Your SOO has been going great so far and you are feeling confident.

You go to your next station – you see Mr. Huff And Puff. He is a 58-year-old man with COPD. He is not using his puffers despite repeated discussions. He is also a 60-pack-year smoker. The first thing the actor says is, “Doc, do you even know what you are doing?! I am still coughing!â€Â 

These types of encounters are called difficult for a reason – but they don’t have to be so daunting! Check out our tips, summarized from this excellent AFP article.

What are other ways a difficult encounter can present on your SOO?

• Personality disorders (eek!)
• Vague historian about symptoms
• Multiple medical issues
• Uncontrolled pain
• Self-destructive behaviours

Key tips to remember during your SOO:

• Be empathetic

• • Nod your head, do not cross your arms, maintain good eye contact, and use your body language to demonstrate that you are actively engaging in the conversation
• Be nonjudgmental 
  • “I can see that your cough is quite bothersome and it has been challenging for you to use the puffers.â€
• Assess for underlying psychological/medical disorders 
  • Ask about a history of mental health concerns
  • Ask about past medical history, medications
  • Ask about substance abuse: “Do you drink alcohol? Do you take any other substances to help manage your symptoms?â€
• Use a patient-centred approach to communication
  • Form a plan with the patient’s involvement: “What were you hoping we could accomplish during today’s appointment?â€

How to manage a difficult encounter:

1. Remember that this is a common occurrence – family physicians experience difficult encounters during 15-30% of visits.
2. Check in with yourself and acknowledge your feelings Are you feeling helpless? Frustrated? You should be aware of what you’re feeling.
3. Communicate effectively with the patient, and focus on them! Be sure to acknowledge that their symptoms are valid.

• • Try the CALMER approach:
    1. Catalyst for change
       • “I hear how frustrating this has been for you… are you ready to make a change today?â€
    2. Alter thoughts to change feelings
       • “I can see how stressed you are about this. Can we discuss a strategy for how to move forward?”
    3. Listen and then make a diagnosis
       • *Do this at the three-minute mark!*
       • “This has clearly been hard for you and has affected your ability to walk long distances and see your friends. It sounds like you feel isolated. You have also missed many days of work, and this has put a strain on you financially. As we discussed, you have been diagnosed with COPD and it seems your symptoms are not well controlled. If it’s okay with you, I would like to address some strategies for addressing some of the barriers and concerns you may have about quitting smoking and using your puffers… are you open to this?â€
    4. Make an agreement
       • Discuss and agree on a healthcare plan
    5. Education and follow-up
       • “I suggest we set realistic goals – these changes take time and are not easy to implement. I am happy to hear that you are open to making these changes. I suggest we have regular follow-up visits – do you think we can see each other in two weeks to see if you were able to implement some of the behavioural changes we discussed today?â€
    6. Reach out and discuss feelings
       • Plan out ways to improve your own feelings and care
       • This will be more important for you in practice. These patients ARE tough, and de-briefing with colleagues often helps normalize what you are feeling. Encounters with difficult patients are excellent opportunities to grow as a clinician.

4. Consider how often you need to meet with the patient, set appropriate boundaries for visits, and agree on attainable goals
   • “You have multiple medical issues that need to be monitored. It is important that we have regular follow-up. Instead of daily visits, I ask that we set up periodic visits on a weekly or monthly basis. ​At your follow-up visits, we can review your medications and side effects that you may be experiencing. We can discuss which interventions are working for you and adjust therapy based on your response.​ Of course, if there are any new symptoms or changes in your current symptoms, I encourage you to book an appointment to see me sooner.”​
   • Don’t be afraid to set boundaries and limits!​​

5. Remember to take care of yourself – otherwise, it will be harder to provide quality care to patients. Burnout is real and occurs when you neglect your self-care. Take this seriously.

Some final suggestions for your SOO:

• Has the patient waited a long time to see you? Acknowledge the delay, thank them for waiting, and give them an honest explanation.
  • “I am sorry that it has taken over a week to see me and I appreciate your patience.â€
• Has the patient not followed your previous recommendations? Remain nonjudgmental and caring. Try not to get frustrated (we know it can be hard at times!).
  • Consider motivational interviewing. Explore the patient’s desire, ability, need, and reason for making a change.
    • “Can you tell me a little bit about what is driving your desire to change this behaviour? Have you had success making this change in the past? What worked for you back then? What did you find was a barrier when you were trying to make this change in the past?â€
• Is the patient reporting multiple medical concerns and requesting for testing that may not be appropriate at the time?
  • Explore the patient’s issues and why they are requesting certain testing
    • “Can you tell me a little bit more about why you would like this test? What are you hoping it will tell us?â€
  • Assess and treat any psychological conditions – especially if the patient demonstrates symptoms indicative of anxiety, depression, and/or a personality disorder
    • “I see that you are quite worried about this, and you’ve told me how much this is stressing you out. Can we explore this further?â€
  • Consider a team approach to care
    • “I would like to connect you with our smoking cessation team – would you be interested in this? I would also like to refer you to one of my colleagues who is a respirologist to help optimize your treatment plan…â€