Understanding the Difficult Patient: A Guide for Pratitioners of Oriental Medicine

Understanding the Difficult Patient A GUIDE FOR PRACTITIONERS OF O R I E N TAL ME DI C IN E

NANCY BILELLO RN, L.Ac.

Blue Poppy Press

Published by: BLUE POPPY PRESS A Division of Blue Poppy Enterprises, Inc. 5441 Western Ave. #2 BOULDER, CO 80301 First Edition October 2005 ISBN 1-891845-32-2 Library of Congress LCCN # 2005933171 COPYRIGHT 2005 © BLUE POPPY PRESS All rights reserved. No part of this book may be reproduced, stored in a retrieval system, transcribed in any form or by any means, electronic, mechanical, photocopy, recording, or any other means, or translated into any language without the prior written permission of the publisher. Disclaimer: The information in this book is given in good faith. However, the translators and the publishers cannot be held responsible for any error or omission. Nor can they be held in any way responsible for treatment given on the basis of information contained in this book. The publishers make this information available to English language readers for scholarly and research purposes only. The publishers do not advocate nor endorse self-medication by laypersons. Chinese medicine is a professional medicine. Laypersons interested in availing themselves of the treatments described in this book should seek out a qualified professional practitioner of Chinese medicine. COMP Designation: Original work using a standard translational terminology Printed at C & M Press, Denver, Colorado on acid-free paper and soy inks.

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■ Table of Contents ■

Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1. An Ounce of Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2. Who Are You?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3. The Noncompliant Patient . . . . . . . . . . . . . . . . . . . . . . . . . . 35 4. The Angry Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 5. The Patient with High Utilization of Health Care . . . . . . 75 6. The Needy/Dependent Patient . . . . . . . . . . . . . . . . . . . . . . 99 7. The Manipulative Patient . . . . . . . . . . . . . . . . . . . . . . . . . . 117 8. The Patient with Communication Problems . . . . . . . . . . 131 9. The Seductive Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 10. The Chronically Late/No-show Patient. . . . . . . . . . . . . . 161 11. The Nonpaying Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 12. Terminating the Therapeutic Relationship. . . . . . . . . . . . 183 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

This book is dedicated to every patient I have had the privilege to serve. You are my greatest teachers.

■ Acknowledgments ■

I would like to thank Bob Flaws, L.Ac., Bruce Staff, and Blue Poppy Press for the opportunity to write this book. Your guidance and support are greatly appreciated. I would also like to acknowledge Fred Jennes, L.Ac. for the original idea for this book. I hope I have done it justice. I would also like to thank my partner, Mark Newmaster for his patience, support, encouragement, and enthusiasm during the writing of this book.

It is of the utmost importance not to take what a patient says or does personally but rather to view behavior as another clue in the therapeutic puzzle before us.

Preface

Receptionist: Mrs. S. is here early for her appointment. Practitioner: Oh no, not “Needy Nelly” again! Wasn’t she just

here a few days ago? She drives me crazy. I just don’t know what to do with her anymore! The above dialogue and variations thereof occur every day in countless health care settings. While most medical training schools focus heavily on theory and application, very few direct attention to the actual relationship that develops between a practitioner and his or her patients. Yet this therapeutic relationship is just as important as any academic knowledge is to the patient’s healing. As practitioners of acupuncture and Oriental medicine, we believe our medicine is holistic. We are very aware that the body does not function as a bunch of individual parts working independently but as a complex entity of interconnecting factors that must all be taken into consideration in both diagnosis and treatment. However, how often do we include patient behavior, and vii

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especially problem behavior, in this model of holism? We are all very complex beings and are propelled to certain behaviors by forces we generally are not aware of. Childhood experiences and family dynamics certainly play a big role in defining our adult behavior. Many physically challenging conditions also shape our moods and personalities. Culture and finances are powerful forces in all of our lives that cannot be ignored. The health care setting seems to be a magnet for attracting problem behavior. Sickness, fear, anxiety, and discomfort induce people to different types of behavior. Asense of entitlement may move someone to act out in a clinic in a way they might not in any other place. Prior negative experiences with health care may carry over into present situations. Problem behavior can manifest in a number of ways. Some patients will demonstrate inappropriate anger. Others may be very demanding or needy, while still others will be completely noncompliant with practitioner advice and instruction. It is a common human reaction when faced with these types of behavior to become defensive and to lash out or “get back” at the person. Health care providers are not afforded this luxury. Even though we are not always taught this in school, a patient’s behavior is very much a part of their overall make-up and is often a result of whatever condition they are seeking help for. Instead of having “knee-jerk” reactions to negative behavior, practitioners must become detectives of sorts and try to figure out what is driving the particular actions. It is of the utmost importance not to take what a patient says or does personally but rather to view behavior as another clue in the therapeutic puzzle before us. It is also our responsibility to find ways to assist the client through their crisis and towards more positive behavior. In school we are taught the fundamentals of theory, advanced practice techniques, clinical “hands-on” experience, and point location, but rarely are we taught how to deal with the actual personality, the spirit of the person who has come to seek our aid.

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Over the past 20 years, I have had the distinct honor and privilege of being a health care provider, first, as an RN and, for the past six years, as a practitioner of acupuncture and Oriental medicine. In spite of all the technical training I have received over the years, my greatest joys and challenges have been in the dayto-day and face-to-face dealings with patients. The many divergent courses of my career so far have put me into contact with an enormous number of people from a wide variety of backgrounds and experience. My patients are a never-ending source of hope, wisdom, and teaching for me. One of the aspects of health care that has always bothered me is the somewhat adversarial attitude that some health care providers take toward their patients. I have known providers who make up nicknames for difficult patients, who give such patients inferior treatment “just to keep them happy,” or who make derogatory comments about problem patients. It would be wonderful if every person who came for treatment were cooperative, compliant, and participated in their own healing with a positive attitude. Certainly, our jobs would be much easier. But the truth is that we are dealing with the world of human suffering in all its various stages and ramifications. Human beings are complex entities, and there is much we do not know about ourselves as individuals and as a species. It is distressing that there is so little instruction in our schools regarding the interaction and relationship between practitioner and patient. Learning how to deal with difficult behavior is a skill that cannot come without direct experience. Although this skill cannot really be taught as such, nor measured in test scores and grades, a certain basic foundation in patient relations would be of enormous benefit to aspiring students. While we may not like or be comfortable with all the conduct patients may exhibit, we must take a detached view and learn to view behavior as another diagnostic tool that can help us

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understand the human being before us. Our job description does not include liking every single person we treat. It does include meeting each and every patient on his or her own level and an obligation to understand them as best we can. It also includes the duty to help them in their journey towards wellness. This book was written largely based on my own experiences as well as those of colleagues in both Western and Oriental medicine. There are numerous books written for Western medical providers regarding problem patients, but none so far written expressly for the practitioner of Oriental medicine. In this book, you will find scenarios and situations unique to the practice of acupuncture and Oriental medicine and the most common problem behaviors that are seen in these clinics. It is my sincere hope that it may be useful to students as well as to experienced practitioners in helping to formulate a better basic understanding of how to provide quality health care to every single patient they meet.

. . . we must constantly look within to find our own truth and, therefore, be able to bring healing to a greater number of people.

Introduction

THE PURPOSE OF THIS BOOK This book is intended as a guide for practitioners of acupuncture and Oriental medicine. It is only a guide. Acupuncture and Oriental medicine are gaining status as viable forms of treatment in the U.S. and are now legal (under the heading of acupuncture) in almost every state, although the scope of practice varies widely from state to state. As this medicine becomes even more widely accepted, new and challenging clinical situations will arise. It is up to each individual practitioner to decide how he or she will deal with problem patients. Policies will vary depending on location and size of clinic, practitioner personality, patient population, and economic realities. Practitioners will also vary in their views of what constitutes problem behavior. The information contained herein is meant to provide a starting place or a focus for those struggling with difficult patients. I have selected 12 distinct problem behaviors to outline and explore, but this is by no means all-inclusive. Likewise, there are situations presented in

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this book that may not have an actual bearing on every clinical situation. It is up to you as the reader to take what can benefit you and leave the rest. The personality profiles and situations in this book are in no way intended to be stereotypes. I have labeled them only for convenience. Within each personality type, myriad forms of behavior may manifest. It is absolutely crucial to view each and every client as if they were your first and only client and to see them within the unique paradigm of their individuality. The information presented here may be used very well in a classroom setting. There are questions for discussion at the end of each chapter, and the “scenarios for discussion” can easily be turned into role-play models. This book may also be used by any individual to help with a specific type of clinical problem. You may choose to read the book from front to back in its entirety or simply refer to the chapters that best suit your needs. I hope every reader will give due consideration to Chapter One, since it is my firm belief that we must constantly look within to find our own truth and, therefore, be able to bring healing to a greater number of people. It is my hope that everyone who picks up this book will find something useful in it and, even more so, that it may foster more excellent and compassionate care for all of our clients. CH APT ER SET-UP The first two chapters in this book outline the “groundwork” of the topic. Chapter One explores how a practitioner might look at his or her own personality, personal issues, and practice style and set-up to determine if there are any elements therein that may contribute to difficult situations in the clinic. In fact, this is a theme throughout the book. It is my firm belief that we cannot fully assist another person without first looking at ourselves. Indeed, we may even be responsible for causing difficulty in our own clinics by the way we have the office set up, the way we carry ourselves, our body language, and our interactions with clients. This chapter will be particularly useful to beginning

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practitioners. It is always easier to start off on the right foot than to have to change established patterns or routines. Chapter Two goes on to define and identify what comprises a difficult patient. You will soon discover that difficult behavior often arises from emotions such as fear, anxiety, feelings of inadequacy, etc. and is not really intended to make the practitioner’s life miserable, no matter how much it may seem so. Factors such as culture, finances, and psychosocial issues are also explored to see how they might contribute to difficult interactions in a health care setting. Chapters Three through Eleven go on to discuss specific types of problem patients and include suggestions for how to handle these situations effectively. Each of these chapters deals with one particular type of problem behavior, except for Chapter Ten in which I combined two types for convenience. Each of these chapters, as well as the first two chapters, includes at least one case history provided as an example to help illustrate the point of the chapter and bring the theoretical into the real world of clinical practice. The case studies are all unique to acupuncture and Oriental medicine. The case studies are presented followed by a “what went wrong” synopsis and suggestions as to how it could have been better managed. Lest the reader think I see myself as a solver of all problems, let me state here that most of these case studies come from my own mistakes and the “what went wrong” part is what I learned as a result of not handling a situation as well as I could have. Of course, names and other identifying details have been changed to protect patient privacy and confidentiality. The suggestions and opinions regarding how any situation could be better handled are just that, suggestions. Only you as a practitioner can really determine how your patient interactions will proceed. Chapters Three through Eleven also include sections titled “clinical presentation,” “contributing factors,” and “the inside story” as well as “questions for discussion.”

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C L I N I C A L P R E S E N TAT I O N : This section describes how the particular patient of that chapter might manifest initially in the clinical setting. Sometimes a problem patient will be readily identifiable from the first minute, but at other times, the problem behavior may be hidden or may manifest later in the therapeutic relationship. Again, these descriptions are not meant as stereotypes, only as helpful descriptions of what might be expected and what to be alert to in order to help fend off problems before they start. C O N T R I B U T I N G FA C T O R S : This section is the meat of the chapter. It always begins with a subtitle called “home base” in keeping with my opinion that we must look to ourselves for causation before blaming patients or extenuating circumstances for the problem behavior. In some chapters, “home base” is the only heading under contributing factors. In other chapters, more in-depth detail is given about patient situations and experiences that may adversely color behavior. THE INSIDE STORY: This section serves as a kind of summary of the chapter as a whole and outlines underlying and often hidden factors that may contribute to undesirable patient conduct. Such factors include cognitive deficits, psychological problems, and psychiatric disorders to name just a few. I want to be clear that I am not a psychologist and have no training in this field. However, after many years of interaction with clients in many different settings, I have become a student of human nature, and certain truths about human nature have revealed themselves to me enough times to allow me a certain degree of comfort in offering my opinions. QUESTIONS FOR DISCUSSION: Each chapter is followed by four questions and one scenario for discussion. The questions may be used as fodder for individual contemplation or may be discussed in a group or classroom

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setting. I believe that exchange of ideas between like-minded people with a similar goal is beneficial in broadening everyone’s horizons and providing different perspectives on each issue. The scenarios for discussion attempt to draw most of the key elements of the chapter into a cohesive and, hopefully, realistic situation that will allow the reader to challenge him or herself in problem-solving. I sincerely hope that this book will be of use to all its readers. I wish you all the best of luck and success in practice!

Physician, heal thyself!

