Crowdsourced Tips to Manage the 6 Most Frustrating Patients - Part I
As chiropractors, we love our patients and our jobs… usually. Challenging chiropractic patients who self-derail progress can be exhausting. So your ChiroUp team identified six of the toughest categories of patients, then we asked our subscribers about the most efficient way to handle these situations. For each of the six scenarios, we asked two questions:
On a scale of 0-10, how frustrating is this scenario?
What’s your best advice for managing this situation?
Our network responded with more than 1000 pieces of advice! So much advice that we divided it into a two-part blog. This week, part one details the problem and the crowdsourced solutions for three common but challenging scenarios:
The Overachiever
The Underachiever
The Long-lister
Knowing how to handle these frustrating situations can help ease the pain 😏 and build stronger relationships. We hope you enjoy your crowdsourced advice!
Scenario 1: The Overachiever
Ruins their progress with ten hours of yard work and a half marathon the first day they feel better.
Frustration score: 4.7
Crowdsourced advice:
Remove guilt- Let them know you would rather have a patient error on the side of too much activity than too little. Tell them you love their “can do” attitude. We find our limits by trial and error.
Have patients take their own advice- Guide the patient to the conclusion that their activity will play a significant role in their symptoms. “Wow! You are passionate about your (yard work)! How do you think this impacts your recovery? Help me understand what is more important to you, a full and fast recovery or 8 hours of landscaping?”
Celebrate the positives- Affirm evidence of their progress, but remind them that they're still healing and are only slightly below the pain threshold: “I’m happy you were feeling so much better and could be so active. Our treatment obviously worked, and that means you can get better, but I think you might have jumped into the deep end a little too quickly, so to stay better, you’ll need to take it easy.”
Explain risks- Let them know a premature return to activity means their progress will be slower than anticipated with a longer recovery and potentially higher long-term recurrence…not to mention increased visits and potentially more out-of-pocket costs. Explain to them that each time they aggravate their symptoms, the clock for recovery starts over and increases. Eventually, they may lose the ability to perform what they love to do unless they make a change. “If you were an athlete, this flare-up would cause you to miss one game, but if you don’t cool it, you’ll be out for the season.” If nothing gets through, support them where they are. It’s their choice, so remind them the gains will be slow, and you may need to increase the frequency of treatment if they’re overloading, but ultimately it’s their life, and you understand everyone’s needs are different.
Relay a vision- Explain that that glimpse of improvement they felt is how they can feel all the time if they give their body time to heal and return to activity more gradually. “After we get this flare-up calmed down, we’ll discuss the right dose of activity that does not stress your system with more than it can handle.” Also, ensure patients understand their limitations are temporary, not permanent, so they don't “freak out.”
Provide pain education- Patients must understand that pain is not a good barometer of recovery and that a lack of pain does not equate to “full recovery.” “Remember, pain is the last thing to come on and the first thing to go away. Just because your pain is gone does not mean your dysfunction is gone and you can do anything you want.” Remind them the body needs time to heal even if they "feel better." Use the analogy of appendicitis or a heart attack. i.e., “You gradually get ill but don't necessarily notice until pain occurs. Once the problem is removed, you have no pain but are not completely recovered for weeks.”
Implement progressive loading- Relay the phases of care and healing. Patients must understand that load management via a gradual, progressive return to activity is crucial for tissue adaptation and recovery. “Let's make sure we return to activity with an action plan, and the essential rule is only to increase activity by 10%, I.e., don’t progress your activity by more than 10% of what you did last week” Encourage patients to think of their first few activity sessions (golf, leaf raking, housework, etc.) as “rehab sessions” in anticipation for a total return to activity- much like a pitcher returning from shoulder surgery needs to play catch before they can pitch again. Use the metaphor of a tachometer in a car; keep it between 1,000 to 2,000 RPM until cleared to "rev up." Encourage breaking tasks and activities into multiple small sessions.
ChiroUp subscribers can download and deliver a new infographic to help overachievers understand how gradual progressive loading will speed their recovery. (Visit the forms library and search “10% rule”)
Anticipate problems- It is essential to educate your patients after the first treatment session with a prelude to what they may experience if they overdo it at the first sign of progress. Don’t forget this patient’s enemy is feeling good and a day of sunshine. Additionally, it is worth noting that patients who tend to be overachievers may also overdo it when it comes to their home exercises, so deliver a dose of caution with susceptible patients, especially athletes.
😂 Funniest reply: Ask, “How much money do you want to make me?” Then tell them I have two kids with out-of-state tuition and thank them for keeping me in business.
ChiroUp summary:
Not surprisingly, Overachievers comprise the least frustrating of the six categories because they are active participants in their health who take action. Just too much action. These weekend warriors simply paid the price for violating the “10% rule.”
