Crowdsourced Tips to Tackle the 6 Most Frustrating Patients- Part II
As chiropractors, we love our patients and our jobs… usually. Challenging patients who self-derail progress can be exhausting. So your ChiroUp team identified six of the most difficult categories of patients, then we asked our subscribers about the best 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 type of 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’re dividing it into a two-part blog. Last week, part one dissected overachievers, underachievers, and patients with extensive problem lists. This week, part two details the problem and the crowdsourced solutions for three more scenarios:
The Time Vacuum
The Skipper
The Grumbler
Knowing how to handle these frustrating situations can help ease the pain 😏 and build stronger relationships. We hope you enjoy your crowdsourced advice!
Scenario 4: The Time Vacuum
Relays a lifetime health history that somehow includes their brother-in-law's neighbor's dog… on every visit.
Frustration score: 7.1
Crowdsourced advice:
First, prove you listen- Letting patients know they are heard often speeds up the visit. Assure patients that you ARE paying attention to them. This starts at the initial exam when you repeat back a synopsis of their patient history. Mirror and follow up on pertinent statements throughout each visit to prove you’re listening. Redirect the conversation to get the information you need to treat the patient, but have some compassion. Some patients are lonely and need some interaction.
Want to review how to relay a new patient history synopsis that will get people talking about how you listen? Watch this ChiroUp Defining Moments video.
Subscribers can review the entire Defining Moments video library by searching “Defining” from their forms library.
Seek what’s essential- Time vacuums often exhibit an uncanny need to focus on anything other than what’s important to their case… And all providers need to stay on schedule. This potential conflict means that essential details may be missed without careful guidance. Providers are responsible for controlling clinical conversations, ensuring the patient can relay ALL important details while not consuming excess time. The following suggestions aim to limit superfluous dialogue to maximize the collection of meaningful patient data.
Take charge- Smile, kill them with kindness, then politely redirect the conversation with a question related to their primary problem as quickly as possible. Control the conversation by interjecting with: “What you said was is important, what I really need to know is…” or “That's great, and of course, very concerning, so which of your daily activities is most impacted?” Shift the focus back to the chief complaint whenever the conversation strays.
Relay time constraints- Remind patients that time taken re-hashing information or relaying their interesting stories takes away from treatment time. Remind them that to cover as much as possible on this visit, they can share the big stuff now, then add details while you’re working. “I appreciate your willing communication. I love to get to know every patient that walks through my door; it's part of what makes this job so much fun. However, we need to exercise some brevity as other patients are waiting to be seen. I hope you know I would treat other patients the same to keep the schedule on time and moving.”
Multi-task- Listen and work simultaneously, then respectfully redirect as needed. Ask them to keep talking while they are being treated. Allow them to talk and walk as you guide them back to the front desk for checkout, maybe for some new exercises they need.
Get them on a table- Apply the art of urging the patient onto the table. Interrupt excess conversation with: “Let's see what your body has to say, and you can tell me the rest while I get to work.” or “That’s interesting, can I check something with you lying down?” Try to get them talking while face down on the table with “While we chat, let me get started.” Once prone, meaningless conversation seems to diminish. Don't ask any questions that could lead into lengthy discussions until the patient is in a position to work on them. When needed, a staff member can instruct the patient to lie prone in preparation for your arrival.
Use nonverbal cues- Use universal gestures, such as tapping on and presenting a chair, to get them to follow non-verbal instructions. One provider said, “Gently touch their elbow and guide them to the table while they’re talking.”
Choose your questions- Ask precise and purposeful questions. Try to keep your questioning binary to avoid tangents. While open-ended questions are the gold standard, some people respond more meaningfully with limited options, i.e., better, worse, same, or different. Walk into the room and say something like, "Let's see how you're moving today?" instead of, "How are you feeling today?" or "How's your day going?"
Leverage your staff- In extreme cases, when you’re unable to maintain control, your team can knock on the door after a set time. Staff can also serve as a good handoff at the end of a visit to deliver exercises, take blood pressure, apply modalities, print a handout, etc.