CHAPTER ONE

An Ounce of Prevention

THE DI FFICULT PRAC TITIO NER Before we start looking at and defining the difficult patient, we should first make sure that we are not being difficult practitioners. Our own behavior and appearance can very definitely impact our relationships with our patients. It is essential that we take a good, long look at ourselves, our own life situation, temperament, philosophy, and mental health. Healing is hard work and can be very draining. If a practitioner is not experienced in dealing with problem personalities, he/she may have an even harder time establishing healthy rapport with such individuals. It is paramount to keep in mind that there are two parties in the therapeutic relationship—the patient does not embark on this voyage entirely alone. And yes, we as practitioners can be a source of difficulty. So, you ask, just how are we to know exactly what our part is in this dynamic relationship? I believe it is essential for any health care provider to heed the old adage, “Know thyself.” 7

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In any situation in which personality or behavior becomes a problem, the practitioner should first ask him or herself some searching questions: 1. Am I doing anything to contribute to or foster this problem? 2. Did I already have a negative impression of this person from a phone conversation or a report of such from my staff? 3. Is this situation bringing up any personal problems for me or reminding me of a situation in the past that was uncomfortable? 4. Is my office set-up or my staff posing some kind of barrier to this patient encounter? The above are all fairly basic questions which most of us could probably answer if we are willing to be honest with ourselves. However, there may be deeper issues affecting us. If you have never experienced any kind of psychotherapy yourself and you feel there are emotional blocks you have yet to explore and purge, it would be of great value to delve into these areas at the beginning of your practice. You need not envision yourself on the couch facing away from a bearded professor who is asking you about your childhood. Today, there are dozens of therapy modalities to choose from, including movement, voice, dance, music, and 12-step programs, in addition to the more traditional talk sessions. And don’t forget to look in our own backyards. Another wonderful avenue of self-exploration might be a series of five phase treatments from a properly trained practitioner. With all these options, you are bound to find one that suits you. By suggesting therapy, I am not suggesting that you are crazy (although, by the time you are finished with school, you may very well feel that you are). I am merely suggesting that we all take a good, hard, and honest look at ourselves before we presume to do the same to others.

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It is crucial for every practitioner to constantly be aware of his/her attitudes towards the patient. We are all human, and we all have our foibles. It is entirely possible that you may find yourself resenting or resisting a patient through no action of the patient’s but rather because he/she reminds you of someone or of an unpleasant situation or memory. During the course of your practice, you will find yourself advising your patients on diet and lifestyle choices. It is not uncommon for an acupuncturist or Oriental medicine practitioner to suggest relaxation techniques, meditation, qigong, or yoga to our patients. What a great idea! So often I hear myself giving such advice to a client and I think to myself, “Hey, that sounds like great advice!” The next step, of course, is to ask myself whether or not I am following it. Working with sick people all day, as stated earlier, can be very draining and, at times, frustrating. Keep yourself in balance with some good, regular disciplines such as those mentioned above. Practices such as qigong or tai ji chuan will help keep your own qi strong and freely flowing, will help you keep a healthy detachment from your clients, clear negative energy, and generally hone your concentration skills. Also make sure your own diet is healthy and that you get your fair share of exercise and rest. In order to care for others effectively, you must first make sure that you are in the best shape possible. In other words: “Physician, heal thyself!” A place of one’s own Of course, the best case scenario is to prevent a difficult situation before it starts or to diffuse a situation which has the potential to become difficult. Once you have taken inventory of your own internal issues, it is time to take a look at the external healing environment you are creating. The ambience of your office, your own demeanor, and that of your staff have a tremendous impact on anyone who walks through your door, from the mailcarrier to the most difficult of your patients. It is well worth some extra time and, yes, money to create an atmosphere that will put

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almost anyone at ease. Needless to say, your choice of decor will and should reflect your own tastes and desires, but remember that the office is a service area for clients, not an advertisement for your political, religious, or social views. Many of us in this profession have strong spiritual convictions and often wish to have mementos of these convictions in our office to provide us with inspiration for our work. However, not all of your patients will share or appreciate your views, and some may even be offended by them. It is easy to try to stereotype the “type” of client who would most likely come for Oriental medical treatment, but you might be surprised at some of the folks who will walk through your door. I believe you want to attract as broad a clientele as possible. So keep the decor of your office relaxing but neutral. Any religious objects are best kept in your private office or workspace where the general public is not likely to see them. Likewise, any political or social literature should be kept out of sight. You can always have these items on hand in case there is someone appropriate with whom you would like to share them. Your office should feel welcoming and calming. You may wish to offer tea or juice to clients. Light, healthy refreshments can add charm and a feeling of hospitality to your office space. If you do offer these, be sure to provide a variety of flavors as well as spoons and convenient trash receptacles. It is certainly appropriate to keep magazines, journals or reprints of articles in your reception area, but again, these should appeal to a broad audience. Don’t feel embarrassed to include the latest issue of a popular magazine about celebrities or decorating among other journals about health or healthy living. While your office should provide some edifying reading material, some people are just too nervous or harried to want to deal with that. Many people will go for that easy reading to help distract them from their problems. (I, personally, am disappointed if I am waiting for an appointment about which I am apprehensive and find no mindless reading material at hand.)

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So give your clients a break and let them choose whether they want education or entertainment. Slow, soothing background music is a nice addition to any office and has the effect of immediately putting people at ease. There is no shortage of “easy listening” or “new age” discs, and they are often fairly inexpensive. (As an aside to this, I might add that I often invite clients to bring in their own music for the treatment rooms as long as it is calm and relaxing. The heavy metal can be saved for another time.) Speaking of the treatment room, do give your patients the choice of music or silence. During a difficult time or at the end of a long workday, some folks just want to doze off or to enjoy a rare opportunity to experience some peace and quiet. Why is it so important to give people choices? One of the surest ways to feel like you are losing control over your life is to incur a serious health condition. Sure, you will treat a large number of people who are seeing you for a transient attack of wind heat or a mild case of disquietude of the spirit, but a larger number will be coming for serious issues that have had a negative impact on their independence and well-being. In such cases, allowing even a simple choice of what magazine to read or what flavor of tea to have can offer these patients a sense of control. If you do have an office staff, choose them carefully. They should be people with whom you feel comfortable and can get along with easily. Before they ever take their first seat at your reception desk, educate them to your expectations and how you wish your patients to be greeted. Your front desk staff should be organized, pleasant, efficient, and professional. (Resist the urge to please your mother by hiring her best friend’s bored teenager for the summer.) It is in everyone’s best interest to have a plan in place in case a truly difficult situation arises. It is prudent to have ready access to emergency numbers for police, suicide hotlines, or domestic violence hotlines. Most of us will never

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need these numbers, but, in a challenging situation, you do not want to be fumbling through the phone book for assistance. Looks aren’t everything, but . . . How you present yourself is every bit as important as how you present your office and your staff. We would all love to roll out of bed and slide off to work in our favorite pair of jeans, but perhaps they should be saved for the weekend. I know Oriental medicine practitioners who do wear jeans and more casual attire to work. Your choice of apparel is entirely up to you, of course, but make your wardrobe decisions carefully. If you know for sure that your clientele will feel comfortable with a practitioner wearing jeans, then there is no harm done. However, your choice of attire may not be acceptable to all people. After even a short time in practice, you will realize that seemingly insignificant events can have a profound affect on people’s behavior. If someone is skeptical or hostile, being greeted by a sloppily dressed or very casually attired practitioner may be just what is needed to provoke undesirable conduct. A professional appearance is more likely to put a new or nervous client at ease and automatically instill a preliminary sense of trust, thereby helping to avert a potential problem situation. Traditional white lab coats are sometimes required in student clinics and do add an air of professionalism. Once outside of school, however, these lab coats are usually optional. In any case, whatever mode of attire you choose, it is never, ever appropriate to wear skimpy or sexually suggestive clothing. Hair length is also a personal choice. Long hair should be tied back when working directly with the patient. It is both unsightly and non-hygienic to have hair hanging down over your patient when you are inserting needles or doing palpation. Ayoung child or extremely agitated client may find it irresistible to tug on a lock of accessible hair. Needless to say, hair of any length should be kept clean.

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Whether you are male or female, it is wise to keep your hands well manicured. Think of how many things you will be doing with your hands, from pulse-taking to needle insertion and removal to abdominal palpation. Some clients may just shut their eyes tight and ask never to be shown a needle. Others, however, will inspect every move you make, especially when it concerns their body. People notice more than you think they do, and your fingernails will be center stage for a good part of the appointment. Make-up and jewelry are also factors to think about. Make-up should be tasteful and not overdone. Jewelry is best limited to smaller items. Some acupuncturists feel that jewelry on the arms and fingers interferes with the transmittal of qi. Whether or not you adhere to this theory, jewelry should not pose any kind of distraction. Beware of excessively long dangling earrings. A confused, irrational or frightened patient may not be able to resist the temptation to give a tug on one of them. This is especially true if you treat infants or very young children. Colognes and perfumes are best avoided. Not all aromas affect every person the same way, and some people may be put off by certain smells. Also bear in mind that some of your clients may be experiencing digestive disorders, including nausea and/or vomiting. A whiff of cologne or perfume may not be the most therapeutic balm for these maladies. Any and all of the suggestions above apply to your office staff as well as to you. Presenting that professional image will do wonders to allay many patients’ misgivings or fears and will benefit your practice in many other ways as well.

■ Remember that many of your patients will be coming to you for their first acupuncture treatment. They may feel nervous, frightened, and leery of the unknown. ■

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Meeting & greeting Feeling at ease with your patients and in turn making them feel at ease with you will go a long way to fostering a healthy therapeutic relationship. Your words should always be chosen carefully. It is important to convey friendliness. Remember that many of your patients will be coming to you for their first acupuncture treatment. They may feel nervous, frightened, and leery of the unknown. Greeting your patients with a warm smile and a friendly handshake will make a good first impression and will be something your returning patients will look forward and come to expect from you. Although the public is becoming more educated and more aware of the benefits of acupuncture, there are still many misconceptions and fears surrounding our medicine. For many patients, acupuncture and Oriental medicine may be a last resort in a long and tiresome journey to find relief from a baffling condition. Some may be coming out of a sense of adventure or curiosity. Still others may have heard good things about acupuncture and Chinese herbal medicine from friends or family and are willing to give it a try. Whatever the case may be, it is beneficial to determine the patient’s acupuncture experience at the time the appointment is made or, at the very latest, as a question on the intake form. Even if you are the only person in your office and you feel it is obvious that you are the practitioner, always introduce yourself to a new patient. Glance at your appointment book in advance so you know who your next patient is. At first, your practice may be slow, and you may have no trouble knowing who is coming in next, but, as your practice grows, it may become easier to lose track of appointments. When greeting a new patient, if you are unsure as to how they prefer to be addressed, use Mr., Ms., or Mrs. with their last name. This is especially true of patients who are somewhat older than you. This form of address may seem overly formal, but it is professional and polite, and most people

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will readily let you know how they prefer to be addressed. Unless you are addressing a child, avoid using words like “sweetie,” “dear,” or “honey.” They are diminutive terms that may sound condescending, especially if you are younger than the person to whom you are speaking. Do not assume that Deborah likes to be called Debbie or that Robert likes to be called Bob. I have found that some people are very particular about their name. So it is always good policy to ask. If you are unsure how to pronounce someone’s name, ask instead of attempting a potentially offensive mispronunciation. Asking denotes respect for the client, and it is always best to ask rather than to risk offense or to sound foolish by mangling someone’s name. If the patient has never had acupuncture or herbal treatment, leave a little extra time to let him or her feel comfortable with you as well as to ask any questions about the procedure. Your explanation should be concise and clear and definitely not couched in Oriental medicine jargon. By the time you are done with your schooling, words like yin vacuity or external contraction of wind heat may be all that is running through your head. Using such terminology will not impress your clients and may alienate them. Remember how strange these terms seemed to you at the beginning of your studies. Then imagine how much stranger they sound to the new client. No one wants to be treated for something they cannot understand and have never heard of. Since it may be out of our scope of practice to use Western medical terminology (depending on your state laws), you may at times have to use some terms specific to Oriental medicine. This is a perfect opportunity to educate your clients and help demystify our medicine. The use of any terms should be accompanied by a clear but brief explanation. Keep a reference book or illustrated posters handy so you can show your clients the channel pathways and some pertinent points. You may want to order or create your own pamphlets written for the layperson for patients to read and take home with them. You may also want to keep a list of books about

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Oriental medicine handy to recommend to ambitious clients who wish to know more about their treatment than an appointment time will allow. I like to recommend Between Heaven and Earth by Harriet Beinfield or, for more ambitious people, The Web that Has No Weaver by Ted Kaptchuk. There are also several others from Blue Poppy Press that may be relevant for your specific patient. Actions speak louder than words We hear and read an awful lot about body language these days and for a good reason. Our body language may serve to enhance or illustrate our message, but it may also belie the words we are POSITIVE BODY LANGUAGE AND PATIENT INTERPRETAT I O N POSITIVE BODY LANGUA GE

PAT IENT TRAN SLAT I O N

Sitting up, comfortably, with slight forward leaning of your upper torso toward the patient.