Scenario 2: The Underachiever
Won't consider performing their home exercises or implementing ADL advice despite your repeated coaching.
Frustration score: 7.4
Crowdsourced advice:
Explain their role- Explain the difference between passive and active therapy. “In one week of seeing you 2-3 times, my influence on your progress amounts to less than an hour. For the other 167 hours between care, your prescribed home exercises and recommendations are essential. Unlike your car, you cannot drop your body off at the chiropractor and expect to pick it up “fixed.” My passive care will improve your mobility and give you temporary relief, but it won't provide 100% relief alone. We are a team. So to speed your recovery, you must play an active role in the process and work at home. You are part of the solution, so help me help you!”
Set expectations: minimal participation equals minimal recovery- Be upfront with the patient and tell them that their degree of recovery past a certain point will depend on them. “Wishful thinking therapy” won't work. Let patients know you’re there for them, but the results are slower and unlikely to be optimal without them being there for themselves. “If you want to get better, you can either come in here 3 times per week for the next six months, or you can come here 1-2 times per week for the next month AND do your exercises at home. It's up to you.” Emphasize that they must accept a lower level of recovery if they are unwilling to change their behavior. "With my passive care alone, we'll only go so far, and you'll plateau. Then I'll discharge you." For repeat offenders, ask, “If you keep skipping your exercises, why do you expect different results? How you are doing things now isn’t working, so let’s try my approach to something new.” Underachievers are more tolerable if they accept the risk of under-participation. Still, if they are not doing what is expected and start blaming their provider for poor results, they should find another doctor.
Paint a vision- Have the patient identify their reason for being under care in the first place, including what they want and what they're losing out on from their condition. Ask, “What does it look and feel like if you don't get better? What does it look and feel like if you do get better?” Then offer hope and dangle the expectation of self-empowerment with self-care. “To speed up our recovery time, you must put in the work at home. Remember when you told me that you wanted to be able to wrestle with your kids without pain? Well, that's unlikely to happen if we can't improve the area's stability, and the only way to do that is if you consistently do the exercises we prescribed. Does that make sense?”
Provide a reason- Explain the importance of their exercises. Patients must understand what's wrong and how their exercises will help. “The best recovery is an active one because your muscles need your help to aid in your complete recovery. The treatment in my office is only part of the solution; what will get you to the next level of your goals is the home therapy and modifying ADLs that contributed to the onset and perpetuation of your problem.”
Uncover barriers- Acknowledge that exercises can be inconvenient, then find out what is logistically getting in the way of their active participation; do they understand that it's part of the treatment and not an optional add-on? Ask them what they feel they should be doing and their reluctance to exercise, then discuss solutions for lack of time and any other barriers they must overcome. “Those exercises I prescribed are the best the science has to offer, and being consistent with those will add a lot of life to your years. What do we need to do to get you consistent with those?" Be vigilant and address underlying psychological barriers such as depression, anxiety, or other biopsychosocial yellow flags, especially fear-avoidance behaviors.
Make exercise easy- Help the patient figure out how to implement their exercises into their daily routine so it doesn't feel like much additional work on their end. Try to get patients to sprinkle their exercises throughout the day instead of trying to find extra time- because they will always find something more important. Define their optimal exercise times so they can set alarms or phone reminders. Encourage small steps. If needed, consider removing some of the less crucial exercises so it’s not overwhelming for them. Start slow, i.e., “Let me give you one specific exercise that is ridiculously easy to implement.”
Want a deeper dive? Check out this prior ChiropUp blog on 7 Steps to Improve Exercise Compliance.
Offer supervision- Try to be understanding that not everyone has the capacity to be a self-starter. Explain the exercises, then have patients demonstrate competency in-office each visit. If necessary, at re-evaluation, recommend co-management with a physical therapist that you trust.
Consider release- Sometimes, the bad cop must let patients know that their exercises are crucial to their treatment plan. Patients may be better served elsewhere if they don't follow treatment recommendations, so politely remind Underachievers that non-compliance may result in referral to another provider. Some survey respondents were passionate about this one:
Be honest and let them know that if they don't wish to complete their part, you will release them from care since it just wastes everyone’s time.
It may be cynical, but I value my reputation more than they value their health, and when they tell their friends I couldn’t get them better, they will leave out the part where they didn’t do anything to help themselves. It’s better if they don’t return until they’re ready to make a change.
Be proactive- Education during your ROF should stress the importance of exercises, ADL advice, and how this will increase their chance of getting better faster. The more they are involved in their recovery, the better the outcome.
😂 Funniest reply: Tell the patient that if they want to treat me like white-coated air, breathing aspirin, they will be in my office forever.