Schedule accordingly- Color code visits in your schedule based on time and complexity. Schedule patients with excessive time needs only before a break or lunch to avoid inconveniencing other patients.
😂 Best reply: Don’t forget those big talkers refer the most patients, so keep them happy.
ChiroUp summary:
The recurring themes for time vacuums are to listen, maintain focus, and get them on the table. Effectively controlling the conversation improves care and saves big TIME. And as providers, our primary commodity is TIME. In fact, the only thing most of us can sell is TIME. At the end of the year, saving 20 seconds per visit add up to several hundred more patients served.
BTW- At ChiroUp we understand that time is your most precious asset, so let us help. ChiroUp is that game-changing solution to help you streamline your practice and take it to a whole new level.
Scenario 5: The Skipper
Tells you how they're finally serious about getting better, then shows up to one out of every three appointments and discontinues care the moment they feel better.
Frustration score: 6.5
Crowdsourced advice:
Set expectations- Begin educating the patient about the importance of consistency on day one. Let them know that they will get results that generally correlate with the consistency of their care. Let them know that you are the facilitator of health, not the miracle worker. You’ll need their help in staying consistent with visits. Encourage them that as their mobility and stability improve, their recommended frequency of care will decrease… but they need to get there first.
Refresh expectations- A quick reminder may be in order when someone begins to show inconsistency: "Established clinical practice guides recommend a schedule of ______. That gives us the best chance of getting you where you want to be concerning your pain, health, and future. Maybe you’ll need exactly that many visits, or maybe you won't. But the point is clear that consistency in the first 2-4 weeks is pretty important. At the end of the day, if you don't stick with the plan, we're good. Just don't blame me if you don't get better. Deal?" Illustrate the analogy of going to the gym regularly to achieve weight loss; “I get it, life gets in the way, but just like inconsistent gym visits yield no results, your sporadic attendance here will hinder meaningful progress.”
Educate- Patients need to understand that pain is a poor barometer of healing. Reinforce that pain is the last symptom to appear and the first to diminish, so if they genuinely want to resolve the problem, they must adhere to the treatment plan even when they start feeling better. Reinforce that “feeling better” doesn't equate to complete recovery.
Subscribers can download this Waterglass infographic from the Chiroup forms library. (Search “Water”) The visual explains how symptoms come and go based on multiple factors.
Meet them where they are- Gently and with compassion, let them know that keeping up with appointments is the best way to get and stay well, but always let them know that your office will be there for whatever choice they make. Identify their goals. Ask the skipper if they are interested in just being patched up or a more corrective approach to their condition. If pain relief is their only goal, then coming on an as-needed basis is acceptable. As one savvy respondent said: “It’s hard to let non-compliant patients dictate care, but it is always up to them how much or little care they want. Encourage them, but don’t demand more from them than they want for themselves. My job is to inform. Their job is to choose what they want to do with that info. If you try to change their values too quickly, they'll change doctors. Reassure them that you can take care of them at any time. It's okay to come in with pain and after missing appointments. It's a safe place. Celebrate their wins and be supportive.”
Identify barriers- Try to understand their side of it. Determine the obstacles to showing up for care - time, cost, perceived value, etc. Time and cost can usually be worked around, but if they don't value the care, they won't show up. Don't make the schedule requirements unmanageable (i.e., three times weekly for months). And be careful with your questions because when you put the onus on a delinquent patient, you will likely get 20 mins of excuses as to why they can't make their appointments.
Don’t take it personally- Continue to do everything you can for the patient. Don’t let it bother you since it typically isn’t a reflection of you as a practitioner. Provide imperfect patients with the opportunity to call for their next appointment. Skippers will be back since future episodes are likely.
Emphasize home care- Provide home exercises and ADLs that can support them if they choose not to come in.
Protect your schedule- Send automated reminders the day before an appointment. Call or send an extra confirmation text to potential skippers 1-2 hours before their scheduled appointment. Some providers do not allow chronic offenders to schedule ahead of time: “If someone misses multiple appointments, they lose the privilege to schedule ahead of time. They can call when they want, and we’ll see if we can get them in that day.”