“I’m bringing my full energy, interest, and attention to this meeting, as well as my efforts on your behalf.”

Maintaining appropriate eye contact, being particularly attentive when the patient is divulging something that is emotionally troubling.

“You and I have an important professional relationship. I will work with you and you can trust me with your physical and emotional concerns.”

Shoulders and upper torso facing or angled toward the patient.

“You are the primary focus of my attention. Not your chart, not my computer. You have my fullest attention while we are together.”

Nodding the head occasionally at key points in the patient’s conversation.

“I’m listening, I’m interested in what you are saying.”

A smile, or other facial expressions, as seems appropriate.

“I’m really happy to see you, and I look forward to working with you. I hope you feel comfortable telling me about your concerns.”

Upper torso not closed off by arms, charts, or medical equipment as much as possible.

“I am available to give you my fullest professional attention. I am always approachable.”

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N E G ATIVE BODY LANGUAGE AND PATIENT INTERPRETAT I O N N E G ATIVE BODY LANGUAGE

PATIE NT TRANSLAT I O N

Examining test results, intake forms, or case research as the patient is speaking about their most deep-seated fears.

“I’m going to ignore your emotional silliness. Only the clinical information here is important to me.”

Responding to the patient’s description of their condition with an occasional “OK” or “I see” without looking up from their chart.

“I can’t get personally involved in your pain. This is purely clinical. You are just a bunch of parts and pieces to me.”

Arms folded over the chest or on the desk while talking with the patient. Holding the chart against the front of the chest, arms folded over it, while talking with patient. Rapid and frequent head nodding while the patient is talking.

“Don’t even think about getting any closer to my personal space.” “This is top secret information and you can’t see it. You wouldn’t understand anyway because this requires my superior intelligence.” “OK. OK. Cut to the chase, because I haven’t got all day.”

Tapping your pen rapidly on the desk, note pad, or file.

“You’re taking up my valuable time here. Can you just get to the facts, please?”

Listening with no facial expression, no movement of your hands, head, or eyes.

“Do you really think I care about this? I’m just enduring this conversation until I can write a prescription and move on.”

Leaning back on your chair, resting comfortably on your lower spine; rocking your reclining office chair. Silently and diligently entering data into the computer with your back toward the patient. Looking at the patient through the bottom of your bifocals with your head tilted up. Looking over the top rim of your

“This is really boring. Maybe I can sleep through it.” “Oh, are you still here? I thought I was finally alone and could get some work done.” “Of course I’m looking down at you. I’m vastly more intelligent and powerful than you are.” “You’d better have the right answer to this. Have I thoroughly intimidated you yet?”

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Understanding the Difficult Patient

speaking. It can also convey unintended messages. As a health care practitioner, your words carry more power than you can imagine. An offhand remark that you forget almost as soon as you utter it may be something the patient takes home and remembers for a long time. Therefore, it is important not to sabotage our verbal messages with body language. However, we are often not as aware of our body language as we are our words. Take some time to observe the body language of others in everyday situations. Do you have an upcoming doctor’s appointment? Are you planning to go to a store where you will need to ask someone for information? Is your car (using body language as only a car can) telling you to get to the mechanic’s? If so, be observant of the way the doctor, clerk, or mechanic holds his/her body and make a mental note of how it positively or negatively affects you. Then take some time to note your own body language. When you are with patients, be conscious of the way you behave with them, just as you are analyzing their behavior with you. As stated above, greet your patients warmly and with a firm handshake or even a light hug if that seems appropriate. As you usher them into the treatment room, hold the door open for them and let them enter the room first. With a new patient, indicate whether they should have a seat in a chair or sit up on the table. If you and your patient are both seated in chairs, have the chairs at a slight angle, rather than facing each other straight on. You don’t want your patients to feel as though they’re at an interrogation. Try not to cross your arms when talking with them. This conveys a message of impatience and being closed off. Keep hands loosely in your lap. Assume a relaxed position—but not too relaxed. An arm casually draped over the back of your chair may make the patient feel that you are too casual and not taking them seriously enough. Leaning a little forward indicates interest and encourages the speaker to continue and to give further details. If you are addressing a patient who is already lying on the table, again keep your arms uncrossed and do not place hands on hips

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as this may be reminiscent of an angry parent about to scold an unruly child. Eye contact is crucial nonverbal communication. This may sometimes be more difficult than you think. If a patient is describing an especially personal physical or emotional problem, you, as the practitioner, may feel embarrassed or at a loss as to how to react. Even so, try to maintain eye contact. Looking away may make the person feel awkward or may make him or her feel that you are uncomfortable and/or unwilling to deal with their problem. On the other hand, don’t just stare at the person either. A little eye movement is required. While we should generally maintain eye contact when the other person is speaking, it is perfectly all right for our eyes to wander when we are speaking. Touching is an integral part of our practice, and we cannot avoid it. In fact, we are actually licensed to touch! In the strictly professional sense of the word, we touch patients when palpating, taking pulses, and inserting and removing needles. Touch can also convey sympathy from the practitioner. If a patient is in pain, is anxious or overwhelmed, a gentle hand on the shoulder can provide comfort and solace. Likewise, a light pat on the back can be reassuring to a patient. These are all acceptable forms of touch. Of course, there are also very inappropriate forms of touch and these will be dealt with in more depth in the chapter on the seductive patient. Listen carefully when a patient gives you details about his/her personal life. Some practitioners even make small notes in the patient’s chart to help them remember the names of the client’s children, an important upcoming trip or anniversary, or other significant events. Do not ignore such details but rather make some comment to show you acknowledge that these details are also important to you. Making reference to these points tells the patient that you are listening to them and that you have an interest in them as a whole person, not just as a medical problem. It will help put them more at ease.

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Understanding the Difficult Patient

Being a healer means being a teacher. You will have lots of advice and instruction to give to your patients on a variety of topics, from diet to posture to herbal therapy. You will most assuredly have patients who do not take your advice to heart or who do not follow your instructions (for more advise on this, see Chapter Three). Try not to assume the old schoolmarm position of pointing or shaking a finger at the patient. This action can easily be perceived as being critical and authoritative and is an instant turn-off for most people. Sign on the dotted line Paperwork is a necessary evil in these times, and even we who practice an ancient system of healing are not exempt from having to deal with it. It is especially frustrating to many of our patients because so many of them will have been to so many other practitioners before they reach our doors and have filled out their health history countless times. Nonetheless, we do need to keep accurate records for legal purposes as well as to have a good, ongoing chart of patient problems and progress. The acupuncture/Oriental medicine intake form should be detailed enough to give the practitioner a truly holistic overview of the patient but easy enough for the patient to fill out without becoming frustrated. Many practitioners use forms in which the patient mostly just has to check boxes to indicate details of the history without having to enter an essay contest. This is a very reasonable way of presenting your forms. In this case, you might want to leave space for yourself to fill in details during the interview process. A thorough intake form will typically prove to be a valuable asset to you if the patient does end up displaying difficult conduct. You can go back over that initial intake to see if you missed any details that might give clues to the patterns underlying the patient’s behavior. The intake form should include information about the patient’s physical as well as emotional state of being. Even if the patient is coming with the sole complaint of a sore shoulder or sprained muscle, a holistic history is beneficial in uncovering possible related factors as well as conditions the

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client has not even mentioned that might also be well treated with acupuncture or Oriental medicine. Many states require that practitioners of acupuncture and Oriental medicine also give patients a disclosure form that outlines the practitioner’s educational and professional background, fee schedule, hours of operation, cancellation policy, and numbers to call in case of grievance. These forms also include any potential adverse effects of the treatments and, therefore, serve as consent forms. For legal purposes, every practitioner should be diligent about having every patient read and sign these forms. If problems should arise in the future, these records could prove very useful as protection for you and your clinic. After reading this chapter, you may feel ■ as though you have just been lectured The main idea by Miss Manners. It is by no means the here is to create intention of this book to dictate to anya nurturing and one what should be worn or said or what safe environment image to present. However, as Oriental that will minimize medicine is welcomed more and more difficulty and into the mainstream, practitioners will maximize benefits be exposed to a larger patient populato you, your tion. Generally speaking, most Oriental medicine practitioners do not wish to practice, and be cast in the same mold as the stereomost of all, typical old doctor who is polite but disyour patients. tant, caring yet conservative. Rules ■ dictating traditional dress and behavior may seem somewhat prim and even outdated. Of course, there is plenty of room for personal choice and freedom. After all, our medicine is unique and most of us want the freedom to express the uniqueness of our practice and of ourselves as we see fit. Certainly different states, cultural climates, and patient populations will help dictate how you present yourself. The main idea here is to create a nurturing and safe environment, one that will

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Understanding the Difficult Patient

minimize difficulty and maximize benefits to you, your practice, and, most of all, your patients. Many of your patients will be experiencing pain, discomfort, and/or a high degree of stress. It is your job to help make them feel comfortable, less stressed, and to offer solace, healing, and compassion. Cases in point: Case 1. Mrs. H.is a 90 year-old woman with arthritic knees who is coming for acupuncture at the suggestion of her family. She is very nervous about the treatment. When she enters the waiting area, she is told to have a seat while she fills out her intake fo rm . The practitioner had brought in a few old chairs for the reception area.Mrs. H. found these quite uncomfortable.When the practitioner greeted her, he was dressed in a pair of old jeans and a casual sports shirt .M rs. H. appeared nervous and uncomfo rt able during her tre at m e n t , even though the practitioner allowed extra time for her appointment given her age and frail condition.She received a good treatment but did not reschedule. As she was leaving, the practitioner overheard her say to her daughter,“I wouldn’t come back here.I can hardly stand those old chairs, and he didn’t look like much of a doctor to me.”

■ What went wrong? In this case, the practitioner’s skill was not in question. In fa c t ,h e gave the client an excellent initial treatment. Unfortunately, however, in an attempt to save some money early in his practice, he placed older,uncomfortable furnishings in his office.An older client like Mrs. H. needs and looks for comfort and a sense of newness to her surroundings in a health care setting. This alone may not have been enough to dissuade her from returning, but the practitioner’s mode of dress left her feeling she was not in the hands of a professional.Even though the skill level was there, the patient’s first impression left a negative enough imprint on her that she did not feel comfortable in making another appointment.

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Case 2. Mr. S. scheduled an acupuncture appointment for a long-standing problem of infertility and impotence. The acupuncturist was young and fairly new at her practice. The client was eager for help and described his history and present condition in detail. The acupuncturist was uncomfortable with the sexual and personal nature of his case and kept shifting in her seat and avoiding eye contact with the patient.The treatment itself went well, but the patient did not return for any follow-up appointments.

■ What went wrong? Although this practitioner had adequate training to treat this client, her age and inexperience left her uncomfortable with the client’s frankness and the details of his condition. Her discomfort was evident in her body language and left the client feeling he could not communicate openly with her. No matter how nervous a practitioner might feel with personal problems such as this one, these are valuable learning experiences. A practitioner should always be aware of his/her body language and the effect it might have on a client as well as on their practice.

QUE STI ONS FOR CHA PT ER ON E: 1. What kinds of personal practices/disciplines are you or could you be practicing to help keep yourself focused and clear? 2. Think of a positive and a negative experience you have had in a health care setting. What made it positive? Negative? 3. Design your future office, bearing in mind the concepts from Chapter One. If you are already in practice, what areas of improvement can you identify in your current office?

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Understanding the Difficult Patient

4. Can you recall any instances in which body language hindered or enhanced a speaker’s intent? 5. Scenario for discussion: Mrs. J. has been to many doctors and other health care providers trying to find relief from symptoms of fibromyalgia. She is tired and more than a little anxious about getting acupuncture treatments. She is afraid they will hurt and maybe make her pain worse. When she enters the office for the first time, the receptionist is on the phone and takes several minutes to complete her call but does not look up or acknowledge the client. When the receptionist finishes the phone, she greets the client, saying, “Hello, Mrs. D.” The client indicates to the receptionist that she is very nervous, but the receptionist only responds, “You’ll have to talk to the acupuncturist about that.” She is asked to have a seat in the waiting area and rustles through some old magazines on the table. When the practitioner comes out to greet her, she notices that his shirt has stains on it and he does not shake her hand. What changes could be made to this scenario to help the client feel more at ease? How could the receptionist have been better trained? What effect do you think this initial encounter might have on this client?

