenging interactions as I prefer to call them, are ones where there is a gap between what the patient wants and what we're able to offer within the confines of the service we have or within the confines of what is medically appropriate or reasonable to do.

So that sort of covers, difficulty where we may not know what to do. Cuz that often is the first thing that, that people beginning their clinical journey worry about. They worry about, am I gonna get the medical knowledge correct? Am I gonna pick the right treatment option? Am I missing something? Am I going to cause a problem to the patient or myself? 

As we get more adept at consultation, the difficulty then tends to arise in terms of I know the medicine and I know how to apply it, but the patient is either resistant to what I'm telling them or I'm not getting the full picture of what is going on with the patient.

Or the patient is wanting something I can't provide. So I guess the difficulty stems from. how do you say no to someone where it's appropriate to do so? How do you really get to the root of what is going on for that patient so that you can match the options that you have more closely? But also how do we align ourselves?

Because good medicine is about alignment. You know, you'll have been through this process before this whole concept of ice ideas, concerns, and expectations. And I have a I guess I have a slightly rogue attitude to it in that I don't think it's taught very well. I don't think the majority of people who are exposed to the concept of asking about a patient's ideas, concerns, and expectations really understand why they're doing it.

And for me it's about alignment. And if you understand that, you then begin to understand why you're asking the question. So, you know, if we take consultations back to their basics, when we are asked about understanding what ideas a patient has, we've got to be quite careful how we phrase that question.

Very often you'll hear junior clinical staff say, what do you think has caused this? When of course, the patient will look at you and go, well, you tell me because the word cause is a particular trigger for them. That's the thing they've been thinking about. What's caused this? What's going on?

What is a better way of inquiring about that is to explore what do you think's triggered this? What do you think's brought this on? And using those sort of more lay terms in your consultation can get you to what it, what we actually want to know is what has the patient paired this symptom with as a trigger.

[00:08:53] Munir Adam: Right. I see. 

[00:08:54] Ed Pooley: And so it's a really about reframing and if you understand what the patient has thought has caused this, or triggered this symptom that they've got, you can start to then peel back the layers because the patient may say, oh, I, I think my shoulder pain came on when I twisted awkwardly. Or they might say, well, I'm not really sure, but there are a few things I'm worried about.

And then it gives you an opening to explore further. And the more skillful you do that, the less difficult a consultation becomes. That's a sort of a general rule that's I guess where I would say the majority of good consulters get to. They sort of stick at that point. They know how to ask ICE well, they know how to interpret the information.

 For me, How you make that difficult conversation easier is going kind of one step beyond that.

Vague agendas

[00:09:47] Munir Adam: Oh, one step beyond that as well. So can I just interrupt you there then because I was thinking to myself that ideas, concerns, and expectations is something which is drilled into trainees so much that you would've thought if there's one thing they're qualifying with, it's an appreciation of getting that out of patients. But now what you're saying is that it's almost deeper than not just asking them, what do you think caused this? But actually almost getting to the hidden agenda or the thing that's behind. In other words, their understanding of what the connections might be between their symptoms and anything else that's happened in their life, 

[00:10:23] Ed Pooley: yes, absolutely. 

[00:10:24] Munir Adam: So it's again, just about the way you phrase it. And but it's not just phrasing, is it, it's also the way you look at it yourself that I'm not just trying to say to them, you give me the diagnosis, but you're actually saying you are living with this and you've noticed it and something must have triggered it, 

[00:10:36] Ed Pooley: I think the way that I like to think about it is that between you and the patient, you are trying to put together pieces of information a bit like you would create a jigsaw: to achieve a full picture. 

And sometimes those pieces are nice and big and they give you loads of information. And sometimes those pieces are tiny and sometimes there's cases where the patient doesn't want to give you the pieces cuz they're embarrassed about them or they're worried, or they're shamed or there is something else going on.

But they'll give you clues that they may be holding something back. And that for me is what makes general practice or primary care or any kind of medicine really exciting. It's understanding that hidden dimension that's going on.

[00:11:20] Munir Adam: But with the ones which are difficult, aren't they the ones. often sit down and then they don't provide any clarity about what it is that they want. And that's often why they felt like heart sinks. And at the end of the golden minute I'm thinking, where do I go from here. 

