A new patient—let’s call her Jane—recently requested a same-day appointment at the New Jersey practice of Sara Erlich, OD. The staff fit her in, despite a busy day and crowded schedule, because Jane implied that it was an emergency. When Jane arrived, she deemed the discussion of her medical history unnecessary for “only an optometrist,” and told Dr. Erlich that she didn’t know her multifocal contact lens prescription. The discussion of costs made her combative; she insisted ODs were “scamming the public with their pretend fitting fees.”

At the end of the hour-long exam, Jane revealed that she had her prescription all along. She just wanted to “test” Dr. Erlich’s skills as an optometrist.

“She then pulls out her checkbook, pays me half-price for the multifocal exam, but states that my exam was far better and more thorough than any ophthalmologist she’s ever seen and she’s going to refer her entire office to me,” Dr. Erlich says. “To me, this patient wasn’t worth even the referrals she brought to my office.”

Chances are, you’ve encountered a Jane or two at some point in your career.

You don’t have to be an OD very long before problem patients find their way in your exam lane—those who refuse to properly care for their contact lenses, linger in the chair with a hundred questions they gleaned from the Internet, refuse to comply with medical recommendations, or throw tantrums over your fitting fees.

“Some people are genuine jerks and others just have complex clinical issues that interfere with commonly accepted social behaviors,” says Gary Gerber, OD, of the consulting firm The Power Practice. “Others have stuff going on in their private lives, and the OD’s practice is, unfortunately, a target on that particular day.”

The Angry Patient
Whether it’s fitting fees, new prescriptions or a long wait, disgruntled patients can find something to make them angry. Fees are a common trigger.

Patients with vision insurance often assume that their visit will be 100% covered, according to Jack Schaeffer, OD, of Birmingham, Ala. “That’s just not possible, especially with contact lens fees,” Dr. Schaeffer says. “So, we deal with all that at the front-end. We tell them up front what all our fees and services are.”

Rather than facing the prospect of an upset patient later, Dr. Schaeffer’s practice gives them the opportunity to choose a practice more in line with what they need.

“We make sure everybody’s on the same page, and we do everything with a smile.”

Building patient rapport is as important as any prescription, says Andrew Gurwood, OD, of Salus University in Philadelphia.
Dr. Gurwood has treated patients in a variety of environments and has taught patient communication with Neal Nyman, OD, at Salus University. In Dr. Gurwood’s experience, patients who are angered when they don’t get the results they expected from a prescription or procedure respond positively when the clinician recognizes their concerns.

His suggestion: Tell the patient that you understand and explain what you can do for them, without reacting to their anger.
“When patients encounter unexpected responses from their physician, they can become offended or defensive,” Dr. Gurwood says. “A physician should always display a calm and situational appropriate demeanor.”

It’s also critical to be honest with patients about what they can and should expect.

“The doctor should give patients the facts. Explaining things and providing clarity is as important a task as gathering and analyzing the exam data,” he says. “I always try to be honest and straight-forward. If I have to tell patients bad news, I try to keep the explanation simple and always include the potential solutions and prognosis. I try to make sure patients understand what to expect, how quickly or how long it will take their malady to go away and how completely it will go away. For my own peace of mind I always end the interaction with three important ‘check’ questions: Was everyone in the office nice to you? Did I answer all your questions? When I answered your questions, did I give you an answer that you understand?”

Unfortunately, even the most proactive approach won’t placate some patients. There are rare occurrences when you’re faced with an unreasonable individual.

“This is a patient that the office manager or optical staff has taken time to listen to, has heard all their complaints and issues, and done the best they can to keep the office systems intact,” Dr. Schaeffer says.

Once that patient has been given every possible courtesy and the practice has made every effort to accommodate their needs within the broad guidelines for the practice, “we may suggest that they find a practice that better meets their needs,” Dr. Schaeffer says.

It’s true that there may come a time when ODs need to “fire” their patients, Dr. Gerber says. Borrowing a phrase from Disney, he adds: “Those patients need to be politely asked to seek their happiness elsewhere.”

The Needy Patient
Dr. Gurwood has a patient with chronic dry eye who calls him every few weeks—to report the same symptoms. Dr. Gurwood gives him the same recommendations every time, but the call eventually comes around again.

“I have patients who are needy,” Dr. Gurwood says. “So, I try to give them what they need.” Sometimes it’s as simple as just being nice.

This is easier said than done, of course.

These often well-meaning patients can be masters of self-diagnosis with 500 questions from Internet research, or they can be patients who appreciate the insights of their doctor a little too much. Either way, demanding or “needy” patients can gobble up a significant amount of time if you let them.

The key is negotiation.

“I have patients who come in with 100 questions. So I negotiate time. I tell them, ‘You’re asking me a lot of questions and I want to answer all of them, but I only have time for two more. If you have more questions after that, we can schedule another appointment. Maybe you can schedule something for next week,’” Dr. Gurwood says.

James Fanelli, OD, of Wilmington, NC, says he answers as many questions as he can, but makes sure to take ownership of the conversation.

“I listen, and then I tell them: ‘I understand what you’ve said and your concerns. Now, here’s what we need to do. If you feel this isn’t the best way to proceed, that’s certainly your right. But here’s what I think.’”

The Non-Compliant Patient
The best possible eye health is always a top priority, so if patients cannot overcome chronic non-compliance, Dr. Schaeffer eventually recommends that they find a practice that better suits their needs.But that recommendation only comes after he and his staff have exhausted all avenues to improve the patient’s ocular health.

“We have an established protocol for at-risk patients, particularly as it relates to contact lenses. This means children, teenagers, anyone who sleeps in their contacts, and those with eye disease.”