Most difficult behavior hides fear, anxiety, or some other negative reality the patient is either unaware of or does not want to face.

CHAPTER TWO

Who Are You?

So, who is this book about anyway? It is about human beings who are in discomfort and who are seeking relief from this discomfort. Because of past or present events—or a combination of both—they may exhibit certain behaviors which interfere with the efficacy of treatment. Oriental medicine is truly a holistic discipline based on the uniqueness of each individual. In my experience, most of us in this profession cringe at defining or pigeon-holing people. For the purpose of this book, however, a brief definition may be helpful. Asurvey of existing literature on the subject reveals a surprising lack of definition. Because providers, too, are individuals, there may be conflicting ideas regarding what constitutes a difficult patient. Hooberman and Hooberman offer a concise, broad definition: “A difficult patient is a person who presents to the caregiver behaviors and emotional difficulties of a severity significant enough to impact adversely on the treatment or the provider.”1

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Understanding the Difficult Patient

Some of the most common patients you will see who fit this definition are those who are noncompliant, angry, overuse the health care system, are needy, rambling, vague, chronically late, seductive, nonpaying, and/or manipulative. That covers a lot of territory! Each of these particular types will be discussed in their own chapter, and, after some time in practice, you may well be able to add to the list. In Chapter One, we looked at the practitioner as a potential source of difficulty in the therapeutic relationship. It is essential to keep in mind that when we are dealing with a patient, we are indeed in a relationship with them. As with any relationship, consideration of the other person will allow us to see a different point of view and not take things so personally. Problematic behavior rarely manifests for its own sake. It generally is an outlet of some sort for a deeper issue of which the individual is not fully aware or is unable to cope with. It is helpful for providers to understand the reasons behind troubling behavior. The term “secondary gains” is often used to describe benefits an individual may receive from an illness. This is often the reality in patients who are noncompliant, for example. Secondary gain can be defined as the use of illness to meet a variety of other needs. This may be the receipt of money for pain and suffering . . . or the sick role may relieve one of professional and family obligations and may be used to obtain attention and sympathy from others.2 Relief from the illness may force the person to face realities he/she does not necessarily want to face or to assume responsibilities he/she does not want to assume. In addition, some patients may feel they have lost control or independence in their lives, and the resulting frustration can leak out in their behavior. Sometimes, it is just plain old fear that holds someone back from true healing. There may also be personal conflicts, about

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27

which the patient is reluctant to talk and which can affect behavior. Financial woes, a divorce or relationship crisis, problems with children or aging parents, and substance abuse are all examples of existing conditions that a patient may not feel are relevant enough to mention to the practitioner but that, nonetheless, affect the therapeutic relationship and treatment outcomes. Consider the following situations: Case 1. E. S. is a 19 year-old man with a long history of depres-

sion, indigestion and fatigue. Before seeking acupuncture treatments, he had been to numerous doctors and therapists but had found little relief for his symptoms. After treating him for several sessions without results, the acupuncturist suspected that he was resisting getting well. When questioned about this possibility, he at first denied it. On his next visit, though, he opened up, expressing a fear of getting well. He felt that if he did get well, he would have to function in society. Having been out of high school only a short while, he realized he did not know what direction he wanted to go in. His parents had quite high expectations of him and were already disappointed that he was not pursuing a college career. They were very alarmed at his state of health, however, and urged him to seek help before entering college. The acupuncturist allowed this patient to vent his fears and referred him to a psychologist with the understanding that he would work on some of the underlying issues preventing his improvement. Case 2. R. S. is a woman in her mid-30s who came for help in

losing weight. She had initial success in shedding about 20 pounds, was very compliant with diet and exercise instructions, and had a positive attitude. The practitioner was quite surprised when she suddenly did not book her usual weekly appointments, then returned in about a month, having gained most of the weight back. Upon discussing the situation, she revealed that, while she was overweight, she used her weight as an explanation as to why she was unable to find a meaningful relationship. She had

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Understanding the Difficult Patient

convinced herself that if she could lose weight, men would find her attractive and her dating problems would be over. At her lower weight, however, she was still not meeting anyone, and she felt it was easier to gain the weight back and have her old excuse rather than look at some tougher underlying issues. Case 3. B.W. is a 60 year-old woman who had recently started chemotherapy treatments for cancer. She was hoping acupuncture would alleviate the side effects of her treatment. Each time she came in, she found fault with something the practitioner was doing. The room was too cold, he was talking too fast, the table was uncomfortable, the needles hurt too much, etc. On one or two occasions, she became angry and irritable for no apparent reason, although she was getting satisfactory results from the treatments. The practitioner realized there had to be something else going on, and the next time she came in, he took a few extra minutes to ask how she was doing and what she was feeling. She began to cry and expressed a high level of fear of the unknown and of the initial diagnosis. It was obvious then that her behavior reflected a valid fear that she had not been able to properly express. Case 4. T. A. is a middle-aged mother of three teenagers who

was suffering from severe allergies. She had tried acupuncture before with good results and was anticipating a good outcome this time as well. Her first two sessions went well, but thereafter she cancelled two consecutive visits on very short notice. She did come in again but started asking about fee structure. She told her acupuncturist she was unable to pay the full fee for that visit because she was short on cash and had no checks with her. The acupuncturist also noted at this time that there was an increase in her anxiety level. She took the liberty of asking the patient if she was experiencing any financial difficulties. At that point, the patient revealed a harrowing tale: One of her teenaged sons had been involved in a drunk driving incident which had caused

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severe injuries to an innocent party, and the family was now involved in a long and very expensive legal battle. When asked why she had not brought any of this up before, she replied, “I didn’t want to unload on you, and I didn’t think this had anything to do with my health or my treatments.” Working together, the practitioner and patient were able to come up with a treatment plan as well as a payment plan that allowed her to continue treatment and devote the energy she needed to her personal situation. Admittedly, not all covert issues will be so easily revealed by simple discussion. Very often, the patient may not be able to identify or express the depth of the truth. The practitioner needs to hone his/her listening skills because, quite often, a casual remark made during the treatment by the patient may hold clues to their behavior problems. From the above cases, it is clear to see that most difficult behavior hides fear, anxiety, or some other negative reality the patient is either unaware of or does not want to face. We do not have to be psychologists to help these patients. A little detective work, a sympathetic ear, and a safe place to receive treatment is enough to correct most behavior and improve the patient’s chances for healing. In other cases, the problem may be beyond our scope of practice. If attempts at discussion do not yield positive results or if the patient is just plain unwilling to talk with you, it is most likely time to refer to a psychologist or therapist. It is important from a legal as well as a practical point of view that we as practitioners understand our scope of practice and do not try to be what we are not. Specific situations and suggestions for handling such situations will be dealt with in the following chapters. We would all like to think we can help every single person who comes to us with every single need they have, but this is not the case. So, when in doubt, refer out!

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Understanding the Difficult Patient

As a final word on attempting to define the problem patient, I would also like to note who is not considered a problem patient. For example, cultural differences do not constitute personality problems. When treating a client who is from a different culture, bear in mind that their behavior may be a reflection of the culture and not an indication of difficulty for the practitioner (other than trying to understand the other culture). For example, in many Asian societies, it is unacceptable to complain about pain; stoicism, especially in males, is seen as an asset. It may be difficult to obtain a good history or to ascertain what is wrong with the patient. This type of patient may also not be expressive in telling you when he is experiencing relief. In many Hispanic cultures, the family unit is placed higher than the individual. It is not unusual for a Hispanic patient to show up in the clinic with two or more family members. Treatment options may be a decision for the whole family to make and not just the patient. There is usually a kind of hierarchy in the family system, with the final decision typically resting with an oldest son or other dominant male figure. There may be much debate and even hesitation during the family discussion. Traditional Arabic cultures often have very strict rules regarding the treatment of female patients. A traditional female Arab patient will most likely not be comfortable or even permitted to be in a room alone with a man. She may have to be accompanied by a male relative. She may not be able or willing to remove clothing to the degree necessary for treatment. Diet is a huge issue when considering cultural influences. So much of our teaching in Oriental medicine focuses on diet, but our teaching may not cross cultural boundaries. No matter how high her cholesterol was, my Italian grandmother was not going to give up the fat in her diet for anything and, furthermore, would not have understood the rationale for doing so. I would not want to be the one to tell a Buddhist that she would be better off adding

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a little red meat to her diet to nourish the blood. Nor would I relish telling my older Greek gentleman that coffee should be eliminated from his diet. If there is a language barrier as well, things may get truly complicated. In this case, it is always best to have the client bring along a companion who can translate. These are just a very few examples of how culture can dictate behavior and, perhaps, hold a challenge for the practitioner. But these patients are not being difficult. They are merely acting as their culture dictates. The difficulty here lies simply in the practitioner’s ability to broaden his/her horizons and reach beyond what is known and familiar in order to accept the client in the exact place he/she is in. As professional health care providers, we must also be able to ■ differentiate between a patient with difficult or challenging behavior and the In the course of patient who suffers from a true psychi- your practice, you atric disorder, such as schizophrenia or will meet many bipolar disorder. Although these patients people who have do pose problems for us, I do not consider diseases that are them problem patients. They are operatvery hard to treat ing under the influence of an actual disor even those that ease. Of course, Oriental medicine can are refractory to treat many psychological and psychiatric disorders, but be sure you are capable and Oriental medicine. comfortable in treating these cases. Again, These cases, there is no shame in referring out if nectoo, should not essary. If you do not have much experibe confused with ence in dealing with these types of the patient disorders, it may be difficult to identify being difficult. the true psychiatric patient from one who It is the disease is merely exhibiting difficult behavior. Of that is difficult. course, if the psychological diagnosis is ■

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Understanding the Difficult Patient

what they are coming to see you for, that will make things fairly obvious. But if they are coming for a different problem, the psychological issue may not be so obvious. Areview of the medications the patient is taking is very helpful. (You should always have a Physician’s Desk Reference handy for quick research.) You may want to include some questions on your intake that specifically ask whether the person has experienced or is experiencing any psychological problems, including suicidal ideation. Consulting with a professional in the field of mental diseases is also an option if you feel you need further information on someone’s behavior. Psychiatric or psychological disorders are only one category of diseases that are difficult to treat. In the course of your practice, you will meet many people who have diseases that are very hard to treat or even those that are refractory to Oriental medicine. These cases, too, should not be confused with the patient being difficult. It is the disease that is difficult. Frustration, fear of inadequacy, pride, and stubbornness are all pitfalls for the practitioner to be aware of. They can lead you to transfer your own feelings onto the patient, when it is really the condition that is vexing you. In cases like these, honest self-appraisal is the only way out. Consulting with senior acupuncturists or herbalists, doing extensive research, and reviewing the case thoroughly are the tools available to help you deal with the situation and not transfer wrongful traits onto the patient. A major concept to keep in mind is that the patient is not there for the practitioner. The practitioner is there for the patient. Patients come in all shapes, sizes, and colors. It is your job to understand what makes a person tick, what drives their actions, and what place in life they are coming from. The patient physically comes to you, but otherwise, it is you who must really come to the patient. You are expected to do your best to meet them where they are and to interact with them at their level without compromising the quality of treatment.

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QUEST IO NS FOR C HAPTER TW O: 1. Think of a situation in your own life where you or someone else exhibited behavior that was masking a deeper issue. Were you or they able to resolve the issue? What were the consequences of the behavior? 2. What does the term “secondary gains” mean? Give an example. 3. What are some common underlying issues that may lead to problematic behavior in a patient? 4. Think about the area where you are or plan to be practicing. What are some of the predominant cultures in this area? How might they pose difficulty in a therapeutic setting? 5. Scenario for discussion: An elderly Japanese gentleman comes to your clinic seeking relief from chronic constipation. He is accompanied by his daughter-in-law. The patient gives very vague answers to questions on the intake form and seems unduly anxious about the treatments but asks very few questions. His daughter-in-law takes the liberty of asking questions as well as answering questions directed at the patient. On subsequent visits, although objectively he appears more comfortable, he insists that the treatments are not helping him. Use your imagination to construe some possible blocks to this patient’s healing. How would you handle the situation?

Endnotes: 1

Hooberman, R. Ph.D. and Hooberman, B. MD, 1998, Managing the Difficult Patient, Madison, CT, Psychosocial Press, p. 8

2

Sohr, Eric MD, 1996, The Difficult Patient, Miami, Medmaster Inc., p. 47

In treating the noncompliant patient, the practitioner needs to let go of the feeling that he/she is the authority in the relationship and must allow the patient to become a willing participant.

