Verbal De-escalation. Rules for Negotiating with an Uncooperative Patient

1. Invite the patient to your office personally.

Don't treat it as an effort, but rather as stretching your legs during the working day (you'll see it pays off).

By opening the door and standing on the doorstep of the office, you show that the patient is your guest, whom you will take care of in a moment as the host,  which gives him a sense of security and helps cool down his possible negative emotions.

Standing in the doorway, you clearly mark the boundary of your territory, as if you were saying "The threshold of this office is the end of the waiting room, I will take care of you, but you need to know that everything in the office will be on my terms."

As befits a good host, greet the patient and / or the child's parents and indicate a place to sit. Do not forget to smile, the patient's mirror neurons are always on the alert.

2. Address the patient using their name. Thanks to this, you acknowledge the patient, because he or she ceases to be anonymous. Always address the patient with due respect.

The lack of anonymity reduces the patient's aggression to a minimum. Use polite forms of address - Mr. / Ms. - that clearly define the boundaries of familiarity.

If we refer to a child who comes to the clinic with parents by name, then we can be more than sure of the success in our cooperation with parents in order to provide the best possible health care.

3. Invite both parents or guardians to the doctor's office.

Do not worry about overcrowding in the office - two people mean a greater chance of a successful visit and that you will be listened to and properly understood.

If the child distracts one of the parents or guardians (usually the mother), the other person will be able to listen to you, and this will prevent them from coming to the office again to ask you the same questions.

If you invite two people, do not ignore any of them, alternate between them and look them in the eye.

Never get involved in any family disputes that you may witness in the office, emphasize clearly what your opinion is and mark it with appropriate gestures. By showing your hands with the fingers pointing up, you inform the interlocutor that you are cutting yourself off from the whole situation.

Try not to take anyone's side - talk about your opinion, you are the authority in this situation, you do not need to be supported by the authority of another person.

4. Make it a habit to shake the patient's hand in greeting.

Don't worry that shaking hands with the patient is a sign of familiarity. It's rather of a kind of extra source of knowledge that you can gain from a handshake. You don't have to do it, if you feel artificial with it, because if you are embarrassed by this gesture, you can be sure that it also embarrasses the patient.

Thanks to a handshake, we will know who we are dealing with, whether with a mentally weak person (when the handshake gives the feeling of  holding a "dead fish"), with a resolute person ( strong grip) or with a very stressed person (sweaty palms).

The type of patient's handshake will help us steer the conversation, especially when we want to convince them of something.

5. Minimize the number of communication barriers between you and the patient.

We are usually separated from the patient by the desk - if you have an important message to convey to them (from their or your point of view), minimize this barrier by leaning your whole body towards the patient.

If you decide that the patient needs an intimate conversation, sit with them at one corner of the desk, this will reduce the distance and increase trust.

Make sure that you are not separated from the patient by "movable" communication barriers, such as: computer screen, binders, files of papers, cards of other patients, etc. The space between you should be clean so that you can read each other's intentions correctly.

Remember!

When talking to someone from a distance, always look into that person in one eye only. Usually, during a conversation from a distance of several dozen centimetres, we cannot decide which eye to look at. We then give the impression of avoiding eye-contact , which is why we do not gain the trust of our interlocutor. Looking and listening to you they will not see that you are looking in only one of his eyes, and you will become more credible with a static gaze.

In special situations, when the patient is very stressed and we want to calm him down, or we really want to convince him of our arguments, we can cover the patient's hand we are shaking with our other hand.

If the patient rubs his eyes when answering our questions, we can assume that he is lying.

Men and young children rub their fingers against the upper eyelid or the eyebrow when lying, while women in such a situation usually rub the lower eyelid under the lash line with their fingers.

6. While talking to the patient, try to look them in the eye as often as possible.

This allows you to control whether he is telling the truth or confabulating.

If the patient looks to the right, it means that he is making up, if to the left - he is trying to remember something, if he looks down - he is hiding something from us.

7. Pay attention to your hands.

Control both your hands, which you should always keep on your desk during an appointment, watch the patient's hands. By placing your hands on top of each other on the desk, you signal to the patient that you are listening.

When you are talking to the patient, place the back of your hands up - it will tell them that you are being honest.

Do not interlace your fingers into a "basket", because this will build a communication "dam" between you and the patient.

Do not steeple your fingers, because it means that no arguments reach you.

Do not point your finger at the patient and do not point your finger at anything - this is a very accusing and unpleasant gesture.

Pay attention to the patient's hands - notice if he is nervously rubbing them, if he is moving his fingers impatiently, or if he is clenching them into a fist - thanks to this you will be able to read his mood (emotions).

Try not to operate your hands and fingers around your mouth. A person covering their mouth during a conversation is perceived as telling lies or refraining from saying something unpleasant.