[00:11:34] Ed Pooley: I, I think that challenging interactions come in all sorts. And yes, we have the patients who come in and they will say virtually nothing. It's a little bit like a blank canvas, and we tend to see this in, I guess, late middle-aged men who aren't familiar with GP settings who will come in and they'll give you really vague answers.

And it's almost always about bowels or worries about. Prostate or bladder or something that's a little bit on the embarrassing side for them. And they'll sit there and they will say, I don't feel well. And you try as really you, you try and pull all these skills out the box and they're not giving you anything to work with.

[00:12:17] Munir Adam: Hmm. It's certainly not that unusual to come across the ones who sit down and they talk about all the things that have been tried to help them with their symptoms and say, nothing's really working and I'm. To be really frank, I just feel like saying to them, just tell me what you want. What painkiller do you want? What medicine do you want? What do you want? I'll do it for you now 

[00:12:39] Ed Pooley: make this discomfort end 

[00:12:40] Munir Adam: And the answer is . Yeah. And their response I dunno, , I'm not sure. 

[00:12:45] Ed Pooley: So a really good way of flipping that round, if you get that kind of patient is to say, would it be fair to say that the things that have been tried so far haven't achieved the result that you wanted, to which the patient will then usually nod, and then you can say, What result were you hoping for? Were you looking to try to reduce the pain level that you're experiencing, improve your sleep, improve your mood, or to try to chip away at all of this over a period of time?

 And what you're doing by phrasing it in that way is that you are giving them options to kind of touch on, and getting them to frame it or provide you information in the way that's helpful to you. Because we know we can do things about pain, we can do things about sleep, we can do things about loneliness or isolation.

"I've tried everything"

[00:13:35] Munir Adam: Sometimes you can sometimes they'll come and they say, we've tried all the different painkillers. We've tried seeing the pain clinic. Sometimes they've not bothered tending the pain clinic, and they don't feel that the pain link's any good. It's services and resources or management steps that we've suggested, which they've sometimes not accepted or they say they've tried it, but it didn't help. 

[00:13:58] Ed Pooley: So in that case, one option that you can then say is, well, it feels like pain relief isn't an option for you. It's not working, it's not doing what you'd hoped it would. So let's look at getting you off this pain relief. At least that way you'll feel less drowsy. You'll have fewer side effects. How about that as a change in focus? You know, I may not be able to fix what is going on for you. And we've acknowledged that. We've tried lots of things. How about if we do less? How about if we demedicalize your life, so that you don't have to be on all these painkillers that are causing you constipation and things like that.

And, and it changes the dynamic of the consultation. Sometimes patients will go, oh, no, don't take me off my medication. Everything's fine. and you can say, well, it doesn't feel fine. It feels like there are some things that we could maybe look at improving, and we have to acknowledge that there are limited options that we have, but we can see how we can use those options in the best way possible.

A bit like, you know, we've got a, we've got a hand of poker cards and we need to work out between us the best way of playing the cards we've got. And patients quite like that analogy. It kind of reaffirms to them that medicine isn't and shouldn't be a, a fix all panacea for every problem because it can't be, it deals with some things very well, but chronic illness, chronic discomfort I don't think we've quite, sorted out the best way forward medically for those people.

 Because often the best way forward isn't a medical one. It may be a, a physical rehabilitation one. It may be a psychological one. It may be exploring the meaning of what. having chronic pain gives them, because often people with chronic pain have developed stories and narratives about their life that give them something, 

[00:15:38] Munir Adam: Certainly this is one common type of difficult encounter or different experience when patients are coming and they've got symptoms and we just can't seem to get on top of those. I've come across some patients I'm sure you have, who have conditions like cancer and it's metastasized, but they're actually making the most of their life and they're very positive. And you've got others who have relatively speaking, much less symptoms, but they seem to not accept it and feel that, they've got the short straw and want you to solve problem for them. 

From ICE to ICIER

[00:16:08] Ed Pooley: Yeah. I think, one of the things that we touched on earlier was this concept of ICE. So I like to modify that. So I go from ICE to ICIER, so , I add an extra 'I' in there, which, which stands for identity. So kind of understanding how that patient views themselves in the wider world, in the wider context, do they view themselves as empowered?