These patients are expected to follow a medical protocol, he explains.

“We absolutely make everything clear up-front. We’re very tolerant and we understand that there are patients who won’t be compliant. We have patience with them. We treat them until they basically decide they won’t be compliant,” Dr. Schaeffer says.

When that time comes, “we tell them that they may be better off using another facility. We will not tolerate non-compliance because it could put the patient’s eye health at risk and it’s our job to provide quality care.”

To combat non-compliance, try to be as proactive and informative as possible. Review the elements of the treatment plan and the goals of therapy, check the patient’s understanding of the illness as well as the treatment, and reaffirm the patient’s commitment and intent with respect to the plan.

Let them know that you can’t help them if they aren’t willing to help themselves.

The Obnoxious Patient
As an OD, you see an array of patients in all walks of life—from plumbers to politicians, from academics to mechanics, from high school seniors to senior citizens.

With such a wide swath of the population capable of walking through your door, it’s inevitable that some patients will harbor inappropriate prejudices, beliefs or behaviors that make their visits uncomfortable for you and your staff.
These are the patients who make sexist or racist comments, refer to others in the office inappropriately, or use profanity—the obnoxious ones, basically.

Dr. Gurwood had a patient who didn’t hesitate to share his off-putting viewpoints during his visits. He would sit in Dr. Gurwood’s chair and inevitably make offensive jokes and remarks.

“But I’m a professional. My job was to fix his eye, not his prejudices. Some of my colleagues who witnessed the behaviors asked, ‘How can you treat that guy?’ And I responded with, ‘How could I not?’ My goal was to fix his eye problem,” he says.
“Remember, eyeballs don’t roll into your chair on their own. They come connected to patients,” Dr. Gurwood continues. “The doctor’s role is to find a solution that works for their eyes in a non-judgmental way while considering the whole person.”

If you can’t tolerate the remarks, be honest, yet professional. Tell the patient that their behavior is inappropriate or unwelcome.

If it gets to the point where the offensive remarks and inappropriate behavior become so overwhelming that you no longer wish to treat the patient, consider asking them to “seek their happiness elsewhere,” as Dr. Gerber puts it.

No Difficult Patients?
Although few ODs would argue that difficult patients don’t exist, there are some who take exception to the concept of “problem patients.”

Rather than view these patients as “problems” or “patients from hell,” approach them as patients in need.

Dr. Schaeffer says his reaction to hearing the term “problem patient” is a bit like hearing fingernails run down a chalkboard.
“Too many times, doctors and their staff hide behind the concept that they have a ‘problem patient,’ rather than understanding that this is a patient who doesn’t understand the practice,” Dr. Schaeffer says.

“There are patients you may not want to have as part of your practice family, but we never approach our patients as ‘problems’.”

Patients have varied needs, especially in how they prefer to receive your education and communication. Some want “just the facts,” while others like to be chatty and sociable.

It’s the duty of the practitioner to try to understand and meet those various needs, according to Dr. Gurwood.

Thus, there’s really no such thing as a “problem patient,” Dr. Gurwood says—just patients with different needs.

“Patients come to your office with problems that you can and can’t see,” he says. “Some of them have family members who have died from a certain condition, and they’re afraid they may have it. Some have suffered from unforeseen complications and they are afraid the current problem is an extension of that issue. Some are worried because they saw what happened to a friend and they don’t want it to happen to them. Some come in with their own prejudices or unrealistic expectations.”
All of these situations create anxiety for the patient, which can manifest in many different ways.

The key to quality optometric eye care is to understand the patient to the best of your ability and do your best to meet their needs, the doctors say.

“Doctors are healers,” Dr. Gurwood says. “If I can heal by providing additional medical advice or just by listening, I try. I treat them all like they’re family.”

Unfortunately, every family has its Chatty Cathy or embarrassing uncle. You may only see them on holidays, but their visits can feel like a lifetime, especially if you’re not well-equipped to handle it.

But if you’re prepared, proactive and persistent, you can avoid some disharmony and focus more on what you do best—providing quality eye care.

Takeaway Tips
Few ODs go their entire careers without encountering difficult patients. Here are a few survival tips to help avoid—or at least manage—the battles.

• Be proactive. This is probably the most effective way to avoid future problems. Explain any fees, difficult treatment regimens or uncomfortable therapies up front. Make sure the patient understands what to expect.

• Be honest. Don’t sugarcoat for their benefit. Tell them about their condition. Again, it’s all about giving them realistic expectations.

• Show patience and understanding. This can be tricky, but try to be as tolerant and patient as possible. You never know what kind of emotional baggage a patient carries into your office.

• Develop and/or maintain company policy. You should have specific policies in place, including a mission statement. These guidelines not only help you understand your practice’s boundaries—they help your staff. It’s effective to know the core mission of your practice, and how you plan to carry it out.

• Have well-trained staff. Your staff helps create a positive practice environment. When they’re well trained and have a positive, synergistic relationship, it can help deflect some common problems. Make sure they understand how to deal with tricky personalities—and then make sure they do it professionally and effectively.

• Practice reflection. Interrupt factual exchanges to acknowledge a patient’s emotional state. Reflective statements, such as “I can see this is upsetting to you,” identify the observed emotions of patients. These statements show the patient that it’s okay to talk about their concerns and fears.

• Legitimize the experience. For example: “I can understand why this upset you.” You don’t have to agree with the patient, but instead demonstrate a willingness to understand the situation from their point of view.

• Partner with the patient. This technique can be used to increase a patient’s participation in their own care by involving them in the decision-making processes. An example: “After we finish the examination, let’s see if we can come up with some solutions.”