Dealing with Time-consuming Patients at Your Medical Practice
Dealing with Time-consuming Patients at Your Medical Practice
What do you do with a very needy, very time-consuming patient? I don’t mean a medically complicated patient, who needs a lot of time spent during visits, or one who needs a lot of tests or prescriptions, or even one who needs a lot of counseling about his disease. I mean the patient who calls five times to 10 times a day, leaving 10-minute messages each time. The same one who will stand at the front desk for half an hour after her visit has concluded.
Case in point: I have a patient who has very well controlled diabetes on one oral medication. She has no complaints when she is here, but she does have a hundred questions. No, I take that back. Not a hundred questions. Just one or two …that she asks a hundred times; questions that have been answered repeatedly during previous visits and during in-between-visit phone calls. Simple enough questions, like “Do you want me to take more medication?”
I have tried to be patient with her, but I hate to have other patients wait, so I have unfortunately taken to just saying, “Your visit is over, I’m going on to the next patient.” Then she sits in the exam room for another 15 minutes still talking, to no one in particular. Then she goes to the front desk and starts talking to the staff, asking them the same questions she asked me. Then she’ll sit in the waiting room for another half hour. It makes other patients uncomfortable. It takes up the valuable time of my staff. Now this past week, she has called every day, a minimum of three times a day (one day 8 times!). My various staff members have talked to her, I have talked to her. And just like her visits, these phone conversations have no end.
I would not mind (well, maybe I would but not much), if there were pertinent issues, if she had a complicated case and needed a lot of medical attention. But she really doesn’t. As a matter of fact, I don’t even think she needs a specialist. I have tried (OK, selfishly) to tell her that she can follow up with her primary-care doctor and that she doesn’t need to see me, but she wants to.
And before you say, "poor woman," you should look at it form her point of view. You might be thinking, "Maybe she’s scared or confused." I’ve already done that, okay? Her first few visits and phone calls, I was patient with her. I gave her as much time and attention as I could. But just like an ER has to tend to more urgent patients first, so do I. And a pregnant woman on an insulin pump with an Hba1c of 11 or a man just diagnosed with thyroid cancer need more time and energy than she should.
I have called her primary-care physician to express my concerns about her ability to care for herself. I worry that this is all a manifestation of dementia or mental illness. I don’t know what else to do from here. I am at a loss — both from a time management standpoint and a patient safety standpoint.
How do I get her to stop calling? How many times do we have to call her back? How do I kick her out of the office when she is here? How do I do any of that and not worry that this time maybe there is actually something wrong?
Excellent ! I think the problem is larger than lonliness...
I think the issue is much larger than loneliness. I'd be concerned about dementia and her ability to care for herself. My next step would be a discussion with her PCP re: her support system: family, caregiver etc.
Agree with Karen. I would also have only ONE staff member communicate with her, especially during office calls and check-out process. Have this staff escort her through the office during her visit including during check-out to avoid having the patient initiate a new conversation with other staff on issues that have already been addressed.
My first impression is that she is a very lonely woman and needs somebody to talk to or somebody to care about her. Maybe suggesting to her she should volunteer her time somewhere will give her something to do. It seems as if she has noting to fixate on besides her illness. Besides that, I guess you may just have to not be her physician any longer.
Of course, sometimes the lingering patient has other issues that have nothing to do with why they came. So it is important to ask if there anything else important bothering them or that they are going through that they need to talk about.
If there is no other issue, I think for these patients it is important to set boundaries. Remind them (with kindness and patience) at the beginning of the session that you have limited time. Let them know it is not appropriate to linger in the waiting room, give them an idea of what concerns are appropriate to call for and which are not. This will have to be constantly reinforced. So when a call or visit is inappropriate, you remind them at the time of the call or visit that this did not warrant a call or visit.... and so the next time this happens (do not call or visit). It is a bit time consuming in the beginning, but in my experience this significantly cuts down on the inappropriate behavior.
This will still be a time consuming patient so you may want to schedule more follow ups than you would for others to reassure and remind of boundaries.... meet them in the middle.
I had a patient with similar behavior, and even thought at one point that she was drug seeking as she kept asking for ambien refills. After some research, I learned that she was no picking up her prescriptions, and forgot where the pharmacy was. After inviting family I to the conversation, it was clear that her behavior was a result of early Alzheimer's dementia. I suggest you try to get her to bring a family member to the next visit, and perhaps discuss her again with her PMD to see if a dementia work up has been initiated. she may truly be forgetting that she has asked the same questions over and over.
She is stalking you.Her behavior sounds like it.Get a restraning order to stop her harassing you.
Dr Ronnie Klein.
Really, this is your idea of a pertinent response?
I sense the response was a reactive one - Sounds more like a JD solution than a MD solution
Feroz
JDs are more reactive than MDs? That generalization sounds reactive to me. I know plenty of caring JDs and MDs, and plenty of callous JDs and MDs.
Are you kidding me? Are you really even a Doctor? Where is your empathy for your patients! This attitude of yours is what gives the profession a bad name! Shame on you!