Charge- Have a missed appointment policy and enforce it.
Relay your written missed appointment policy on the first visit.
The first time they no-show or cancel without adequate notice, verbally review the policy. Let them know your practice has a waiting list, and they will be charged if they miss any more visits without notification. Their choice, their responsibility!
Charge their card on file for any subsequent misses.
Do not recall them if they miss three or more appointments in a defined period.
Subscribers can download this sample missed appointment policy from the Chiroup forms library. (Search “Missed”)
*It is essential to adapt your missed appointment policy to comply with any applicable laws, regulations, and guidelines.
Release? - The advice we received for skippers seems to be equally divided into two opposing camps:
A. “Release them if they won’t listen.”
B. “Provide the best care you can on their terms.”
Whether you should continue treatment on a sub-optimal schedule or release it primarily depends on whether the patient will be satisfied with sub-optimal results. If they expect more than they’re earning, releasing them may be the best alternative: “I think we may want to consider pausing care until you can commit to a more consistent treatment schedule, as these gaps in treatment are costing you time and money with little to show for it. I’ll be here whenever you can commit to a more consistent schedule.”
*Patients with ongoing complaints should be referred (in writing) and understand the importance of seeing their PCP or another provider for follow-up.
😂 Best reply: Go home, have a beer, and repeat after me, "Non-compliant patients ensure you'll always be busy."
ChiroUp summary:
The skipper scenario had the highest percentage of respondents answered with “no idea-help me with this one.” Fortunately, the skipper scenario overlaps with underachievers and shares many of the same management strategies, particularly “Help me help you.”
Scenario 6: The Grumbler
Despite a “very high pain threshold,” their challenging complaints and dismal attitude wouldn't improve even after a divine miracle.
Frustration score: 6.9
Crowdsourced advice:
Adjust their attitude- Explain the importance of positive thinking. Tell them their attitude will determine their potential altitude of comfort, pain relief, and problem resolution. Help them to envision what it would feel like to live pain-free and to summon the powers of positive expectation.
Adjust your attitude- Grumblers can be energy vampires, but remember that “everybody is fighting a silent battle about which we know nothing.” Some people are grumpy because they've been in pain a long time, their support networks are frayed, and they've been to many providers who promised them the miracle cure only to come up short. If you can get to know this person and get through the gruff exterior, you’ll often discover a reason for their grumbling. Kindness wins out with the grumbler. Shower grumblers with love and compassion while giving the best treatment possible. They’re probably not used to people being nice to them.
Be supportive- Grumblers often lack confidence and need acceptance and support. Encourage them on a steady basis to build trust. “Grumblers require a light tread. I will always validate their pain but try to move them away from living there. This does not happen overnight and requires a good relationship.” Talk about grandkids, hunting, military service, the weather, or anything else to get on their side and crack that tough exterior. The grumbler’s demeanor often softens as they improve, and they may end up being one of your favorites.
Don’t take it personally- Grumblers are usually equal-opportunity complainers. Stay positive, and don't slide down to their level. And if they are coming back, you can generally assume they're getting something positive from your treatment.
Dig for specifics- A grumbler's pessimistic attitude can prevent them from recognizing small victories. However, they are more likely to acknowledge progress if you ask specific questions like:
Are you still feeling pain all day?
Are you still only sleeping 2 hours?
Is the area of pain localizing?
Get excited when they tell you about any positive change in their symptoms. Encourage them that every bit counts and they are moving in the right direction.
Emphasize objective progress- Grumblers often need proof that they are achieving their goals to believe it. Use pain indexes and functional test scores to demonstrate improvements. Point out something they could not do beforehand and how they've progressed. Emphasize objective improvements in ROM, orthopedic tests, etc. If subjective progress lags, explain that “your body is improving, and symptoms almost always follow suit, but not necessarily at the same time.”
