Teaching Residents and Fellows to Redirect ‘Difficult’ Patient Encounters

It happens. Once in a while, patients come in for a medical appointment and act very distracted, talkative and anxious, barely stopping to take a breath, when they meet with a doctor. Physicians with less experience sometimes let these patients continue talking at length, without interruption, for fear of appearing rude or uncaring. But in many instances, this type of patient behavior masks something deeper – a major challenge, concern or life event – that generates enough anxiety to distract both parties from any medical issue at hand.

photos of Residents role playing to learn how to address challenging patients
Family medicine residents Alicia Kepich, M.D. and Ingrid Gutierrez, M.D., role play with Kassandra M. Bosire, M.D.

Education to the rescue: A new model developed at the University of Miami Miller School of Medicine educates residents and fellows on how to effectively redirect patients during these difficult interactions. Called “The 7Cs protocol,” it provides a framework for junior physicians to act, versus react, during stressful patient encounters.

Historically, “the visit would then last far longer, which would lead to the residents and patients alike feeling quite frustrated because no one was getting their needs met. This type of scenario is a kind of lose-lose situation,” said Heidi Allespach, Ph.D., associate professor of clinical family medicine, medicine and surgery, and Director of Behavioral Medicine in the family medicine, internal medicine and surgery residency and fellowship programs.

Instead, the strategy trains residents and fellows these 7Cs:

1. Calm down, step back, get centered and think clearly. This helps them to see things more objectively and not to personalize the patient’s behavior, Allespach said.

2. Connect with the patient, either by gently touching their hand or shoulder and then making a comment such as ‘Ms. Jones, it seems like you have a lot on your mind but I’d like to bring you back to our discussion about your blood pressure.’ Allespach said, “If residents are not comfortable touching a patient’s hand or shoulder, I suggest they move their chair a little closer to the patient in order to make this connection.

3. Concern. The doctor shows concern by helping the patient to become aware of their behavior. An example of what the physician might say is, ‘Unfortunately, we only have a limited amount of time together. I’ve noticed every time you come in you’re very talkative and have a lot on your mind. I’m concerned about you.’

4. Cause. The physician encourages the patient to identify any underlying reasons for their behavior. The doctor asks the patient if there is anything in their life causing them to feel fearful, upset or anxious.

For example, a resident met with a very talkative and agitated patient. The resident wanted to help but time was passing and the resident started feeling frustrated, Allespach said. The resident realized she needed to calm down and relax. “She then touched the patient’s hand, thereby grounding her, and when she explored the underlying cause with the patient, the patient became tearful.” It turned out the patient was feeling depressed and helpless because she was unable to be there for family back in Cuba, including a sick son. These distressing emotions, in turn, were causing her to experience significant gastrointestinal pain and headaches – which were the reasons she had come to see her doctor that day.

“Once a resident can illuminate the underlying cause for the patient’s ‘problematic’ behavior, which often goes deep, a really beautiful thing happens,” Allespach said. “It becomes a win-win. The patient can talk about what is really concerning them and, consequently, their presenting symptoms lessen, and the resident then feels that they are truly able to help the patient.”

5. Comfort the patient. After identifying the cause, a simple statement of reassurance from the physician, such as, “I feel quite honored that you’ve told me what is happening in your life right now. Everything you are feeling is normal and I will be here to help you get through this tough time” can be very helpful, Allespach says.

6. Contract. After completing the other five Cs, the resident is encouraged to make a “contract” with the patient, which involves an agreement to address the target behavior should it arise again and, if it does, to obtain the patient’s permission to redirect them back to the topic at hand.

7. Continuity. Wherever possible, it’s important that any subsequent appointments be made with the same physician in order to maintain and strengthen the connection, concern and comfort provided by the initial doctor.  In the example above, “the resident said the experience really deepened her relationship with the patient and they enjoyed more satisfying and meaningful interactions from that point on,” Allespach said.

Along with Erin N. Marcus, M.D., associate professor of clinical medicine, and Kassandra M. Bosire, M.D., assistant clinical professor of family medicine, Allespach shares these strategies with a wider audience of medical educators in an article entitled “Sailing on the ‘7 Cs’: Teaching Junior Doctors How to Redirect Patients during Difficult Consultations in Primary Care,” which was published online on April 11 and will appear in print in the April 2017 issue of the journal Education for Primary Care.

Importantly, the training does not aim for junior physicians to memorize rote responses. “These points aren’t a blueprint. They are part of a general guide to coping with complex encounters in the clinic,” Marcus said. “It can be frustrating for our young doctors when they are in the middle of a busy clinic with a very unfocused patient, and it is helpful to use these points as a scaffolding for their clinical interactions.”

“I really feel this is a topic that is vastly overlooked and undertaught,” Bosire said. “We as trainers of junior physicians are well versed on advising our residents on what information needs to be obtained in an interview to present a good ‘HPI’ [history of present illness], but we often fall short on providing them the skills needed on how to be great accumulators of information when interviewing patients.

“This paper gives the junior physician permission to redirect challenging patients, which improves both patient outcomes and provider competency for similar patients that are promised to present in the future.”