CHAPTER THREE

The Noncompliant Patient

By far, the most commonly experienced difficult behavior in any clinic, Western or Eastern, is noncompliance. Ask any provider who has been in practice for even just a few months and he or she will be able to relate more than one instance of noncompliance. It is the perennial plague of doctors, nurses, physical and occupational therapists, and now practitioners of acupuncture and Oriental medicine. Noncompliance is a complex topic with a very simple definition: “Noncompliance can be defined as the patient’s refusal to follow prescribed treatment recommendations, large and small.”1 It is easy to become frustrated with a client’s seeming unwillingness to participate in their own care. We cannot understand why they would spend so much time and money on treatments and neglect the important follow-through instructions that hold the key to their well-being. What’s going on in this case? Is it wrong to assume that someone coming to us for treatment really wants to get better? Why else would they be coming? Why would 35

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Understanding the Difficult Patient

they waste time and money seeking help if they don’t want to follow the advice of the practitioner? C L I N I C A L P R E S E N TAT I O N : ■

Not following practitioner recommendations and prescriptions

■

High utilization of health care system

■

Chronic complaints that have gone unresolved for a long period of time

■

Discovery of past noncompliant behavior

C O N T R I B U T I N G FA C T O R S : Home base There are countless factors that contribute to a client’s noncompliance. Let us again begin with ourselves. As discussed in Chapter One, your dress and demeanor, the words and actions of your staff, and the ambience of your office influence the way a person will react to you. If something offensive or confusing was said, however unintentionally, the patient may feel guarded and may want or need more time to form a good impression. Most patients will not actually tell you that something you or your staff did or said had a negative impact. ■ Most people maintain a level of social If the office is not politeness and do not wish to offend or comfortable or risk any kind of confrontation or unpleasdoes not have a antness. However, their feelings may be professional feel, expressed in future actions and attitudes. It is important to remember the effect your that might also words have on your patients. They are affect the coming to you for health care, and that client’s attitude. implies an inherent level of trust. Your ■ words hold an enormous amount of power. Even an offhand comment can stick in someone’s mind for better or worse. Always be aware of your speech and choose

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your words carefully lest you inadvertently give someone the wrong impression. If the office is not comfortable or does not have a professional feel, that might also affect the client’s attitude. People will tend to be more compliant if they feel they are being treated by a professional. If they do not have this impression, they may not hold the practitioner’s advice in as high regard as it deserves. Another good policy is to be a role model for your patients. It is up to each practitioner to decide how much of his/her personal life to reveal to patients. It does not hurt, however, to let patients know in some way that you exercise regularly, take herbs yourself, go for acupuncture treatments, etc. It puts you on a more equal level with the patient and also provides some guidance and motivation for them. As acupuncture’s popularity increases, practitioners will be seeing a wider and wider variety of people in their offices. Keep in mind that your values and those of your patients may not be the same. As always, individuality plays a crucial role in the therapeutic relationship. Your idea of optimal quality of life may actually differ quite drastically from your patients’. A surprising number of people will put up with a surprising amount of discomfort and still feel they have a good quality of life. They have a right to feel this way, even if you think their quality of life is not ideal and could be improved. Any further improvement may not seem worth it to the patient if it involves actions or changes in lifestyle or diet that are unpalatable. Discomfort is a valid option, and one that patients have a right to choose, however difficult that may be for practitioners to comprehend or accept. Case in point: G. D. had been suffering from severe heartburn for years. She also had accompanying symptoms of bloating,borborygmus, and constipation.After about three months of weekly acupuncture

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Understanding the Difficult Patient

treatments, the heartburn was largely resolved, but some of the other symptoms remained and were slow to resolve with acupuncture alone.The patient had already changed some dietary habits, and the practitioner next suggested a course of herbal treatment to augment the acupuncture.The patient was agreeable and was sent home with an appropriate formula in powder form. When she returned the following week,she told the practitioner that the taste was awful and she could not tolerate it.The practitioner explained that the formula was custom-made for her symptoms and patterns and he was not able to provide it in pill or tincture form. The patient then decided against the herbs and stated,“That’s OK. I feel so much better than when I first started coming that a little bloating now and then isn’t that big a deal.” The practitioner also explained that the remaining symptoms indicated that the root of the problem had not been sufficiently eradicated and that the symptoms might worsen. The patient responded that,“Oh, I’ll just come back for more acupuncture if that happens.”

■ What went wrong? As conscientious providers, most of us can sense how this particular practitioner might have felt frustrated. He knew that the patient could have had an even better quality of life and longer lasting effects, but the patient’s point of view was that she was satisfied with her present level of health and it was not worth the trouble or the taste of the herbs for her to continue with that course. Although nothing technically went wrong here, the practitioner’s fru st r ation could be mitigated by realizing that this patient’s view of health was different from his and that each patient must be given the respect to decide what type of treatment they want.

It’s all Chinese to me Another area to examine is how you are presenting the information you wish the patient to heed. Acommon mistake of both

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Western and Oriental medicine providers is using language that patients do not understand or giving instructions that do not make sense to them. Even though the complex language of Oriental medicine may have sounded strange to you at first, after years of schooling, reading, and engaging in discussion with colleagues, the language has become a natural part of your vocabulary and you feel comfortable hearing someone lecture about “damp heat in the liver-gallbladder” or telling someone you think the “heart and kidneys are not interacting.” Your patients, however, have not gone to Oriental medical school and such terminology sounds even more incomprehensive to them than does Western medi-speak! Cases in point: Case 1. B. J. started acupuncture treatments after suffering an attack of Bell’s palsy. Her most troubling symptom was facial drooping and an inability to close one eye completely. In addition to needles and herbs, the acupuncturist made some recommendations. She told the patient that her symptoms were caused by wind in the channels and instructed the patient to keep her head and ears covered when it was windy out and not to stand directly near any air-conditioning units or indoor fans. The patient left the office bewildered. She thought to herself,“What does wind have to do with anything? It’s summertime and I just woke up with these symptoms one day. That sounds like the strangest bunch of malarkey I’ve ever heard.I am not going to sweat to death this summer by avoiding air-conditioning or fans!”

■ What went wrong? The acupuncturi st ’s explanation was obviously not thorough enough. She made the incorrect assumption that the patient could understand the theories of Oriental medicine without having been through the training. A few extra minutes explaining that channels are often portals to the elements and that environmental elements can actually enter and become trapped

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in the body via the channels might have been helpful. The client could have been told that some types of neurological symptoms are often thought to be the result of wind lodged in the channels and vessels. Although the concept might still have

■ Respect your clients’ intelligence while also recognizing their limitations. ■

seemed strange to the client,the extended explanation might at least have made some sense whereas the first explanation was simply too arcane to grasp. Case 2. Mr. G. was seeking treatment for sinus congestion that was severe and had persisted since his childhood. His pulses were very slippery and he complained of large amounts of nasal drainage and a productive cough. The practitioner made some

dietary recommendations, including cutting out salads and uncooked vegetables. Mr. G. left the clinic confused,thinking,“I thought acupuncture was ‘natural healing.’ Salads and vegetables are good for you. I don’t know if this guy knows what he’s doing! I’m not going to stop eating healthy food just because of a sinus problem!”

■ What went wrong? Again, the explanation did not satisfy or even make sense to the client.There are so many perceptions regarding health. The public is inundated with all kinds of conflicting messages, but many, if not most,people assume that salads and vegetables cannot possibly be harmful. A simple explanation of the role of the “Chinese” spleen in the process of digestion and the engenderment of phlegm, the fact that digestion is likened to a process of cooking, and the spleen’s aversion to dampness according to Oriental medicine might all have helped the patient understand that the spleen benefits from warmth and the predigestion of cooking in order to properly transform food and fluids and prevent them from stagnating in the body.

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Come again? Sometimes the practitioner does give a good and complete explanation to the patient, the patient appears to understand, but noncompliance occurs nonetheless. In this type of case, the patient’s understanding may be faulty. This may be especially true if English is not the patient’s primary language. Even if he/she seems to understand what you are saying, it is worth having them repeat it back to you to make sure. If it is a true language barrier, a translator or interpreter is absolutely necessary in order to avoid confusion. In all cases, keep your wording simple but not patronizing. Respect your patients’ intelligence while also recognizing their limitations. In other cases, the patient may have misconstrued your meaning. Written instructions Giving written instructions is always a good idea. Nowadays, we are all so busy and preoccupied with myriad issues that verbal instructions are easily and often forgotten. Having something written down on paper also lends it more validity and serves as a reminder to the client (unless, of course, they have forgotten where they put it!). Writing out instructions leaves less room for misunderstanding or misconstruction of the provider’s intent. When giving written material to clients, it is best to use your letterhead or paper printed with your name, address, and phone number. This serves two purposes. First, it looks professional and is more likely to make an impression. Secondly, it is yet another way to get your name out of your office and into the world. Make sure your written instructions are easy to read and understand. You can use a variety of methods to get your point across. There are several companies that sell various types of instructional brochures already printed. Just stamp your name and information and give them out to the patient. You can also easily create your own pamphlets, brochures, or instruction sheets on a computer and have them printed yourself. Of course, you can always handwrite instructions as well, but be sure you do

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not have typical “doctor’s handwriting” that no one can read. If writing out instructions by hand, print legibly. Do not use script. Black ink on white or light-colored paper is easiest for most people to read. A larger piece of paper, for example an 8 x 10” sheet rather than a memo-sized sheet, is less likely to get misplaced. Written instructions are especially important when prescribing herbs. Many of your patients will be totally unfamiliar with herbs. Whether you choose to prescribe bulk herbs, powders, or pills, people want clear instructions . They want to know exactly how to prepare the herbs, how and when to take them, if they will interfere with any of their other medications, if there are any side effects, and if they can add anything to make them taste better. Patients will appreciate having something to look over when they get home or to share with their family and friends. Case in point: D. C. is a middle-aged woman who is interested in Chinese herbal therapy for persistent dizziness and fatigue. She had had good results at other times in her life with herbal therapy, but this practitioner was new to her. The herbalist prescribed an appropriate formula and verbally instructed the patient that the powdered herbal formula was to be taken with hot water in tea form twice a day. On follow-up visits, the client told the herbalist she was taking the herbs every day, but, after a month or so, no change in symptoms was noticed. On further questioning, the patient revealed that she was taking the formula as a “tea.” To her, that meant she could add a little sugar to the formula, had poured herself a full cup, and sipped it slowly while eating her meals.

■ What went wrong? Although the herbalist was diligent in telling the patient how to take the formula, he made the mistake of assuming she knew how to take Chinese herbs from her previous experiences. He,

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therefore, did not give her written instructions and also did not make his instructions as detailed as they should have been.No matter what the patient tells you about past experiences, never assume they know what your particular expectations are. It is always wise to view each patient as if they have never had an Oriental medicine experience befo re . That way, misunderstandings are less likely.

Money makes the world go round Depending on where you live and practice and your own personal philosophy, you may or may not accept insurance. The truth is that most acupuncture practices are still largely cashbased. Even in cases where insurance is accepted, most policies do not cover herbs, including liniments, ointments, and other external applications. Your clients may already be paying out cash for the acupuncture treatments. Having to purchase herbs or other products recommended by you might be a financial burden. Many people will already be taking vitamins or supplements that can be quite steep in price. They may be reluctant to let go of these therapies, especially if their bottles are not yet empty. This is also true of referrals to other disciplines, such as chiropractic, massage therapy, energy work, etc. Finances are an extremely personal subject. Some people have no qualms telling you up-front what they can or cannot afford, but others may be reluctant or even embarrassed to admit they cannot afford a suggested therapy or remedy. Of course, if you dispense products from your office with payment due at the time, the patient will have to either pay or not. However, some practitioners may send their patients to pick up a prescription at an herbal pharmacy. The patient may decide to wait until he/she can afford it to pick it up or may not pick it up at all. When making recommendations that will be an added cost to the patient, do not be afraid to broach the subject in a tactful way. If the patient indicates that they cannot, in fact, afford your suggestion, you need to respect that and not show anger or frustration to them. In these cases,

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you may have to forego that particular avenue, offer reduced rates, or just administer acupuncture to the extent that the client can afford. Case in point: P. M. has been suffering from upper-and mid-back pain for many years. The patient works at a computer for most of her workday and, generally, has experienced quite a bit of stress in her life. After several acupuncture treatments, the pain was improving and the acupuncturist recommended some ergonomically correct furniture to use while at the computer. The client stated she would approach her employer with the suggestions. The practitioner also suggested that the client step away from the computer at least once an hour and do some neck and shoulder rolls to help alleviate st a g n at i o n . The patient stopped her acupuncture treatments a short time later, stating that her pain was “so much better.” A few weeks later she returned, stating that the pain was “creeping back again and is getting pretty bad.”

