Consultant’s Corner: Understanding Bariatric Risk—A Legal, Clinical, and Customer Service Focus

| August 18, 2008

by James W. Saxton, JD; Maggie M. Finkelstein, JD;
and Susan Gallagher Camden, RN, MSN, PhD

All from Stevens & Lee, Lawyers and ConsultantsMost of our patients and staff members get along fine. However, occasionally a patient or family member will become unreasonably upset, affecting staff members and even other patients. Our office manager is responsible for handling angry patients, but last week he was out of the office when a patient’s wife became very upset and the receptionist didn’t really know what to do. The situation really got out of hand. Any ideas?
Experts: Angry patients and family members pose one of the most unsettling challenges for an office practice. However, it is important to recognize that however unsettling, anger is part of being human. We see it expressed everywhere—sometimes for good reason, sometimes not. Most experts explain that anger is simply a feeling; it is not necessarily bad or good any more than joy, hurt, or fear is considered bad or good. It is not feeling anger that causes problems; it is what the angry individual chooses to do when feeling angry that is either productive or unproductive. For this reason, anger can be a very difficult emotion. Both our own anger and other people’s anger can create stress.

It is important to recognize that anger is a secondary emotion, meaning it occurs after some other feeling occurs. This is why anger is so stressful in healthcare. Patients and even healthcare providers might feel angry after feeling misunderstood, afraid, or hurt. Many people feel anger in the face of criticism, but first the person probably felt hurt. This is important to understand—anger functions in response to a threat and is often used to block off physical or emotional pain.
On the other hand, while anger allows a person to vent frustration, it seems to create problems in two ways. One way is when angry expression is used to escape the core feelings the anger is attempting to mask; the other way is when anger is suppressed or repressed or expressed inappropriately. Repressing anger tends to distort one’s ability to understand the core feelings the anger is masking. Patients are best served when they learn to recognize hurt, fear, frustration, or anxiety and what causes these feelings, so they can continue their journey toward success. The second problem that angry expression leads to is fear and defensiveness of others. Anger expressed in the form of rage, passive-aggressive behavior, or defensiveness creates problems not only because this expression of anger causes damage to others, but because the real issues are not addressed. It is very difficult to stay in a problem-solving mode when someone is yelling or raging. It is also very difficult to solve problems when people behave in passive-aggressive ways.

The most typical, and human, reaction by the healthcare professional who is confronted by the angry patient or family is to either get angry back or to physically or psychologically withdraw; neither are helpful coping strategies. Most practices, like yours, have assigned an individual staff member to address issues pertaining to the angry patient. You recognize the problems inherent with this process by virtue of the question asked. Patients who express this feeling of anger in an inappropriate manner seldom schedule this at the time your staff member is available to intervene. Anger is a difficult feeling for both patients and staff members because it does not feel good and is not acceptable in our culture. Staff members are often unclear how to respond in the face of an angry individual.

The good news is that you can put into place strategies that can help. A policy in writing to handle the needs of the angry patient is part of a sound loss-control program. In developing a policy, consider ways to engage the patient for purposes of better communication (Table 1). The BATHE model is one such model designed to help clinicians understand and manage needs of the angry patient and responses of staff members (Table 2). As with any difficult patient situation, communication techniques are especially important so that the patient, staff members, and surgeons do not become further frustrated. The BATHE Model is designed to create an empathetic environment. Both of these models should be considered in creating a policy for handling an angry patient.
A policy does not only help staff understand the expectations and process, but also assists in staff training and education efforts as well. A policy should include not only understanding the process and reasons for management of the angry patient, but also role playing.

Case Study: Handling a Difficult Patient
Let’s use an example of a patient who always seems to come into the office complaining about something. Annette has complained about the weather, traffic, and parking, or how long she has to wait. When Annette enters the office, staff members feel and express their frustration before an interaction even occurs: “Oh, not her. I didn’t see her on the schedule for today!” What is the stressor? Annette. What is the painful core feeling? Anxiety. Staff members feel anxious, probably because they believe they ought to be able to make Annette happy. It is interesting that we call people like Annette difficult when the real problem is that we do not know what to do with them. Think about this: They are very consistent in their behavior. They always come in and complain. So, the real problem is that we often think we have to fix whatever they think is wrong. A key in managing our own anger and that of others is being able to stay separate from them. What is essential is the ability to see that another person’s complaints, anger, or frustration may have little to do with the office or staff members. The patient may simply be mad at life.

From a risk management perspective, a written policy is helpful to guide all staff members on all levels in understanding the process of handling an angry patient and their role in promoting customer service excellence. The written policy ought to describe avenues the staff member might take in addressing this challenge. The goal of the policy is to work toward consistency in customer service excellence and satisfaction while maintaining respect for patients and staff members. For example, when patients become angry and express their anger inappropriately at staff members, staff members who work in a professional environment lose the right to react. Keep in mind, professionals do not lose the right to self respect—just the right to respond in a like way to an inappropriate patient. For example, consider the following scenario:

