Management strategies

Our professional responsibility is to rise above interpersonal conflict and facilitate productive communication by establishing a caring and responsible relationship with such patients. An appropriate strategy is to follow Professor Aldrich's precepts 3 for the 'difficult' patients who do not have an organic disorder or a psychiatric illness.

1. Give up trying to cure them—they are using their symptoms to maintain their relationship with you: accept them as they are.

2. Accept their symptoms as expressions of their neurosis. Make a primary positive diagnosis— only test if you have to.

3. Structure a program for them, e.g. 'Mrs Jones, I have decided that we should meet for 15 minutes every second Wednesday at 10 a.m.'

4. During the consultation, demonstrate your genuine interest in the person's life, garden, work and so on; show less interest, even boredom, for the litany of complaints.

Other management guidelines include:

• Use reassurance with caution—it is insufficient by itself and should be soundly based.

• Be honest and maintain trust.

• Allow the patient a fair share of your time—this is your part of the contract. At the same time indicate that there are limits to your time (set rules).

• Be polite yet assertive.

• Avoid using labels of convenience and placebo therapy.

• Be honest about your understanding (or lack of understanding) of the problems.

• Remember that the consultation is often the therapy, without a prescription.

• Do not undermine other doctors. Avoid collusion.

• Have limited objectives—zealous attempts to cure may be inappropriate.

• Do not abandon the patient, however frustrating the relationship. Accept this as a legitimate role.

• Remain available if alternative therapies are sought by the patient.

• Take extra care with the 'familiar' patient and sometimes the patient who brings gifts. Maintain your professional role.

• If you are uncomfortable with counselling, consider early referral to a counsellor while maintaining contact in the future.

• You may have to accept that there are some people no one can help.

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