■ What went wrong? In this case, the acupuncturist was surprised that the patient had stopped her treatments, since she had been experiencing quite a bit of improvement but the pain was not completely gone. She was even more surprised when the client returned, stating the back pain was worse.The acupuncturist did not realize that the patient’s company would not pay for new furniture and that any adjustment would have to be paid for by the patient herself. Furthermore,the patient was afraid to step away from her desk, even for short periods of time, because her boss was very strict and did not like to see his employees not working during prescribed workday hours. The patient felt too embarrassed to reveal these facts to the practitioner, but the practitioner could have discovered the truth with some compassionate and well-directed questions about how the patient was doing with her suggestions.

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When is a door not a door? Sometimes, noncompliance is not really noncompliance. Chronic fatigue syndrome (CFS), anxiety, severe stress, brain injury, and senile dementia are all examples of symptom manifestation. These symptoms are directly related to the patient’s disease and must be considered when giving recommendations, even in writing. Those who suffer from CFS are often so exhausted from simply trying to get through the day that they may literally not have the energy to devote to follow-up suggestions or self-care. Anxiety narrows a person’s field of awareness so that, at times, all they can comprehend is the anxiety itself. Or they may become preoccupied with the thought or event causing the anxiety and be unable to focus attention on anything else. The practitioner’s recommendations may themselves be a source of anxiety for the patient, which he or she may then choose to avoid in order to avoid becoming overwhelmed. It is certainly no secret that we live in a fast-paced, high-stress world. Many of your patients may be coming to you solely for the purpose of stress reduction. The young mother with a sick child, the salesman working on commission to provide for his family, and the working mother juggling home and office responsibilities are all examples of people whose stress level is so high they may not be able to devote their energy to self-care. In this automobile-crazed society, there is no shortage of car accident victims, and you will see your fair share of them in your practice. Brain injury is more common than you may realize and need not be severe in order to affect a person’s cognitive functioning. Many people who have suffered brain trauma can hold jobs and may not appear to have any deficits, but there is often a low level of compromised functioning going on. Concentration may not be as sharp as it once was. There may be evidence of increased forgetfulness or the patient may become easily fatigued. Sleep disturbances are not uncommon in such cases. All of these factors serve to distract the patient from full attention to compliance.

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More and more senior citizens are seeking out alternative medicine, tired of taking too many pills and feeling ignored by the existing health care system. Like brain injury, dementia need not be severe or even obvious but may certainly affect the client’s ability to adhere to advice. Forgetfulness is another unfortunate reality of aging in some people and may not even be apparent to anyone but the person experiencing it. This type of patient may be having difficulty accepting these realities in themselves and so may be unwilling or unable to share with the practitioner that this is happening. If a family member accompanies this client, it is worthwhile to review the instructions with them as well to insure greater understanding and compliance. The main point here is to differentiate between a patient who is truly noncompliant and one whose noncompliance is a result of their baseline health status. Case in point: Mr. J., an 85 year-old gentleman, is coming for acupuncture because of an old case of “shingles” which still causes him a lot of pain even though the lesions have resolved. This client is quite mentally alert, still drives, and is very active in his local civic association. His Chinese herbalist gives him a formula in pill form, instructing him to take four capsules three times a day. The herbalist also gives written instructions. The client appears to understand the instructions and states he should have no problem taking the pills. He seems excited that the herbs might provide him some long-sought relief. When he returns two weeks later for a follow-up herbal consult, he tells the herbalist that his symptoms are still bothering him quite a bit. When asked about the pills, the client states he has been taking them every day. The herbalist is somewhat confused because the formula he prescribed seems to fit the client’s pattern differentiation exactly. He urges the patient to come again in two weeks. However, the p atient did not re t u rn for that scheduled ap p o i n t m e n t . T h e

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herbalist called the patient’s home to see what had happened. The patient’s wife answered the phone. After a brief conversation, the wife started laughing and said,“Oh, you mean that bag of capsules you gave him? He’s lucky if he remembers to take them once a day!”After a little more discussion, the wife explained t h at , while her husband generally functioned quite well, he needed constant reminders about pills, medicines, and appointments, and that she was the one who often helped him out with such matters.

■ What went wrong? In this case, the patient intended to take the herbs and did not intend to miss his appointment. Because of the patient’s initial presentation, the herbalist did not suspect any cognitive dysfunction.While it is extremely important not to stereotype and to realize that many senior citizens have no memory loss at all, memory loss may be a covert aspect of someone’s life. In this case,the herbalist could have recruited the wife’s help in ensuring patient compliance. For example, she could have placed the herbal capsules in the patient’s regular pillbox so that he would remember to take them. The herbalist could also have agreed to give the patient a reminder call the night before his appointments to help keep him on track.

T HE INSI DE STO RY: One of the most devastating effects of illness that an individual can experience is the loss of independence and control. A oncehealthy woman who maintained an active lifestyle and is now limited by the symptoms of fibromyalgia is a good example of such a situation. Likewise, the elderly gentleman who has just had his car keys taken by his family because of poor eyesight and failing memory also experiences a debilitating loss of control. It is human nature to want some kind of control over our lives and our health. Adults generally do not want to feel like

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helpless children who cannot care for themselves. Most people abhor the thought, let alone the reality, of having to depend on others, of feeling like a burden. When faced with such a loss of control, it is instinctual to look to the areas that we can control, however small they may seem. Patients want to do what they can to get well, but also don’t want to feel like they’re just at the mercy of the health care system. The decision to follow or not to follow health care instructions may give the patient a sense of control, even if it is not conducive to healing. The need for independence and control may sometimes take precedence over the need for optimal health. Recognizing this need to express, regain or establish a sense of control and independence will assist the practitioner in understanding patient behavior, especially when it comes to failure to adhere to instructions. Case in point: Mrs. R. J.,a bright 80 year-old, was brought into the clinic by her son who was hoping that acupuncture would help decrease her knee pain from arthritis. She had been living in her own apartment but had moved to an assisted living facility two years ago at the insistence of her family who were concerned about her safety. The assisted living facility provided meals and assistance with bathing as well as house-cleaning and laundry services. Although the patient had had to rely heavily on her family when she was living on her own, the move to assisted living really made her feel helpless. She had not wanted to move in the first place, was in unfamiliar territory, surrounded by unfamiliar people.She especially resented having to have a stranger help her with her bath. She also did not want to come for acupuncture treatments, but her son had insisted after he saw a TV special about the benefits of acupuncture in treating arthritis. So she had reluctantly agreed to go. The acupuncturist gave her a treatment with needles and also recommended she buy some Zheng Gu Shui Orthopedic Water, (a commonly used Chinese ready-made

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herbal liniment) to apply at home between treatments. The patient was taught how to apply the liniment with instructions for twice daily applications. When she came back for her second visit, the acupuncturist asked how she was doing with the liniment. She stated that she had not used the Zheng Gu Shui at all, sayi n g ,“ T h ey can make me come here, but they can’t make me use this smelly stuff!”

■ What went wrong? There may have been some clues during the initial intake interview regarding the patient’s feelings. She may have been hesitant to say anything directly in front of her son, but just the facts of her age and her living situation could have alerted the acupuncturist to a potential problem. In this case, presenting the instructions as a choice for the patient rather than as an instruction may have helped: Acupuncturist: Mrs. J., some of my patients with arthritis

have used this special liniment and have found it relieves their pain. Mrs. J.: Well, I don’t want it. I take too many things as it is. Acupuncturist: You don’t have to try it. It’s just a suggestion.

Some people choose to use this because it helps them feel better and they don’t have to come to the office as frequently. Mrs. J.: You mean they won’t have to drag me here as much? Acupuncturist: Maybe not! But it’s up to you. I can give you

a small sample to try. If you like it, you can buy a bottle, but if you don’t like it, you don’t have to keep using it. Mrs. J.: Well, if it means I might be able to cut down on my

visits here, maybe I can try it for a while. But if I don’t like it, I’m not going to use it.

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Acupuncturist: That’s fine. But please let me know how it

works for you. That’ll help me know if it’s effective for others in your situation. Mrs. J.: Well, I can do that, especially if it might help some-

one else. In the above scenario, the acupuncturist’s approach did two things: It gave the patient a choice and therefore some control over whether or not to use the oliniment. It also gave her the opportunity to feel like she might be able to be helpful, which further lessened her feelings of powerlessness. In treating the noncompliant patient, the practitioner needs to let go of the feeling that he/she is the authority in the relationship and must allow the patient to become a willing participant. Understanding the client’s situation and the effect of illness on their lifestyle will help the practitioner find more healthy and empowering avenues for follow-up teaching.Helping the client to achieve as much independence as possible and to leave behind the “sick role” will be a healing in and of itself!

QUEST IONS FOR C HAPT ER T HR EE: 1. Why do you think noncompliance is such a big problem in the clinic? Have you ever been noncompliant with a health care provider’s instructions? If so, what were the reasons behind your behavior? 2. How might a practitioner unwittingly contribute to noncompliant behavior? 3. Name three other factors that may contribute to noncompliance. 4. Think of a situation that made you feel helpless and out of control. How did powerlessness make you feel? What were some actions you took to regain your sense of control?

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5. Scenario for discussion: A middle-aged man who is supporting a wife and three teenagers comes to your clinic seeking relief from longstanding back pain. The patient had been going to a gym regularly and lifting weights. Part of your teaching includes telling the patient he should refrain from weightlifting until his back is stronger and the pain is resolved. The patient acknowledges that his activities at the gym might be aggravating the back pain and agrees to “lay off” for a while. When he returns to the clinic, his back pain is worse than ever, and he admits he “just had to lift some weights the other night.” What are some underlying causes that might be instrumental in the man’s decision to continue harmful actions? How would you handle this situation?

Endnote: 1

Hooberman, R. Ph.D. and Hooberman, B. MD, 1998, Managing the Difficult Patient, Madison, CT, Psychosocial Press, p. 57

There is a lot of repressed anger out in the world today and that poses a danger to each individual’s health as well as to the therapeutic relationship.

C H A P T E R FO U R

The Angry Patient

It’s my perception that anger is becoming a more and more commonly expressed emotion in modern society. Most practitioners of Oriental medicine in the Western world are all too familiar with the irritability (literally “easy anger”) that goes along with liver depression qi stagnation. The bowstring pulse is probably the first one you learned to identify and the one that you will feel most comfortable identifying. We live in a world and create lifestyles for ourselves that often end up in denial of our own needs. Our fast pace of living contributes to such phenomena as road rage. Lack of feeling like part of a community, spiritual disenfranchisement, and disintegration of the family may contribute to a sense of rage and anger, as do histories of physical, sexual, or verbal abuse. The current state of the health care system in this country leaves many people feeling like they have been neglected, treated like a number or a statistic, or just plain inconvenienced. Political climates may also foment anger in certain populations. Overall, 53

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we as a society are not taught how to express our anger. Women in particular are taught from an early age that they should not display anger or even feel it, let alone give vent to it or recognize it as a healthy emotion. There is a lot of repressed anger out in the world today and that poses a danger to each individual’s health as well as to the therapeutic relationship. In other words, anger is a force to be reckoned with in ourselves as well as in our patients. Pent up feelings need to be let out somewhere—and that somewhere is often a health care setting! You may well find yourself the innocent target of a patient’s anger. It is important to understand the source of the anger and that, in most cases, although you may be the target, you are not the source. Although it is a natural reaction to lash out if we are attacked, health care providers are really not afforded this luxury. Keep in mind that helping a patient through their anger is part of helping them heal. If you can separate yourself and not take it personally, you will go a long way to achieving the goal of ultimate and deep healing. C L I N I C A L P R E S E N TAT I O N : ■

Frequent complaints about other people, work, the world, life in general

■

Chinese medical diagnosis of a liver-wood pattern, a bowstring pulse, tongue with red or purple tip and edges

■

Relatives or friends reporting bursts of anger or irritation

■

Difficulty holding a job

■

Body language: fidgeting,“huffing and puffing,” constantly looking at watch, shaking head, rolling eyes

C O N T R I B U T I N G FA C T O R S : Home base You have set up your office to accommodate anyone who would come to you. Your staff are pleasant and efficient, and your office