Dig deeper- Humans, including doctors, naturally overlook chronic complainers (i.e., the boy who cried wolf.) This is a perilous proposition for providers responsible for addressing numerous concerns. Either take the extra moments to perform a reasonable H&P for any new complaints or find someone else who will. “Sometimes grumblers have real (undiagnosed) problems, and you certainly don’t want to be the one who misses something on an already grumpy patient.” If chiropractic care alone isn't working, bring in another set of hands. Comanagement, or referral, may be a good option for this patient.
Address biopsychosocial issues- There are likely more than physical MSK issues in a grumbler’s presentation, so use a biopsychosocial approach to identify faulty beliefs or psychological problems. Sprinkle in pain science education on each visit to help correct unhealthy thoughts. When necessary, initiate a cognitive behavioral therapy referral with a social worker, therapist, or other mental health professional.
ChiroUp Subscriber Assets:
Review the ChiroUp Chronic pain condition reference for a synopsis of the latest assessment and management tools.
Download the “Rethinking Chronic Pain” infographic to educate and empower your patients. (Search “Chronic” in the ChiroUp forms library)
Set deadlines- Set and relay clear objective milestones, “within the next six visits, I would expect that you’ll be at least 25% better and your pain score will drop to “x.” If so, we’ll begin to decrease treatment frequency, but if you’re not at least 25% better, I need to release you and refer you to someone else.” Many commenters relayed a similar outcome from this discussion: “Surprisingly, the majority will suddenly become more positive and start improving on the next visit, and the ones who don’t improve get referred out.”
Consider referral- At some point, "I can't help you any further" will either remarkably improve their condition or they discharge. If patients don't feel they should continue or recovery is impossible, review their alternatives and refer them to the best option. Release them with dignity and make it safe for them to return in the future. “You don’t seem to be improving with my care plans “A” or “B.” So rather than trying my option “C,” I think you should see someone with a completely different skill set and try their “A” plan. I’m referring you to (provider), but I will welcome you back anytime.”
😂 Best reply: I know a great chiropractor down the road with better skills and equipment for your case.
ChiroUp summary:
The keys to managing grumblers are maintaining compassion, focusing on what has improved, seeking comorbidities (including faulty biopsychosocial beliefs), setting firm outcome goals, and considering co-management or referral when needed.
Did you miss Challenging Patients Part I? Check it out here.
Series Conclusion
So which of the six scenarios is most frustrating to practicing chiropractors? Here are the final rankings:
Interestingly, most reviewers relayed varying degrees of frustration for each of the six situations- some scenarios ranked high for them, while others ranked low. And every scenario earned a broad range of frustration ranging from 1 to 10. This means we all have pet peeves, but not all are alike.
Sometimes coaching challenging patients means that we need to coach ourselves first. And when our best effort is not enough, it’s probably time to move on: “In all these situations, I remember that the bad crowds out the good, and sometimes you have to weed the garden.”
We hope this two-part blog provided valuable tools to UP your patient care. ChiroUp is very grateful to all subscribers who contributed to this blog series. Thank you for your sage advice. We’re proud to be on the same mission to make our profession the undeniable best choice for patients and payors! 💪
The Final Frustrations
Oh yes, the final survey question was, “Did we miss any other frustrating scenarios?” Apparently so, and you weren’t shy about telling us which patients test your patience:
Miracle seeker- Only comes to you when their pain is 10/10, and they are leaving on a two-week vacation tomorrow.
The Skeptic- Instantly drop out of care when another doctor or other point of authority tells them to stop seeing you.
The INey- After numerous discussions about the intervertebral disc and spinal stenosis, the patient asks, Did it crack? Is it IN now?
The Malingerer- Exaggerates symptoms for emotional or financial gain.
The Insurance Houdini- Patients who modify or quit care whenever their insurance benefits change.
The Director- The patient who relays how to treat them, “My doctor said to…, My attorney wants me to… My last chiropractor did ..."
The Neck-ophobes- Strongly averse to neck manipulation, despite a lack of contraindication (or other rational scientific evidence).
Check out our Frustrating Patients Funny Video Series to see what these scenarios really look like in clinic… 🤣
