8 Ways To Stay On Time Despite Demanding Patients

In a word: Boundaries. 

Some patients need much more than you can give. They expect you to be their psychologist, doctor, nurse, financial advisor, transportation advisor, parental authority, relationship coach and life coach. It’s not the patients’ fault. Society tells them “the doctor knows everything.” And that includes you, nurse practitioner, whether you like it or not. So they expect you to wave your magic wand and solve all their problems.

I bet you’ve tried to be all those things to patients at different times, too. I know I have. But giving more than you are able is a short, well-paved road leading straight to stress and burnout.

So how do you stay on time and help demanding patients who sometimes seem unhelpable?

Firmly, humbly and kindly.

Boundary #1: Listen Without Interrupting for 90 seconds, No Exceptions

As discussed in last week’s blog, you absolutely must build rapport by obeying the 90-second rule and listen for 90 full seconds. This will decrease your overall visit length even with demanding and/or high-need patients, because they will feel heard.

Boundary #2: Listen Without Interrupting for ONLY 90 seconds

After 90 seconds, interrupt firmly but respectfully and acknowledge that they have many difficult issues. Sympathize appropriately but briefly, and state that because you are a nurse practitioner, you are going to focus on just a couple of the medical and/or nursing issues, the ones that you feel like you can “fix” during this visit.

Boundary #3: Know What You’re Good For

Don’t try to fix everything. Yes, you’ve been brainwashed to think you’re supposed to know everything too. You aren’t. Laser focus in on a few issues that are well within your scope of practice, and address them thoroughly.

If a patient’s main problem that they really want help navigating the impending foreclosure on their home, you simply can’t help them, unless you have personal experience with that. If you don’t, state something like “that must be awful and overwhelming,” and then steer them back into issues within your scope.

Boundary #4: Define The Visit Right Away

Once the 90 seconds are up, ask the patient to pick the most important two issues to focus on for today.

They will invariably say “but they’re all important! I need to talk about all of them!” I say “I want to make sure we take care of the things that are most important to you during our time today.”

When they start talking, write down the first two issues they mention, and say them out loud as you write them. If they start talking about a third issue, ask them: “so, we already have two issues… which one of these do you want to remove so we can talk about this third issue? I just want to make sure which are the ones that we absolutely can’t miss.”

When you have two issues chosen, ask them to tell you about issue #1. At that point, they will almost always start talking about issue #1, and be much more easily directed from that point.

Boundary #5: Humility – Make It About You

Patients often get annoyed when you hold them to the 2 issues. I make it about me, and blame the “system.” Everybody hates the “system,” and it’s easy to demonize. Also, it’s true; you can’t change US government requirements, insurance companies, our fragmented “sick care” system.

I explain that I want to do a good job helping them and that I need to focus, because my brain can “only handle so much,” and I want to make sure we have time to truly address the chosen issues rather than glossing over a bunch of things. Again, this is 100% true.

If you make it about them they can argue you until they are blue in the face, but they know they can’t change my brain capacity, so they don’t resist as hard. Usually.

Boundary #6: Be Okay With Pissing Patients Off

Sometimes patients will stay upset no matter what you do or say. However, you are setting these boundaries are for you as much as for them. You are creating a respectful time and space in which to conduct the office visit and address their most important issues. Sometimes, they will just have to stay mad.

Boundary #7: End Negotiations Firmly

Some patients are psychotic, unpardonably rude or otherwise truly undirectable. Ignore them. Talk over them. Walk out of the room. Call the police. Don’t martyr yourself. You are providing a professional service, and should not take abuse for any reason.

With certain patients I would walk into the exam room and immediately demand that they tell me the two most important issues, violating my own 90-second rule. Every time they tried to go off topic in the slightest, I would remind them that before we start talking they MUST pick ONLY two issues. Then and only then would I allow them to talk.

They tended to hem and haw and get upset the first couple of visits with me, and after that they would come prepared with the two “critical” issues and a list of a couple more that we would talk about if we had time. Win win win.

We often talked about 3 or 4 or more issues during the visit, because they’re related. But I always made them start with two.

Boundary #8 – Bite the Bullet

Sometimes you just have to suck it up and let the patient throw you off schedule. Patients who are suicidal, newly pregnant and don’t want to be, have a new cancer diagnosis, or simply hit your own personal triggers will sometimes throw you off track. That’s okay.

At that point, turn off your “clinical brain” for a few minutes and just be there with them for a couple of minutes as a human being. As soon as you feasibly can, turn your “clinical brain” back on and keep moving forward.

Take Care of You!