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space is quiet, welcoming, well lit, and calm. You welcome all your patients with a pleasant smile, a handshake, and some friendly words. Your manner is gracious and even-toned. What on earth could possibly anger one of your patients? Keep in mind that a truly angry person does not just become angry overnight. More often than not, he/she has had anger brewing inside for quite some time and is subconsciously looking for a place to “blow off some steam.” It sometimes does not take much to set someone off. Always be conscious of your time. Many of your patients may be coming to you on their lunch break or between other appointments and have to be somewhere at a certain time. People generally do not like to be kept waiting more than five or ten minutes. They may have had previous experience at a health care provider’s office in which they were kept waiting up to an hour just to be given a quick, ten minute examination. Try to be at your office well before your first patient arrives and to have the treatment rooms and paperwork neat, organized, and ready to go. If you are running late and have a staff, call ahead so they can alert the patient that you are on your way. If you do not have a staff, keep a list of your patients’ phone numbers (for example in your cell phone memory or in a palm pilot; those gadgets really do come in handy sometimes) and call them as soon as possible to let them know you will be delayed. It helps to give a reason so the person can understand that you are not slacking off. If you cannot reach them in time and they are already waiting at your door when you arrive, there is not much you can do except to express your regret. Apologize to them for your lateness and tell them you recognize how valuable their time is. You may even want to give them a discount if you are considerably late. Keep your initial intake short and convenient for your patients. Many people who come to see you will have already visited several providers and, therefore, have filled out many history forms. They are probably really sick of it. A form that uses check marks

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instead of lines is more convenient for most people. Keep all intake questions simple. Any further details can be gathered during your discussion time with the patient. If possible, keep an eye on the patient as they are filling out the form. If they seem to be getting aggravated or generally having trouble, you might want to suggest that you just go into the room together and go over the questions with them, filling in the answers yourself as you go along. It is helpful to get an idea from a first-time patient as to what they are coming to see you for. ■ If it seems like a complicated problem, you I have often been will be duly alerted to the fact that the persurprised at how son may be experiencing frustration or many people do may have a large amount of information not ask about to share with you and you may be able to fees up-front. ease them into that first visit more gently with this foreknowledge. I would rather have this Make sure your disclosure form is up-tounderstood at date and that you have clearly stated your the beginning of fees and cancellation policy. Most people the treatment only give the disclosure form a cursory rather than to look. So you might want to have these have the patient items in bold print or italicized, or you express dismay might want to verbally point out these items to the patient. I have often been surat the cost after prised at how many people do not ask a full treatment about fees up-front. I would rather have has been this understood at the beginning of the administered. treatment rather than to have the patient ■ express dismay at the cost after a full treatment has been administered. Likewise, it is best not to have a surprised patient when you explain you have to charge them for a missed appointment. If they have insurance, do be sure you can accept their insurance and that they understand any copayments that are required. If problems with insurance do arise, try to address them as quickly as possible and do everything you

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can to keep the patient informed of the claim status. If it is an injury situation and the patient’s lawyer requests records from you, try to expedite the sending of such records (with the patient’s written consent, of course). Bear in mind to whom you are speaking. As discussed in Chapter One, do not use words like “honey” or “sweetie” unless you feel they are appropriate. Do not use diminutive terms when speaking to seniors. Likewise, do not use a patronizing tone either. This standard applies to your staff as well. Instruct your employees to be professional and courteous at all times, even in the face of someone who is angry. If they feel uncomfortable, have them refer the situation to you. Angry retorts or expressions of exasperation with a patient are unacceptable behaviors from staff members and should never be tolerated. You may want to set scheduled times to meet with your staff, i.e., monthly or bimonthly, to discuss office procedures and issues. At these meetings, employees should also be encouraged to verbalize any problems they may be having with patients. Employees must be made to feel that their comments will be taken seriously, will not hinder their job, and will be kept confidential. Explain as much as you can about what you are doing, especially if it is the person’s first visit to an acupuncturist. Be honest about how much relief they can realistically expect from Oriental medicine as well as the time they can be expected to wait for results. In this day and age, we have become so accustomed to instant gratification that many of our patients have a difficult time understanding why our treatments do not provide immediate relief all the time. Case in point: Mrs. K. came to an acupuncturist for her first appointment. She had called and spoken to the practitioner first, explaining that she wanted to be treated for high blood pressure,and that her

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pressure had risen dramatically after her husband had died recently. While she was filling out the intake form, the practitioner noticed she was fidgeting and sighing a lot and was writing quite a lot of information but allowed her to continue on with the form. At one point,the practitioner came out to the waiting room and said,“Take your time filling out that form.It seems like you’ve got a lot going on.” At that point, the patient slammed the clipboard down on the table and said,“You bet I do. I am so fed up with all this writing! I don’t even know where to start or if this will even help me!” The practitioner told the patient to do the best she could filling out the form and then they would go over it together. The patient agreed, but continued to sigh and fidget until it was done.It took a few more visits until this patient felt more at ease in the clinic.

■ What went wrong? In this case, there were several clues that the practitioner ignored. Just the fact that someone has high blood pressure can often indicate that they have some stress in their lives. In addition,this woman had told the practitioner that she had recently been widowed. Such a life-changing event often causes anger in a person. We can all experience anger at a sudden loss, at the unfairness of the situation, or even at the deceased for having left the bereaved behind. When the practitioner noticed the patient’s body language, it should have been a clear indication that the patient was having difficulty with the questionnaire. If the practitioner had acknowledged and recognized these signs earlier, she could have just taken the patient into the room and conducted the initial interview, filling out the form as they went along.It would probably have been beneficial to give the patient a little time to vent or to talk a bit about her recent loss. A little sympathy can go a long way. If the situation had been better addressed at the first visit, it may not have taken a long time for the patient to feel comfortable.

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Sick and tired of being sick and tired It is a fact that many of your patients will have been grappling with a particular health issue long before they come to see you. Although acupuncture and Oriental medicine are entering the mainstream, they are still often thought ■ of as a last resort. You can never underYou can never estimate the effect that a long-term illness underestimate or chronic pain has on the sufferer. If you the effect that yourself have enjoyed relatively good a long-term health, you may not understand all the illness or chronic ramifications of a severe or prolonged illness. It is human nature to crave indepain has pendence and to abhor becoming helpless on the sufferer. or a burden to others. This is true at any ■ age, but younger people with compromised health may have an especially difficult time accepting limitations on activity, diet, and freedom that their peers are unencumbered by. Physical compromise affects thought and emotion. It is hard to concentrate, difficult to think clearly, and not easy to communicate clearly when one’s body is not cooperating. Socializing becomes awkward and, at times, downright impossible. Even simple tasks such as preparing a meal or brewing a pot of tea take on immense proportions. Independence decreases and frustration mounts as the condition progresses or simply does not improve. Long searches for answers on the Internet, at doctors’ offices, and in alternative health care clinics can lead to exhaustion and despair if a solution does not seem forthcoming. Illness has a profound affect on family life as well. It can interfere with the ability to interact with and enjoy children and grandchildren. Younger parents may not be able to be as active as they’d like at their children’s school activities, and older people may feel deprived of quality time with their grandchildren. Marriages often go through drastic changes when one partner

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is sick. Roles within the family may change. If it is the breadwinner who is ill, he/she may experience a crisis in self-image and self-worth. If it is the primary care-taking parent who is ill, children may feel ill at ease with the other parent taking over. Security is threatened. Finances are almost always an issue in cases of illness, especially when it has been going on for some time. And the longer a condition persists, the greater the negative impact is likely to be. Even someone whose complaint is relatively new will still experience many of the above problems, even without the added factor of chronicity. People are impatient to get better and feel they want a cure or at least some relief as soon as possible. All the above situations can lead to anger. Most people do not realize just how much anger is building up inside them. They may want to appear and feel strong for themselves as well as for their friends and family. Anger may be perceived as a sign of weakness or an indication that they “can’t handle” the situation, even though anger, in this case, is a perfectly valid emotion. Repressed anger is bound to seep out at some point. Case in point: S. V. is a 35 year-old mother of five children who was diagnosed with a rare form of cancer about two years ago. Her prognosis is not very positive.Her husband,in addition to bearing the burden of being the main breadwinner, has also had to take over most of the child-rearing tasks. She has sought acupuncture for relief from severe and debilitating pain in her legs and hips as a result of some of the chemotherapy she has been receiving. The acupuncturist had been doing home visits for her because her condition prevented her from easily getting out of the house. On all of the previous visits, the patient and her family had been very pleasant and extremely appreciative that someone would come to the house to administer treatments. On one occasion,

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however, as the acupuncturist was helping the patient attain a comfortable position in bed, the patient suddenly became quite agitated and lashed out at the acupuncturist,saying,“Why don’t you just get the hell out of here! You’re not helping at all, and you don’t understand anything. I don’t even think you know what you’re doing.”Caught off guard, the acupuncturist replied,“Well, I was just trying to help. I don’t know what else to do. Maybe we should just forget it and continue next week.” The patient agreed and the acupuncturist left without doing a treatment.

■ What went wrong? In this case, the acupuncturist had an inappropriate response to what she perceived as inappropriate anger on the patient’s part. Her competency had been questioned and she felt helpless to assist the patient. A better solution would have been to allow the patient to vent a little more. She might have even asked some pointed questions such as,“Has anything new been bothering you lately?”or,“You seem really upset today. Would it help to talk about it before starting the treatment?” By denying the patient’s need and failing to recognize that there was an underlying issue,the acupuncturist actually made the situation worse by 1) not assuaging the patient’s anger and 2) by not giving a treatment which would have alleviated some of the patient’s pain.Further conversation would have revealed that the patient’s six year-old daughter was having a class party and had asked her mother to bake cookies for the event, not understanding that her mother was not able to fulfill this basic request. The patient was then overcome by her powerlessness and frustration and lashed out at the first person she could. The patient and acupuncturist were able to talk about the event the next day. She confided to the acupuncturist that she was afraid to express anger to her husband because “he’s so good and helpful all the time and I feel like I’m always dumping on him.”

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It’s all their fault Sometimes a patient will express anger that has nothing to do with you. In fact, they may even be somewhat conspiratorial, trying to gain you as an ally against someone or something they are upset with. This is often the case when a patient is angry with another health care practitioner or with the existing health care system in general. We all take a great deal of pride in our work and sincerely want the best for our patients. When we hear a patient complain about another health care provider, it is tempting to want to know the details, and it is easy to make a snap judgment and end up siding with the patient. In such cases, it is imperative to remember that you are hearing only one side of the story, and the patient’s view of the situation may very well be colored by their own feelings and/or past experiences. Hearing this type of complaint becomes an even more emotional issue if the complaint is against another acupuncturist. Before plunging in and “siding” with the patient, it is again important for you to examine your own feelings and motives. Sometimes a lack of confidence or a feeling of inse■ curity, especially at the beginning of your It is important to practice, can lure you into saying someunderstand the thing negative about another health care source of the provider. There is an inherent sense of anger and that, superiority in such a case, a tendency to in most cases, think, “Well, I may not be the best practialthough you tioner in the world, but at least I’m not as bad as that guy.” may be the target, you are If the patient’s complaint is against a not the source. Western MD, there may be an even greater ■ sense of righteous indignation and a feeling that, “Western medicine is bad and alternative medicine is good.” As Oriental medicine practitioners become more accepted in the medical world, keep in mind that these same physicians are your colleagues. You do not want to become guilty of the same criticism that has plagued our medicine. Likewise, a comment

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against a fellow acupuncturist does nothing except destroy the unity of our profession. So proceed with extreme caution when a patient complains about another practitioner. As stated above, you do not usually have the benefit of knowing both sides of the story. Always keep an open mind, supporting the patient while remaining neutral. Granted, not an easy trick! Sometimes the patient’s complaint might be absolutely valid. Perhaps they really were mistreated, misdiagnosed, their care badly managed. As we all know, the current health care system in this country is far from perfect and fraught with myriad problems. Most of us have had our own experiences with this system. In fact, that may be the very reason you decided to study Oriental medicine. Even so, be careful about bad-mouthing. Find tactful ways to recognize the patient’s frustration and anger while refraining from your own criticism of the situation. So often, people just want someone to listen to them, and that is all you need to do. Other times, however, the patient may be actively trying to solicit a response from you. Again, my best advice is to remain neutral. Case in point: Acupuncturist: Well, Mary, have you ever had acupuncture

before? Patient: Yes, I did, last year, but he was absolutely horrible. I didn’t even want to come again, but my friend referred me to you and said you were a miracle-worker. So I thought I’d try one more time. Acupuncturist: Well, I don’t know that I’m a miracle-worker,

but tell me, why didn’t you like acupuncture the last time you had it? Patient: Oh, I went to some guy down on Main Street and, right

off the bat, I didn’t like the office. There wasn’t enough privacy. Then he told me he could fix my back in three treatments.