Do they view themselves as someone who who just has all the bad luck in the world and nothing they do ever works. Do they view themselves as a person who takes charge of situations? Do they take medication if they would like to prevent illness, for example? So good way of, incorporating that into a consultation would be to say, for example, if you're looking at a cardiovascular type consultation would be to say, are you the type of person that would like to take a tablet to reduce your risk of harm, of high blood pressure in the future, or high cholesterol in the future? Even if there may be no tangible benefit to you now, or you may not feel any different, and a person may say I hadn't really thought about it. What are the pros and the cons? Or they might. . Yeah, I guess it's a bit like an insurance policy. Why not? Or they might say, well, I can't really see the benefit now.

So you can work with that bit of information and again, align what you could offer to what the patient is telling you about themselves. 

So, so that's the extra I and the R comes from reasoning. So it's helpful to know how the person came to the conclusion they came to. So, for example, if they say something like, oh, I've got this terrible chest it's the seasonal thing I always get, I need some antibiotics to, to shift it.

We know their expectation, they want some antibiotics. If you then ask about reasoning and say so every year you have some sort of chest infection, which seems like quite bad luck. What had made you pair. the symptoms you're getting with the need for antibiotics. Oh, well it's cuz it's green , and when you cough up green phlegm, that means it's bacterial, doesn't it?

And then again, it opens up another window for you to specifically address something that may not have been voiced. It gives you the opportunity to educate and empower as well. So I add those two additional steps to ice. So add in a question about identity, how the person sees themselves in relation to their illness, their symptoms in the wider world, but also how a person rationalizes and makes , reasoning part of their assessment.

[00:18:34] Munir Adam: And , it's very common for us to find as clinicians that we're, we're in a situation when they are demanding some medication, for example, antibiotics for a chest infection, we go into a defensive mode and start explaining to them why it's not necessary and so on. And what you're mentioning here is a reasoning to actually explore their rationale for why they want the antibiotics. So let me get this right. So I see a, so ideas, concerns...

identity, expectations, reasoning. 

expectations, and then reasoning. Okay, that's nice thing to remember. I'll hold my judgment back on that for now. But I'll certainly put it to use and see where it takes me. 

Manipulative help-rejectors

[00:19:12] Munir Adam: Let's talk about some other types of difficult encounters. 

[00:19:15] Ed Pooley: The ones that, and I get asked this a lot, is the, is, you do a lot of work on consultation skills and you seem to like really challenging patients. Who are the ones that wind you up ? What are the patient interactions that you dread? And I think for me, the ones that I still find difficult to this day are what we call the manipulative help rejectors.

They're the people who are coming in, often on a weekly or fortnightly basis. There's generally quite an element of drama to how they present. Sometimes it will be in extremis, and they will want everything done, but then they'll say that there's lots of reasons why what you suggest is either rubbish or ineffective or it's been tried before and it's very, very easy certainly as a junior clinician to get sucked into the drama of feeling that you need to do something.

So there's a generally a risk of you going above and beyond which a, as a one-off isn't necessarily a bad thing, but it's important to remember that going above and beyond for one patient may reduce your ability to go above and beyond or normal for other patients just simply because you will get used up.

 But it can also suck you into something called a drama triangle as well, where the patient is positioning themselves as a victim who needs to be fixed and only you can fix them. And you end up in this somewhat dysfunctional relationship with the patient where everything is externalized to you as the rescuer to do something.

You offer lots of solutions and then the person reacts to that and then rejects everything, generally in quite a dramatic way. 

[00:20:53] Munir Adam: These are the ones who blame everything but themself and expect that the lies outside of themself and not accept responsibility. And if I'm understand you correct, what you're saying is that actually, by going along with this, you reinforcing that.

[00:21:06] Ed Pooley: Are. You tend to reinforce that belief system. Usually the process behind it is, is a psychological one. And it's usually a subconscious game that a person is playing or they're reenacting something. So they may be reenacting the dynamic that they had with their parents, where their parents told them what they had to do, but they didn't want to.

So they, instead of rebelling against their parents when they were a helpless child, they're rebelling against the authority figure, and then leaving feeling good that they've rejected or, turned down that authority figure in some way.

[00:21:39] Munir Adam: But I, we wouldn't know that would we, I wouldn't have a clue what's going on deep in their subconscious. 