8. Tell the patient what you are doing or will be doing about his problem.

If you need more time to write down something or complete the file, apologize to the patient, ask for a moment of patience and inform the patient that you will complete their visit details - this information will prevent them from feeling unnecessary and ignored. By going out to get the patient on the threshold of the office, you gained an advantage, but you also took on the role of the host, you decide on the course of the visit, but you also have to take care of your guest.

By informing the patient on an ongoing basis about the course of the visit and examination, you will gain their trust and encourage him to cooperate.

9. When talking to the patient, use gestures to emphasize the words.

  When explaining to the patient how and how often to administer the vaccine or take medications, look at them and use appropriate gestures, for example underline "3 times a day" or "3 doses" with the pointing of three fingers; when saying "never" cut the air with your hand horizontally .

If you are listening to the patient, nod your head.

When something is not clear to you, gently interrupt the patient and use the phrase of understanding: "If I understood correctly, you said that ...". The patient will confirm or explain what he meant.

10. Adapt your language to the patient.

Don't use complicated phrases, speak very simple language.

Keep in mind that probably none of your patients will understand professional medical terminology.

Misunderstanding is the source of ignorance, and ignorance leads to fear - if the patient does not understand you, he will start to fear, if he becomes afraid, he will stop listening to you.

Talk to the patient in accordance with the principle that "the glass is half full" in mind - most patients come to the doctor to find comfort, so go with this expectation and pass on to them in a positive way the crucial information - this is the best the way to talk about prevention.

11. If the patient is aggressive, do not enter into discussions with them.

An attempt to stem the patient's aggression or ask them to leave the office will only increase their anger.

Although it is very difficult, wait, let the patient vent. The lack of reaction on your part will baffle them, silence and ridicule them in their own eyes.

After the attack, address them by first or last name and ask if you can help with anything (eg: "Mrs. Jones, I can see that you are very upset. How can I help you?").

12. If you are giving a patient a choice, never make the choice for them.

  Patients tend to shift responsibility for their health decisions to the doctor. If the patient is indecisive, ask them to think carefully and make a decision later - this procedure will paradoxically make them take it faster, so as not to risk another visit to the office.

When the patient asks for your opinion, express it, but make it clear that it is your opinion.

When the patient asks what you would do in his place, say that you are not in his place and that it is difficult for you to empathize with his situation. You can say what decisions other patients make in a similar situation.

13. Don't feel offended when a patient is suspicious. Don't be offended when he asks or has doubts, including about your answers.

Make sure you are right and don't get upset when the patient tries to challenge your competence. Your hesitation and anger may indicate the your uncertainty about the knowledge you have.

The huge amount of unverified information in the media and the Internet means that patients do not know who they can trust - stick to your opinion (but you must be convinced of it).

14. When talking about prophylaxis, do not hide anything.

When you talk to a patient about vaccinations, for example, you are required to inform them of all options.

Do not avoid answering troublesome questions, for example, about unwanted vaccine reactions. Answer them clearly and matter-of-factly, do not try to underestimate them in the eyes of the patient, because it will arouse his suspicion, use arguments, not emotions.

Use real-life examples to illustrate the arguments.

If you are uncomfortable talking about money, write the amounts for each option on a piece of paper and give it to the parents or patient.

15. In a conversation with a patient, avoid the question "Why ?!".

This question is accusatory, stigmatizes the patient and disrupts communication.

Replace it with "What happened ...?" - it is more empathetic and shows genuine interest, not an objection.

16. Young children are among the most demanding patients.

Toddlers get bored quickly, that's their nature, so don't expect them to listen to you like adults.

Children are great at discovering any falsehood - do not try to win them over by coaxing or distorting your voice.

Usually, children do not like visits to doctor's offices and that will not change. You can only tone the dislike down: try to talk to them as to adults and explain certain things to them, referring to the authority of their parents.

Don't lie to the child, don't say something won't hurt, if it hurts, that something will be pleasant, if you know it's going to be unpleasant. Once a child is cheated by a doctor, he will no longer trust any other doctor, and this trauma will also accompany him in his adult life.

17. Ending the visit is the most difficult part of the encounter.

At the end of the visit, the patient is already distracted: either happy that the visit is ending and that he will soon leave a situation that is uncomfortable for him, or worried about the diagnosis and thinking about it.

Don't be mislead by the patient’s nodding his head - his thoughts are usually out of the office.

It is important to help yourself with gestures at the end of the visit and to focus the patient's full attention on yourself, to inform him about the procedure (diagnostics, treatment, vaccinations, etc.).

At the end of the visit, always ask the patient if what you said is clear to them and say that if he or she did not understand something, you will be happy to explain it again.

If you see that the patient is very distracted, write down your indications on a piece of paper and give it to them, it will be a reminder and a necessary tool for them after leaving the office.

The fact that at the beginning of the visit you personally invited the patient to the office by getting up from the desk will also allow you to easily end the visit, which is especially important in the case of a chattering patient, because when you get up from behind the desk, you signal that the visit is over and you will now be going to the door to invite the next patient in.

Dr Irena Malinowska, WSEPiNM, Kielce, 2019