Annette: (Patient arrives 30 minutes late for her appointment and angrily registers at front desk) “This isn’t going to take long, is it?”
Receptionist: “There is one patient ahead of you, so it’s going to be about 10 minutes before you will see Dr. Hughes.”
Annette: (In a very angry and quite loud tone) “Ten minutes! You’ve got to be kidding. I had a two o’clock doctor appointment and he didn’t even see me until 3:15. That is why I am late. You people must think we have nothing better to do than to wait for you! What is the matter with you?”
Receptionist: “It sounds like you’ve had a very frustrating day. It’s aggravating when you’re busy and people don’t keep their appointed times. I do have one patient in front of you; it won’t be longer than ten minutes. Annette, Dr. Hughes wants to have enough time to review your postoperative lab values with you today.”
Annette: “This is ridiculous! What the *&!# is wrong with you people? You and the doctor are all alike!”
Receptionist: (Calmly) “Annette, it sounds like you’re frustrated, but I don’t want to be sworn at or yelled at. Let me have you speak with our office manager while I set up for your visit so you aren’t delayed any more.”
Annette: “No, no, I’m fine. You’re right, I am just so frustrated, and I have horrible headaches today.”
Receptionist: “Well then, you are in the right place and we are glad you are here…can I get you something while you wait?”

Discussion
This receptionist does not allow the patient’s bad day to ruin hers or affect other patients. She empathizes with the patient, but also sets limits by telling Annette she does not want to be sworn at or yelled at, and maintains the adult: adult relationship. The receptionist offers the patient someone else who might relate differently to her. The receptionist disapproved of Annette’s behavior but still respected her. Assertive communication respects one’s self and the other. When it becomes clear to this receptionist that nothing she will say or do will work with Annette, she still does not take it personally. Her offer to allow Annette an opportunity to discover her primary concern in the privacy of the office manager’s office displays interest in helping her, even if Annette is difficult. This powerful message can have unlimited positive impact on Annette and any other patients observing what took place. The receptionist focused on serving without losing her own self respect. A policy in writing to guide the receptionist, or all staff members for that matter, on handling angry patients in a consistent, respectful manner is a good risk management strategy.

A couple of years following surgery, we have seen that some of our patients become depressed. Why is this? You would think they would be ecstatic about their weight loss and physical appearance, but surprisingly, not all are. Our male population in particular has been having more problems than we anticipated. Should we make special concessions for this patient population?
Experts: There has been increasing interest in literature pertaining to male depression—not just in the weight loss surgery patient—but men in general. Certainly weight loss surgery has an extremely positive impact on the individual’s overall health and quality of life; however, the many changes that accompany massive weight loss can be stressful in a way the patient could not have anticipated. Roles, relationships, opportunities, and the mandate to make choices all work together to create varying levels of stress.

As part of preoperative clearance, a behavioral healthcare provider is asked to evaluate the surgical candidate. The ASMBS has published suggestions to guide providers in understanding the purpose of preoperative psychological screening. As valuable as the assessment is, it is not a substitute for long-term follow-up and continued assessment and intervention as needed, which leads to a more comprehensive discussion of long-term follow-up. One of the reasons long-term follow-up is important is not only to capture physical progress and assessment, but also threats to emotional and mental health. Patients evolve through the life cycle and can develop depression regardless of the positive changes and attained weight loss goals.

Each year, depression affects about six million American men and 12 million American women. These numbers may not tell the whole story, especially among the male population because men may be reluctant to discuss depression. This is probably why experts believe many men with depression are undiagnosed, and consequently are untreated. When men return for their annual follow-up visits, they are more likely to focus on physical complaints—headaches, digestive problems, or chronic pain—rather than on emotional issues. In both men and women, common signs and symptoms of depression include sleeping poorly, sadness, guilt, lack of energy or joy, and a feeling of worthlessness. In some cases, men are unaware that physical symptoms, such as headaches, digestive disorders, chronic pain, or fatigue, could be symptoms of male depression. As the specialty of weight loss surgery evolves, so do the many nuances of managing the needs of complex individuals who become our patients. Behaviors such as depression, anger, and anxiety may simply become more apparent as the many changes that emerge from weight loss surgery unfold. Long-term follow-up along with understanding and recognizing these challenges are part of the exciting and emerging role of those interested in improving care for those on their weight loss journey.

It is also not only the patient that may experience emotional responses to weight loss surgery. We have seen spouses and significant others who are unable to cope with their partner’s weight loss and new attitude. This is why education of the impact of weight loss surgery is essential for both the patient and family.

Suggested Reading
1. Saxton JW. The Satisfied Patient: A Guide to Preventing Malpractice Claims by Providing Excellent Customer Service. Marblehead MA: HCPro, Inc.;2003.
2. Stewart MR, Lieberman J. The Fifteen Minute Hour: Applied Psychotherapy for the Primary Care Physician, 2nd Edition. Westport, Connecticut: Pager Publishing;1993.
3. Boyle D, Dingell B, Platt F. Invite, listen, and summarize: A patient-centered communication technique. Academic Med. 2005;80(1):29–32.
4. Reich, WR. What care can mean for pharmaceutical ethics. J Pharr Teaching. 1996;5:1–17.
5. Suggestions for the pre-surgical psychological assessment of bariatric candidates. Accessed at: www.asbs.org/html/pdf/PsychPreSurgicalAssessment.pdf.
6. Male depression: Don’t ignore the symptoms. Accessed at: www.mayoclinic.com/health/male-depression.

Category: Consultant’s Corner

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