ChiroUp summary:
The two recurring crowdsourced suggestions for motivating an Underachiever were:
Help me help you
An educated patient is a compliant patient
And ChiroUp subscribers know that’s where we shine:
“I make sure all of my patients understand what’s wrong and what they need to do at home with ChiroUp exercise and ADL reports. They absolutely help me improve compliance” (Dr. ML, Texas)
ChiroUp condition reports answer the four essential patient questions while delivering condition-specific exercises and ADLs that inspire and motivate patients to take action. And it’s ridiculously easy to deliver in four clicks or less.
Not using ChiroUp yet? Check out this preview of how ChiroUp can make your life easier.
Scenario 3: The Long Lister
Arrives with a list of the 41 disorders they've suffered from since the last visit.
Frustration score: 7.4
Crowdsourced advice:
Be thorough- Listen carefully and perform a thorough evaluation to cover all bases, then try to understand if any complaints are related to a root cause. We can often tie many of their MSK problems with a good exam. The first visit is often equal parts clinical examination and rapport building; however, with long listers, it’s much more about building rapport. Be understanding- What many of these patients lack in their healthcare experience is somebody who listens to them without dismissing them as crazy.
Stay in your lane- Don’t overlook anything significant. Listen to every complaint, then recognize what is outside your expertise and refer those out accordingly.
Be upfront- Honesty is king. “I don’t want you to have unrealistic expectations.” Relay that because of visit time constraints, you only have so much time that can be directed at their problems. “I see you have a list of questions/ problems. I’ll do my best to address as many as possible within your appointment time, but we can’t go over, or you will be inconveniencing those waiting. You may need to make another appointment if we don’t get through everything.” Let them know that the more they bring, the less time you have to give each one full attention. “While every ache and pain is important, my time with you here is limited. It sounds like we need to schedule some special time to sit down and review this additional information. Is it okay to get you treated today and then schedule extra time just for this?"
Prioritize and stay focused- Don’t get spread too thin. Document all the reported symptoms, but focus your treatment on only the most significant. Ask patients to communicate their most troubling complaint, then rank their others from most problematic to least. Limit your treatment to the one or two highest priority complaints first, then as those get better, focus on more. “We won't have time to address everything today effectively. Otherwise, we’re bouncing all over the place trying to multitask and less likely to accomplish anything. So if I had a magic wand, what area/condition would you want to feel better with today, or what item resolved would most improve your quality of life? Let’s pick your one or two greatest concerns and start with that today. The others will get addressed on successive visits.” And sometimes, the doctor needs to determine the most pressing issue through consultation and exam (since sometimes asking is like telling someone to relax and you get the opposite effect), then tell them where you’ll start and why.
Explain regional interdependence- Reign them in by explaining that compensating patterns can cause pain in many different regions. If we address the primary issue, many of these other pain patterns self-resolve. “Everything in the body works together, so we will often see improvements in surrounding areas as we work to fix the top complaint. Once we see progress there, we can reassess anything that is sticking around.”
Think globally- It seems obvious, but don’t get distracted and forget to include the spine, which can be the epicenter of more diffuse complaints. Counsel patients on global culprits like inactivity, biomechanical functional deficits, and pro-inflammatory diets. Consider systemic inflammatory disorders that frequently generate multi-joint complaints. Likewise, identify biopsychosocial issues that lead to chronic pain. Here are two ChiroUp graphics to help.
Inflammatory Arthropathy
Rethinking Chronic Pain
Provide home tools- Encourage self-management via home exercises and ADLs for the issues you’re not initially addressing in-office. Then follow up to see if they’re participating at home- it’s a good barometer of how much they really care about their other problem.
Identify chronic offenders- Few things are more frustrating than a long-lister whose list gets longer in proportion to the number of other patients waiting. Identify chronic offenders, flag their accounts, and only allow them to schedule at the end of your morning shift so as not to impact other patients. Give them extra time but not all-day time.
😂 Funniest reply: Just adjust C1!
ChiroUp summary:
Prioritizing complaints and setting realistic time expectations are crucial for long-listers. Additionally, providing home tools such as exercises and ADLs for unaddressed issues can empower patients to take self-management measures and demonstrate their commitment to their overall well-being.
In Conclusion
Sometimes coaching challenging patients means that we need to coach ourselves first. Knowing how to handle these frustrating situations helps everyone's day go more smoothly. We hope this information provided some valuable tools to UP your patient care.
Now, check out Challenging Patients- Part II where we’ll detail the problem and your crowdsourced solutions for three more scenarios:
The Time Vacuum
The Skipper
The Grumbler
Check out our Frustrating Patients Funny Video Series to see what these scenarios really look like in clinic… 🤣