Dr. Atiq Kahlid
You haven't said how old she is, but sounds as if she might be older. If she is, has she lost her husband recently? Sometimes an older person depends on their spouse and when they are gone can't function or remember. Sure it could be early dementia or alzheimer's disease. Taping a coversation answering her questions might be an option, having things written down for her to take if its the same question.
Dealing with elderly patients is just a fact of life, its going to get worse and you have to learn how to deal responsibly, patiently and ethically with them. Imagine if it were your parent, how would you want them dealt with it you weren't around to handle the situation?
Indeed, try to flesh out what is happening in her home. Get a sense of this from relatives involved in her care and ask someone to accompany her during the visit. If there is a psychiatric component, by all means, bring in the specialist. Is she forgetful because of a health condition or due to medications? If the cause is determined, a targeted approach is better. For example, yesterday I had to get a Xopenex nebulizer for asthma exacerbation. At the end of the treatment, I was somewhat incoherent when speaking but pretty clear in what I was thinking. My NP treating me gave me a summary of the visit and explicit instructions for my home treatment. I was quite grateful.
Since the patient in question s habitually taking a lot of time, more effort should be taken in finding her issues not related to the reason for the visit.
There is always a root behind the problems you encounter with your patients. I think you have certainly done the right thing by contacting her primary physician but unfortunately, it sounds like she has placed her trust in you. Again, unfortunately, that means you will be the one who must deal with the issue.
With the information you have presented, I don't think you are dealing with a physical illness but rather one that revolves around anxiety. If I'm correct, she doesn't need a physician she needs a therapist.
How to deal with this? Sometimes you have to take the time to fix a problem. I would recommend you have your staff do a little research to find out which therapists in your area that take her insurance. I would call and speak to them (remembering HIPAA) and discover one that could help her deal with heightened anxiety and just as you would refer her to a specialist if you noticed problems with heart, kidneys or lungs, refer her to that specialist. BTW, it is too much to give her a list of therapists as that would overwhelm her. It is better to give her one you think she can trust and send her to that one.
When you speak to her about this, be very straight forward and say, "I have noticed you have a lot of anxiety about your (issue she is seeing you for) and I am not trained to help you in that area, so I'm referring you to my colleague ___. She specializes in anxiety and if you approve can work with me to help you through this. Then give her the number to the therapist.
She may or may not take advantage of this but being able to ensure her that her insurance will cover this will go a long way to help. IF she goes to the therapist, that gives you a very powerful question to ask her when she does the 100 questions during her visit. "____ this sounds to me like you are becoming anxious again. Have you spoken to ____ about this?" If not, then say, "Can you promise me you are going to speak to her today about your heightened anxiety regarding this issue?"
Good luck!
Stalking? I don't get any sense that this patient is malevolent. And she is not stalking if she hasn't been barred from the premises. There are no grounds for a restraining order if nothing illegal is occurring. If she asks the same question over and over and doesn't appear to remember the answer, it sounds far more likely that she is a patient with dementia rather than a criminal.
Thank you to a voice of reason!
Perhaps the doc who proposed that the patient is a stalker was just having a very bad day or week, or has truly been victimized himself in this manner, and was quick to jump to conclusions that are so easy to quickly tap out and disseminate prematurely with a click of the mouse/keypad before further reflection sets in. It's hard to imagine that he really believes this is a case of stalking or anything resembling it.
Have you ever thought of referral to a behavioral health professional? That was the first reaction that I had to your concerns. This complaint is not unique -- in fact is probably more common than you may hitnk. Our practice, which specializes in psychophysiology, works with patients who need the patient education and counseling delivered in a format and time that cannot be delivered in the format and constraints of a high volume specialty practice.
Have you ever thought of referral to a behavioral health professional? That was the first reaction that I had to your concerns. This complaint is not unique -- in fact is probably more common than you may hitnk. Our practice, which specializes in psychophysiology, works with patients who need the patient education and counseling delivered in a format and time that cannot be delivered in the format and constraints of a high volume specialty practice.
This is what is missing. FREE/very low cost social workers, and Mental Therapy.
The problem, many thing we need money for war not mental health and equality and higher stand-red of living.
Restraining order is a problem not a solution.
First I commend you on your show of patience and care that your note indicates. You are a good Person, I could sense. . and a good Physician (I hope as well) :-)
When such patients come to the office have an employee escort them to an exam room and complete paperwork etc and do attend to the patient early as possible.
If possible schedule such patients towards the end of day, slow days - I understand you cannot always do that - but if possible it is best to get them when the office is not buzzing with activity
Have some relative or responsible companion accompany her for her visits
Give her good reading material that she feel informative and helpful. .
Keep smiling - Pray and Meditate :-) and keep a stop watch :-) make sure you are not giving more than 15 mins - You have a business to run. . There are other patients and issues to attend . . Wish you all the Best . . Feroz
I think that it would definitely be worth evaluating for a psychiatric disorder. A few examples:
1) Generalized anxiety disorder, depression, hypochondriasis and OCD - may present with excessive worry and repetitive questioning about health. Reassuring the patient is usually only helpful for several minutes. You want to work on helping the patient understand that nothing is certain in medicine. You can never guarantee that a treatment will definitely be effective or that a medication will be well tolerated. You will want to help the patient live with some level of uncertainty. Brief regular visits with the GP can often be helpful at avoiding unnecessary use of services.