[00:21:44] Ed Pooley: You wouldn't generally have a knowledge about that. Generally speaking though it's often worth just dealing with the face presentation, which is, this person comes in week in, week out, they want something from me. But when I suggest what could be a solution, they reject it and say that it won't work for them.

[00:22:02] Munir Adam: Yeah, it's a horrible feeling don't like it. You're, you're making the effort to think provide a solution and they, they don't want to accept it. Even though you think it's reasonable, almost feels a little bit disrespectful... 

[00:22:11] Ed Pooley: It, it does. the key thing is to drag the process kicking and screaming into the light. And the way that you do that is that you say to a person, it feels like we've been here before. I have limited options as to what I can offer, but none of them seem to fit. So I guess what might be helpful is for me to get some solutions or options from you about what might help and to see how I can facilitate those for you. 

What you are doing is you are encouraging the person to come up with their own solution. So rather than the valid. Being because they have got one over on the authority figure. The validation becomes that you are reinforcing that they're an autonomous being and can come up with solutions themselves.

[00:22:59] Munir Adam: That sounds really sensible, but do they ?

[00:23:03] Ed Pooley: Sometimes they do. Sometimes they will say, well, I don't know what to suggest, . And you can say, well, what we can do is let's park things for now. If there are any changes in the future or any new drugs come online or any new developments, I'll contact you and let you know. If you think of anything in the meantime or certainly anything that you wouldn't want to try, then you can contact me. Take care. Have a great day. You know where I am if you need me. 

[00:23:26] Munir Adam: It certainly sounds much more like an adult to adult conversation, what you're suggesting compared to this, where we often find ourselves where you feel like you are the one who's got to fix the problem. and you can't. 

Health lament: Hairdressor mode

[00:23:39] Ed Pooley: What's really interesting is the concept of health lament. So lament are kind of tales that people have about themselves and about their identity that gives them meaning and substance, and some of these chronic laments where the story never gets fixed or never reaches a conclusion are ones that we can just acknowledge but don't feel we have to participate in. So I often tell people to go into what I call hairdresser mode. so when you are sat having your haircut, you are about your life, the pa the hairdressers asking you how are things, oh, well, you know, I've got this terrible arthritis in my knee, and oh, well, things aren't what they used to be. And all of these youngsters, I can never get in the shops without feeling nervous. 

And all of these issues come tumbling out, but the hairdresser doesn't feel the urge to fix any of them. All they do is just simply acknowledge them and the patient unloads that and burdens it and then moves on. But they get their hair done because the focus has been on making them look good or making them feel different.

It's not been upon medically fixing stuff. So I remember, one patient who was possibly one of the most challenging patients I'd ever, dealt with, who had quite a complex range of, medically unexplained symptoms, fibromyalgia, chronic fatigue syndrome, and was , very invested in finding physical treatments for this and had exhausted everything.

 But she was, and I'll have to change some of the details here for confidentiality, obviously I discovered one day that she was the most incredible cook, you know, most incredible baker. And once I discovered that, because I'd asked her about her identity, I'd said, you know, what kind of things do you do outside of dealing with all of this stuff and all of the stress that these symptoms cause?

Oh, well, Dr. I, I really enjoy baking. It's one prizes and, it really gives me a sense of achievement. All the consultations from then on became about validating her other than ill life. So I would say things like, oh, how's the baking going? Have you won any prizes lately? How's it all going? Are you able to keep up and do what you normally do?

Oh, yes. It's wonderful. I must bring you in some when I'm next passing and I just say, oh, that's, that's wonderful. Keep going on. I'll see you when I need to. And we'll, keep an eye on your blood pressure and your weight and all of these physical parameters just to make sure that we can do the things we need to do. and we'll just ignore the rest 

And then there was a lot of, there was a lot of trauma that this person had gone through in their early life, and in their early adulthood that was very clearly anchoring a lot of , these physical symptoms and physical conditions and that she just couldn't let go of a lot of them they've become part of her life and now her new identity. But we managed to shift the nature of the consultation to focus on the other aspects of her life and actually what initially started off as a person coming in once every two or three weeks, then become a patient who would come in once every six months, every 12 months. And the relationship was just much more functional, certainly from my end of things, because I noticed that I wasn't feeling stressed, I wasn't feeling anxious. And from her end, she would come in smiling and talk about those other aspects of her life, recognize that I couldn't fix everything.

