This, she says, starts with physicians improving their own communication skills to better ensure that all patients have realistic expectations about their treatment outcome and recovery. Beyond that, however, it means tuning in to the red flags that may identify such patients and to examine their own behavior and practices for triggers that may cause or exacerbate difficult encounters.
"Patients can be difficult for a variety of reasons," Dr. Ritvo says, associate professor of psychiatry at the University of Miami, Miller School of Medicine. "They may have mood, anxiety or personality disorders," she says, adding that body dysmorphic disorders are especially common in dermatologic or cosmetic patients.Tricks of the trade Yet with 5 percent to 25 percent of cosmetics patients fitting this description, Dr. Ritvo says it behooves physicians to incorporate some tricks of her trade.
"Using an empathetic, honest and direct communication style, doctors can improve their effectiveness and quality of care and avoid considerable aggravation and even lawsuits," she says.
This may entail modifications to the office environment and implementation of policies to support these efforts. It may also mean physicians should cast a critical eye on their own behavior to recognize how they may inadvertently contribute to patient care problems.
Identifying difficult patients Unlike "perfect patients" who tend to be educated, communicative, cooperative and even grateful, the difficult patient is demanding and intermittently dissatisfied. This may be due to unrealistic expectations or underlying mental illness, but there are plenty telltale "red flags," including a long laundry list of complaints about previous procedures and doctors. They may also be willing to spend money they don't have and be frustrated that repeated procedures aren't getting them the results they expected.
Dr. Ritvo described a number of difficult personality styles not only in terms of their behavior but in the response their personality is likely to elicit in others. They included dependent clingers, entitled demanders, manipulative help rejecters and self destructive/deniers. (Groves, J. Taking Care of the Hateful Patient. NEJM. 1978; 298:16, 883-888.)
What doctors can do Dr. Ritvo, who has presented her methods at meetings and in small workshops around the country and in Mexico and Canada, says there is much that physicians can do to head off problems, starting with the physical environment and interactional style of staff and physicians.
"Make sure you and your staff maintain a clean, organized, courteous office environment in which patients and their concerns are treated with respect," she says.
"Be sure to make proper introductions, complete with handshake and good eye contact. You, your staff and the physical setting should convey a feeling of warmth, hopefulness and helpfulness. Cosmetic patients come with expectations that they will leave your office looking better, which they may consciously or unconsciously equate with being happier."
She also recommends implementing good medical practices designed to know your patient and manage their expectations. This includes eliciting information carefully during the patients' history and taking the time to answer all questions, providing handouts and other materials if necessary.
It is particularly important, she says, that cosmetics patients fully understand what their procedure involves and what it is likely to accomplish.