2) Autism, asperger's, schizophrenia - may present with poor social skills. The patient may not understand that the conversation is over and you have other work to do. Politely insist that you have to stop and it is time for them to leave. Explain that you will not listen to phone messages and if there is an emergency, she should go to the ER or call 911, otherwise you will discuss the issue at the next visit.
3) Dementia, traumatic brain injuries etc.. - The patient may be confused and not remember the answers that you have given her. Test her memory regarding other subjects (current events, the President etc...)
My first thought was also loneliness or dementia- but I have several patients with neither who are also infinite time sinks-and some who are sick, but very manipulative.
Some , after years consideration, some are complete narcissists.
Apsberger's and some forme frustes of these- many engineers and scientists are easier- you give an action plan,with clear directives,. You will get back many graphs, almost in power point, but it will be data you can work with.
I have started setting the timer on my phone to to buzz after 15 minutes for some of these , to help me wrap up, walk ahead to to front desk to be very clear about the follow up to help wrap up the visit.
These patients are why I shudder at a patient portal- I am trying to get it designed to a limited number characters like a text , so I don't get daily" War and Peace " in my inbox.
I agree, those kinds of patients are also out there. Before going into medical research, I practiced law, focusing on civil rights/government accountability. I don't know how many people go into doctors' offices expecting free medical treatment, but I'd say around 30% of the people who called me thought they were entitled to pick my brain free-of-charge for an hour or so. It wouldn't concern them at all if they knew that even before economic collapse of 2007/2008 (that we're still trying to recover from), 50% of attorneys in Washington were working grueling hours and earning less than $60,000 per year, taking at least a decade just to pay off their student loans. These gold diggers would call numerous attorneys sequentially to try to get free legal advice about about contract disputes and the like. After a few months, I stopped offering a free initial 15 minute consultation and required a $50 fee for a 30 minute initial consultation. If the person calling was genuine and in a dire situation, I'd make an exception and try to steer him/her in the right direction.
Since it applies to physicians as much as lawyers, it's worth sharing that in seminars on running a law practice, I'd often be advised to look out for signs of borderline personality traits, i.e., an initially far-too intense shower of praise and exclamations of personal compatibility, likely to be followed by an intense, angry reaction when the person inevitably perceives abandonment. And yes, there are the narcissists, though I'd assume there is probably a much higher rate of it among doctors and lawyers than among patients in general.
if this is not a mental or mentality problem, but just a bewildered person she could get on to the diabetes web-sites where fellow diabetic people can share problems. Some answers can be quite forthright, but many are helpful - even such statements as ' I feel that way too!' There is no time restraint and the web community will ignore open statements or offer suggestions if an answer is available. At least this way she may find out that she is not SO badly off as many diabetic people.
Are there any Diabetic groups that meet together near by?? Useful to let new patients learn that they are not alone and that most people can cope excellently despite having a chronic disorder.
It took me a few years to figure this one out. This is what helped in the end. I delegated one of the staff as a time keeper. When the appointment time ran over, he would knock on the door and inform me that time was up. It was easier at that point to end the appointment or reschedule, and we were able to do it without hurting the patient's feelings.
Good Luck!
Tanya Harris, MD
I often run into such a scenario: she is here for migraines, going on for 40+ years, no she is in her 50-60's, wants me to fix her now. Then she talks about her hand, her wrist, her hip pain and her mother-in-law and her animals and her ex-husband, and on and on. If I do not interrupt her, she can talk forever. This happens so often and I will try the knock on the door technique. Thank you.
I got one better than that,she is going by systems,neuro,pulm,kidneys,now we are on muskeq.all ngtv very complicated patient
I sympathize with the Doctor and the patient. I was not a needy or lonely person until visible illness chronic and progressive being treated with pain medications that I cannot tolerate. Too many pcp's are prescribing antidepressants which further harm a patient if due diligence for unordinary diseases is not looked for. Recently I read an article in a medical journal that mental illness was rising due to this ignorance. I have went to a therapist for dealing with chronic illness and she insists its an autoimmune problem that is causing my decline. Saw physchiatrist and the diagnosis is body dysmorphic. How can this be when on viewing they can see that a patient is in pain and visible signs of illness are present. Physician do no harm, remember the oath to help a patient. If you are unable to do so, refer them to someone else.
My mom has the same problem. She has early onset of Dementia and forgets that she has asked a question numerous times before. Her Physician has insisted that she not come alone to her office visits. She must be accompanied by myself or my brother. The Physician explained to us just what the problem is, as described in your scenario, and it is our responsibility to get her out of the office in a timely manner. It also helps, with her, to write down her questions along with the answer. That way, when she needs to ask it again, she can read the answer. If she calls the office, they take a message and then call me with the answer and I call my Mom & explain that she needs to call me, not the office next time.