And we had a much more functional relationship as a result.

[00:27:04] Munir Adam: . When I reflect on what patients normally come with is the negative, what's not right about my health, what's not right about my wellbeing? That's what they come in with. That's what they focus on and what we focus on and address. What you've suggested here is that sometimes it's better if they come and actually talk about some positive things. If you know that the negative things are not going to be possible to resolve anyway, 

[00:27:28] Ed Pooley: I'm really interested in how the psychotherapeutic modalities can impact us in terms of how we consult on a day-to-day basis.

 It was very popular in the 1950s and sixties to use things like transactional analysis as a way of understanding the consultation. And I think we've lost the understanding of some of the limits of medicine where, for example, we should be involved in care and where we should maybe withdraw a bit and actually empower patients rather than disempowering them.

 I think for me, one of the most interesting frameworks is, is from Hellman, who was a social anthropologist who tried to understand, what the thought process is of patients who experience symptoms, and he came up with this idea that they wonder why me?

What have I done? , how long is it gonna be? What impact is this gonna have on my life? And actually, those things haven't gone away. Those aspects of symptoms are still vitally important for patients to understand. And if we can tease out some of those, we often find that a lot of the difficulty in consultations can be diminished because you are actually addressing the hidden fears and the things that patients, often, it's often a second or third level of the consultation.

Demanding patients

[00:28:43] Munir Adam: Some patients are at the complete opposite end of the spectrum, aren't they? They're the ones who rather than feeling helpless and hopeless, they tend to demand, they want to be referred. They feel they have the answer to all the problems. They want to have investigations.

That's a different kind of patient that I find is difficult to manage sometimes because those demands are unreasonable. This not medically justified. How do you find that... i

[00:29:06] Ed Pooley: I do find that happens. I, I think, again, that can be a challenging group of people to work with. But if you understand why they're asking for that, what they're asking for is they're asking for more of a degree of certainty about what is happening to them than they feel that they're getting from you.

And you can really feel that as a, as a criticism of your skill as a GP. But what's quite helpful is to, is to flip it round on its head. One area that I find, I'm now much more comfortable with is when it comes to investigations. So let's say I have someone who comes in with back pain and they've had it for three months, four months, five months.

And at that point they've gone through those thought processes and they're thinking, will this ever get better? And this doesn't fit my expectation of what back pain should be like, you know, for me, back pain should be there for one week. I should be in bed, I should get lots of pain relief, and then I should just be able to get up and move around.

And, and we know that back pain doesn't always follow that path. And so you'll examine them and at some point there'll be, some sort of suggestion about imaging. You know, can I have an x-ray ? Can I have an MRI scan? Rather than saying no to that, what I tend to do is to say, you know what? that's a thought I've had myself. And one of the ways that we can use those scans give us the information we need is to use them when we're uncertain about what's going on. So I get the sense that you are worried that this back pain is not really going the way it should be, or where we might not have got the actual target of what's going on. And the patient will say, oh yes, well, I did wonder. I, you know, it's not behaving as it should do. And so then what I'll say is, well, actually what we are looking for in an MRI scan is two things. We're looking for where a nerve is pinched at your back or in your spinal cord. And we're also looking at where we might want to operate or do something about a problem where a nerve is squashed.

But actually when I examine you, part of that examination is to test if any of those nerves are squashed. And I can't find any nerves that are squashed. And the way that I check for nerves being squashed is to do this test, this test, and this test, and the patient's like, oh, right. So they, then it builds confidence that I'm able to do the things that are unvoiced, but they're worried about.

So, part of my new way of doing things is to deliberately talk through what I'm doing and what I'm looking for when I'm examining a person. I'll try and be as specific possible. So I won't tend to say, oh, this is sciatic pain, or this is low back pain. I'll tend to say actually what we can see from testing you is that there's these two muscles in your back.

One's called your Quadratus lumborum and one's called your, you know, erectus spiny. And these ones are the ones that are really hurt and ascending the signal to your brain that's causing a lot of pain. And we need to get them moving in a new way. We need to change that signal. And so what we need to do is to find a way to change the signal.

And the best person for that is someone who's got expertise in physical movement and rehabilitation. So I'm gonna have a word with our specialist physio to see what they recommend in terms of getting these muscles to work more normally. And that's gonna take a couple of months at least, because it takes time for brain circuits to adapt and it, by doing that, what you are doing is you're taking a patient on a journey of explaining what you can. You are highlighting your expertise and your knowledge, and you are also selling a solution to a patient that exactly matches the thing that you have identified as a problem.

Whereas if you just say, oh, it's low back pain. Have some naproxen, come back, if it's not gone in two months, if it hasn't gone in two months, the patient is left with this sort of slightly uncertain process in their head, this unclosed loop.

And, you anticipation is an incredibly powerful psychological driver. If we've got these unclosed loops in our head where we're thinking, but what if it's cancer? What if it's, what if it's something really serious ? My family member had this and it, it got missed and they then died.

Or all of these thoughts that people have by being open patient and pinpointing stuff and making it a collaborative thing where you're not really saying no. What you're saying is that's a reasonable suggestion, but a better approach might be X, Y, and z. Again, it's more of a negotiation and it tends to get people on board much easier, and it tends to smooth out those difficulties in the consultation.

[00:33:43] Munir Adam: It's probably not always straightforward to know which bits to share with the patient in terms of that conversation. Cuz I do find often with junior staff they're talking through everything that they're thinking and sometimes it's counterproductive cuz they're sharing information which just causes more anxiety to the patient.

 It can be a bit tricky to know when to say what and which better to share and what not to share. In general, would you say that sharing your examination, finding is a good idea?

[00:34:09] Ed Pooley: It depends on the patient and your previous experience of the patient. I think I would start by sharing a little, I would start with rather than voicing your internal monologue, which can be, I really hope this person doesn't have cancer. Oh, well, let me just check they haven't lost any weight that, that kind of process.

What you is saying things like, let's just have a look at how your hips are moving. Good. This tells me that the ligaments and the structures around the hip are working as normal. Let's have a look at us stretching the nerves in your leg. Ah, that's interesting. I found a little bit of irritation here. 

So I think we need to address that further. Let's explore that bit in more depth. So then you can say, well, this is what I've found, but in the back of my mind, I have an expectation of how long these symptoms should last and if they don't behave themselves, or if you start to notice other symptoms as well. Like for example, you know, if you start to lose some weight or you start to have difficulty with your bowels or your waterworks, it's at that point that I might need to reexamine and reevaluate things. And we need to adapt the plan. 

And I'll often use the word the plan going forward. That feels much more collaborative. It gets the patient's expectations and understanding on board, and it's forming that jigsaw with taking turns and being respectful to each other's sort of approach. And it seems to work much better.

Intimidating patients

[00:35:27] Munir Adam: You speak of respectful. Sometimes you get those who come and they're not so respectful. 

And this takes different forms. You've got the obvious aggressive type, the ones who come and they almost make you feel intimidated or threatened. And then there are others they articulate very well, but often their language and their style is a little condescending they effectively talk down to you 

[00:35:52] Ed Pooley: Absolutely. I think what's often a very helpful thing to do is to. gently confront that. So if you find that a person is being quite pushy or they are demanding stuff, or they've come in with a long list of expectations, what I find often helpful to say is, it feels like you've had to fight to get what you've needed in the past. Is that how you're feeling now? 

And then a patient may say, yes, it is. I, I feel like I've been brushed off in the past. And then you can say, so what I want to make sure today is I really understood what's going on so that I can use my expertise to find the best way forward. And I can get your opinion about what might be suitable and what you might like to consider.

And again, it just rebalances that, that interaction. But again you've got to slightly confront it in a delicate, respectful way. You could say something such as, Something feels a bit off to me. It feels like you've come with a long list and you've got to push to, to get to what you need. Is that how you are feeling? 

And again, the patient may say, no, that's not how I'm feeling at all. , you can say, well, you we've talked about what might be going on, and you've got a very clear list of the things that you'd like. Some of those, I can't do some of those I'm not allowed to do because of local policy or, because of medical management decisions that have been made and are taken outta my hands.

How should we proceed here? What would feel like an appropriate way forward? Again, you are keeping calm, you are keeping neutral. 

If a patient is angry,, It's an emotion that's designed to focus attention. It's designed to tell people, shut up, listen to me. I need something. But it's a secondary emotion in most cases. It's triggered by fear, shame, guilt, sadness, loneliness, all these sort of emotions that, that, are a trigger for anger. So the key thing with any type of anger is to acknowledge it first and to say things like, I can see that you're frustrated with this process.

You know, I'm feeling quite frustrated I'd like to get you the things that I feel would help. It feels like you want to get some answers. Let's just take a step back and see how we can move this forward.

[00:38:07] Munir Adam: One situation where acknowledging always helps me is when I've kept a patient waiting a long time.

When they come in, cuz I have on occasion made the mistake of not acknowledging that and then the consultation's been tense right from beginning to end. Whereas all you have to really say is, I'm sorry that you've been kept waiting a long time.

Or, thank you for waiting. You don't even have to apologize sometimes. And actually 99% of the time they'll say, no, it's okay. I understand you've been busy. That's all they want. 

Four causes of disharmony

[00:38:36] Ed Pooley: Yeah. I think, if you look at the reasons why there is often disharmony in relationships between primary care and patients. There, there are often four causative factors, and they are that there's an attitude issue where patients feel that , your attitude has been awful,

there's been a mismatch; again, that, that could be projection or any other number of sim things that actually the patient has brought to the scenario. It could be about access. Access is probably the single biggest one. So time waiting, how long it's taken to get to the appointment.

Acknowledgement. So that's acknowledging something about the patient. So acknowledging that they've had to wait, acknowledging that, you know, the medicine that you can offer hasn't, or isn't ever going to fully a hundred percent deal with their symptoms. And the last one is action. Whether there's a mismatch between what the patient wants and what you're able to offer, or you haven't done something when you said you would, or you've delayed a referral or something.

So it tends to be one of those four things, attitude, acknowledgement, access, or action. And if we're aware of those, we can take proactive steps to recognize when a patient might get frustrated with it and then bring that into the consulting room. And then the consultation gets somewhat contaminated.

One of the things I take pride in is giving each symptom it's full airing. And I don't think I'm gonna be able to cover one go today. So actually I'm gonna need to rebook you in so that I can get things sorted for you fully, so I'm not missing anything.

[00:40:06] Munir Adam: Ed, I dunno how you articulate things in this way , it's not unusual for me to see myself and trainees and so on saying things like, oh, that's another problem. Can you just book another... 

[00:40:16] Ed Pooley: it's a bit like chess. It's a bit like knowing the moves and reading the room and having a plan for it. But using the patient's language back and reflecting back to them, I think is very helpful. And it's something that, some people find easy, some people find more difficult, but it's quite good to have rehearsed what to do in, maybe two or three of those situations that can derail any of it.

 So what do you do if the patient starts to get angry? What do you do if the patient starts to then talk about the other child that they've brought into the consulting room, who's ill? You know, what things do you have to think about there and how might you deal with it? 

[00:40:52] Munir Adam: And and sometimes you're in that situation, you do know the answer. You've been in that it's a familiar scenario and you manage it better. And there's other situations we feel completely lost. 

Can difficult actually be fun?

[00:41:01] Munir Adam: But one thing I'd like to ask you about is do you still get that feeling of discomfort when you're in those scenarios?

Does a heart sink stop becoming a heartsink?, or is it a case of just managing them more effectively and better, but you're still feeling that discomfort? I I'm not asking the parallel to that might be that after years of training, I guess I've become a lot better at breaking bad. but I still don't enjoy breaking bad news. It's still something I'd much rather not to do. 

[00:41:31] Ed Pooley: Experience and reflection and deliberately focusing on how you might manage that situation allows you to separate out the emotional panic that we get with the, oh, no, not Mr. Smith again with X, Y, and z to, okay, it's Mr. Smith again. Let's see how we can manage it. So you, you end up separating out the emotional dysregulation that you can feel, and you start to replace it plan.

[00:42:00] Munir Adam: There's another one that's just come to me, which I know I experience. I've gotta ask you. This patient comes along and says, so-and-so's has advised I need to have, I dunno, an MRI scan I saw so-and-so specialist or consultant in some place, and they've said, I need this done. You have no evidence of that written down anywhere. You don't know if they're telling the truth. They're saying it as a matter of fact, this is what's got to happen. And I'm thinking, ah, I, no, I don't No, there's no reason why you need this done.

[00:42:32] Ed Pooley: I, I think in those cases what I tend to do is to say, okay, I might have some bad news for you. I, it is something I might be able to do, but I probably am not gonna be able to do it. And the reason for that is that these processes we have to go through, so if I'm going to expose you to ionizing radiation, I've got to take responsibility for that.

And so what I'd like is I'd like for your specialist to contact me and I can have a discussion with this specialist about the best way forward. And it might be about them requesting the scan, or it might be that we can come up with a better solution about what I'm able to offer. Cause often my hands are tied in these situations and just leave it at that and then end the interaction by saying that you're gonna come back to the patient.

 It buys you that thinking space, that time to think and reflect rather than being stuck in panic mode of either agreeing to something you later regret or can't do, or knee-jerk saying no, when actually you may be able to do it. Or it may be one of those things that on reflection is a suitable thing to do, but you've created yourself a bit of time and distance to reflect and proceed accordingly.

[00:43:43] Munir Adam: Hmm. Listening to all of these things from you, it's sounds like the whole area of dealing with difficult encounters is like a specialty on its own. The different scenarios we've discussed, they've got different solutions, but there's some sort of overlap in terms of the way you are explaining the approach to those situations. 

[00:44:00] Ed Pooley: What I'm doing is just applying techniques from negotiation and psychotherapy and positive psychology and sales, and just using those techniques to augment my consulting style. You know, we talked before about the Facebook group I run, that was specifically designed to look at how do we manage challenging consultations and interaction every day?

[00:44:24] Munir Adam: But you know what else you should do? You should start doing local difficult... 

almost like a, kind of a, live do you know,

[00:44:30] Ed Pooley: I have this, one of the, one of the things I do think the NHS could improve upon is we're very good at dealing with the here and the now. We're very good at firefighting. We're very good at dealing with acute, severe illness. What we're perhaps less good at doing is integrating and being a bit more holistic.

So I would love to have, clinics set up where you have, a GP who is adept at dealing with medically unexplained symptoms. You've got maybe a neurologist and a cardiologist who likewise, aren't hamstrung by their specialist knowledge and can think a little bit more broadly. You might have a physiotherapist and you might also have a psychotherapist.

And all of those people together can evaluate a patient's symptoms and work out the best way forward for them. But those kind of endeavors are often really, really expensive. And sadly, a lot of patients who would benefit most from them aren't in the groups of people that win votes or sometimes vote anyway.

 I would love to have a sort of a specialist medically unexplained symptoms, difficult conversations, service that would adequately help patients who fall under that umbrella.

[00:45:40] Munir Adam: My own personal view is that sometimes we make things too complex. And and then we're looking for a very complicated solution to something and sometimes having a very simple conversation, because these are simple conversations. They're not very far-fetched or complex One thing for sure, the way that you've explained this, it's full of positivity and it's, it does inspire some hope. . And, I I'll if I'm stuck with a difficult patient.

I'll jump onto your Facebook group and 

Ed, help me out! 

[00:46:06] Ed Pooley: No problem at all! All. 

[00:46:06] Munir Adam: Thanks for joining., 

[00:46:08] Ed Pooley: cheers. Take care.

[00:46:09] Munir Adam: Okay.

Final words

[00:46:13] Munir Adam: And you can find out more about this and find out more tips and ideas in Ed Pooley's Facebook group, or have a look at some of the books that he has published. Well, we hope you found this beneficial, and I would recommend to try to apply these techniques, learn about them, apply them, practice them, and you might be surprised. Of course, we didn't try to cover every possible type of encounter or heart sink, firstly, because that will take hours. But also because the shift in mindset and approach is really what we're after. Hopefully the renewed confidence can take you a long way in developing your own solutions when you're faced with a novel, challenging situation just by feeling more empowered. 

But don't expect it to always be easy. Challenges are part of life, and this episode was really about getting a little bit better at managing those rather than expecting them to be eliminated from our professional lives. 

That's it for today. Do keep the feedback, ratings and reviews coming on Apple Podcasts or using the link in the show notes. It really does mean a lot to us if you do, and so do spread the word as well. And for now, on behalf of Primary Care UK and the Integrated Care Support Services, keep well and keep safe.