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Well, after the third treatment, my pain was worse than ever. I don’t think he had a very good bedside manner either. Acupuncturist: Your pain actually got worse? What kind of treatments did he do? Patient: Oh, he just stuck a bunch of needles in me and burned

some stuff on them, too. I thought it was kind of weird, and I was afraid he might even burn me. Acupuncturist: Well, that doesn’t sound like you got the results

you wanted. Don’t worry, I won’t use any of that burning stuff, and I’m sure your pain won’t get worse with me! ■ What went wrong? In the above situation, the acupuncturist was a fairly new practitioner who did not want to be seen in the same light as the patient’s previous acupuncturi st .T h e re fo re , he tried to disassociate himself as much as possible from his colleague and to try to prove to the patient that his services would be superior. What may not have occurred to him was that the patient had done some very heavy lifting between the second and third treatments, and it was the burden of activity that made the pain worse,not the acupuncture treatments. A good health care provider must always be cognizant of all possible angles of a story. Another possibility might have been that the patient had gone to a chiropractor or massage therapist, which may have temporarily exacerbated the pain. Experienced practitioners know that sometimes a condition gets worse initially after treatment due to long stagnation of qi but that, once the stagnation is successfully resolved, the desired relief will be felt. Indeed, this acupuncturist may even run the risk of embarrassing himself if his treatments did not produce satisfactory results.

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Mea culpa, mea culpa And now for the hard part. You may at times find yourself as the direct target of a patient’s anger. What’s worse, the patient may have a valid reason for being angry with you. This is probably one of the most difficult situations for any health care provider to deal with. Pride, self-esteem, and integrity all come into play and are all threatened. We are all human. We do make mistakes. We certainly do not intend to cause harm. In fact, we are ethically bound to adhere to the Hippocratic Oath: “First, do no harm.” But, sometimes, our best efforts are thwarted. Oriental medicine is an art and a science that takes years to master. In the United States, we do not have the benefit of intensive clinical training such as would be received in a Chinese medical school in China. Most of us do not even have the benefit of a good postgraduate internship. We are faced with the pressures ■ of entering a new profession, having to Your internal pay back loans, make a living, market ourstruggle with such selves, and provide optimal care. a scenario is your problem, not As if all that weren’t enough, we are genthe patient’s! erally faced with treating patients who have what the Chinese call “knotty disSo put the ego eases.” These are complicated conditions aside and with multiple patterns and, often, conjust say, flicting signs and symptoms. Given all “I’m sorry.” this, it is not unforgivable that you may ■ err in your diagnostic skills. Most unfortunately, sometimes this type of error will cause further hardship to the patient. No one wants that, but it does happen. In such a case, there is a very simple remedy. However, simple does not necessarily mean easy. The simple solution is: apologize. I have had so many conversations with patients who were upset with previous care they received. Time and time again, I hear comments such as, “I’m not even mad that she made a mistake.

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What really bothered me is that she didn’t even apologize.” For most of us, ego gets in the way of true humility. Apologizing is difficult. It forces us to admit we are not perfect, that we do make mistakes and that, on occasion, these mistakes may injure or inconvenience the very person we are trying to help. The effects of finding yourself in this situation can be very uncomfortable, causing you to question your competency and your worth. However, none of that matters to the patient. He/she simply wants to be acknowledged and made to feel that, even though an error was made, it was not intentional. They have a right to be angry and to expect reparation of some kind. These are simply the things that any of us would want. Your internal struggle with such a scenario is your problem, not the patient’s. A simple apology along with a solution to correct the problem is all they want, and certainly the least they deserve. You will be surprised at how a simple apology will actually elevate you in the patient’s eyes. It will, in fact, help and not hinder your practice. So put the ego aside and just say, “I’m sorry.” Another related situation is one in which the patient asks you a question to which you do not know the answer. When this occurs, you may internally feel stupid. You may also feel frustrated that you do not know the answer. Again, you may question your competency and your worth. But similarly, I have found that most patients don’t really care if you don’t know. They care that you can admit it and make an effort to find the answer. Society has so long accepted the word of physicians and other health care providers as the final word that people are actually sick of the “doctor as God.” It is, in fact, refreshing for a lot of people to know that you are just as human as they are. Anger brews when the patient feels that the provider is making up answers, avoiding the question, or just dismissing it as not important. The best way to handle such a situation is simply to admit that you do not know and then offer to follow up with some research

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and get back to the patient. But, if you take this route, be sure you really do get back to them. A phone call to their home with the information is exceptional service and will make the patient feel very cared for. However, even providing the information at the next visit will be welcomed. Most patients will be pleasantly surprised that you cared enough to have taken the time and energy to pursue their requests. A little humility will actually boost your image and your practice. Cases in point: Case 1. B .K . made an appointment for acupuncture to help her through chemotherapy for breast cancer. While going over her history, she becomes increasingly agitated as she reveals to the practitioner that her diagnosis and subsequent treatment were delayed because her physician failed to read her ultrasound report in a timely manner. She was understandably upset that her prognosis would be adversely affected by this oversight.The practitioner found herself taking on the patient’s emotion, imagining herself in that same situation and the conversation went like this: Acupuncturist: That is horrible! I can’t believe that happened

to you. If I were you, I would consider some legal action. Patient: I thought about that, but wasn’t sure if that’s some-

thing I really want to pursue. Acupuncturist: Well, I would give it serious consideration if I

were you. These doctors think they can get away with anything. I’m glad you are coming for acupuncture. You can be sure nothing like that will happen in my clinic. Patient: Now that you mention it, I think you’re right. I am

not going to just let this slide by.

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■ What went wrong? In this case, the practitioner was a little too empathetic. She accentuated and furthered the patient’s anger with her response. In addition, real harm was caused—not to the patient, but to the initial physician. Without knowing the full circumstances, the acupuncturist not only fueled the patient’s anger but also created a potentially volatile legal situation for a doctor she didn’t even know. A better way to handle this situation would be to empathize with the patient without bad-mouthing the other physician. For example: Acupuncturist: Wow, I guess that must have really made you mad. I would certainly be angry if that happened to me. Patient: It sure did! I should just call and give that doctor a

piece of my mind. Acupuncturist: I can understand how you might feel, but doc-

tors are human, too. Maybe you should give yourself a day or two to process all this and then call the doctor to discuss the situation when you are a little calmer. I’m sure she did not intend to hurt you. Doctors are so busy these days, it’s a wonder they can do their job at all. Patient: Yeah, I guess you’re right. I’ve always liked this doc-

tor and I think she’d be open to talking to me. In this case, the acupuncturist helped diffuse the patient’s anger while avoiding negative commentary about another provider and also offered a viable plan of action for the patient to follow. Case 2. Mrs. M. came for acupuncture for chronic sinusitis. The acupuncturist needled Si Liao (St 2) as part of the treatment.The next day, the patient called and was extremely upset. She had developed a quite obvious bruising just below her right eye .S h e was livid and called to let the acupuncturist know how she felt as well as to cancel her next appointment.

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Patient: Do you know what you did to me? I thought acupunc-

ture was supposed to be harmless. Now I look like I’ve been in a fight. I wish I had never come to see you. I feel worse than ever! Acupuncturist: Well, these things happen. I’m sorry, but you

did sign a consent form that states clearly that bruising is a potential danger. Anyway, it’s no big deal. It’ll go away in a few days. Patient: What am I supposed to do in the meantime? Tell

everyone I walked into a door? Yeah, right! You people shouldn’t be allowed to practice. I think this is all really just a bunch of quackery. I’m going to tell all my friends never to get acupuncture! Acupuncturist: Well, you can do that if you want to, but I think

you’re making a big deal out of nothing. ■ What went wrong? In this case, the acupuncturist was caught off guard by the phone call and was also immediately horrified by what had happened to the patient. Instead of admitting and claiming responsibility for the error, he became defensive and tried to dismiss the complaint. In fact,he even tried to transfer the blame to the patient for not reading the consent form more carefully. A more therapeutic conversation might sound like this: Patient: Do you know what you did to me? I thought acupunc-

ture was supposed to be harmless. Now I look like I’ve been in a fight. I wish I had never come to see you. I feel worse than ever! Acupuncturist: Oh my word, I am so sorry! That point below

the eye is a delicate one. It’s very rare that a thing like this would happen and I apologize for the trouble this is causing you.

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Patient: That’s all very well and good, but what am I supposed to do now? I think this acupuncture is a crock! Acupuncturist: I can certainly understand how you feel. I’d be pretty steamed if that happened to me. Unfortunately, there’s not much I can do right now. Please know that this will resolve in a few days. In the meantime, you might want to try some ice over the area. Maybe a little concealer would help to make it seem less obvious. I would be happy to refund your money for that treatment. I really hope this does not deter you from ever using acupuncture. I would like the opportunity to continue treating you, and I promise not to use that point again. Patient: Well, I appreciate your apology. I guess it’s not the

worst thing that could happen. I don’t know if I want to try it again, but give me a few days to think about it. Acupuncturist: Fair enough. But please do not hesitate to call

me if you have further concerns. In this case, a prompt apology automatically took the conversation down a few notches. The acupuncturist sympathized with the patient, made a sincere apology, and also offered some possible ways to deal with the situation as well as offering to refund the money. In addition,she kept the door open for future communication. The patient was still upset but not nearly as much as she had been at the outset of the conversation.An even greater response on the part of the acupuncturist would be to call the patient in a few days just to check and see how she’s doing.

Boy, am I steamed! A last word about anger: As practitioners, we create a space of safety and freedom for our patients, in which they may express

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a variety of emotions. We do not share this luxury with them. However, our own lives are also filled with events and people that have an effect on us and we will at times find ourselves victims of our own anger. It is essential that we not let our anger seep out and affect the patient or the treatment. If something in your personality or in your personal life is angering you, take stock of that before you go to work in the morning. Use the tools at your disposal to help check your anger: meditation, deep breathing, qigong, tai ji chuan, yoga, or even a little Xiao Yao San (Rambling Powder)! If necessary, take a few seconds of deep breathing in between patients to help keep your anger at bay during your workday. Be sure to find a therapeutic way to handle the situation that is angering you so you can eradicate it before it snowballs. On occasion, you may find that you are angry with a patient. This is especially likely to happen in cases of noncompliance, violence, seduction, or anger on the part of the patient. It is never, ever appropriate for a practitioner to lose his/her temper with a patient. It is completely acceptable to calmly express your frustration or disapproval of patient behavior and to use the occasion to problem solve with the patient. Cases in point: Case 1. Mr. H.,an acupuncturist, was experiencing some marital difficulties. He and his wife had a fight before work one morning.On the way to the office,Mr. H. kept replaying the scene of the fight over and over in his mind, which made him more and more furious. By the time he got to the office,he was consumed with the argument.While treating his first patient, the patient complained that the needles were more painful than usual. The patient’s complaint further aggravated him and he told the patient,“You just must be more sensitive than usual today.”

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■ What went wrong? Mr. H. failed to spend some time doing self-healing before going to work that morning. He might have restored himself to calmness by doing some deep rhythmic breathing while driving to work, putting on some relaxing music, or even making a brief telephone call to a friend to vent a little.When the patient complained about the needle sensation, he should not have made it seem like the patient was somehow at fault.It also would have been inappropriate to start telling the patient about his own troubles, but the patient’s comment should have served as a warning sign that he was allowing his personal life to hinder his treatments. Case 2. Mr. W. had been coming to the Oriental medical clinic for several weeks and had been given an herbal prescription for stomach heat. He was consistently noncompliant with the herbs, and the practitioner was becoming fed up with this particular case. One day when Mr. W. came to the clinic, he told the herbalist he had again neglected to take his herbs and was still having lots of heartburn and epigastric pain. The herbalist let out a heavy sigh, shook her head in disbelief, and said,“Well, you’ve only got yourself to blame. I don’t know what you expect me to do if you won’t take your herbs. Of course you’re still having pain, but that’s your fault, not mine!” The patient then became very irritated,got up and left the clinic, stating he would not be coming back.

■ What went wrong? The herbalist had allowed a situation of noncompliance to continue for too long. She should have addressed this problem sooner rather than letting her anger build up. Then she committed the cardinal sin of blaming the patient, which only served to lose her a patient and send someone away in anger, which is certainly not therapeutic for anyone. Instead, she should have devoted some time to discovering why the patient repeatedly neglected

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his prescribed therapy. If she could not unearth the reason, she might have considered tactfully ending the therapeutic relationship with this patient,prescribing an alternate remedy, or referring him to a different modality that might suit him better.

Anger is a complex emotion and can have many roots. You do need to be aware of the harmful effects of unchecked anger. If you are to be a true healer, you must be willing to be a healer on every level, and sometimes helping a patient manage his/her anger is part of a therapeutic treatment, even if the anger does not appear to have any direct correlation to the condition for which the patient is seeking treatment. Above and beyond all, we must keep our own anger under control and participate in our own healing so we can better serve our patients. T HE INSI DE STO RY: Anger is an emotion that most people have a difficult time dealing with in an effective manner. Some people express their anger inappropriately but see nothing wrong with that. Others tend to submerge their anger for fear of losing control, appearing negative in front of others, or being afraid of their own anger. The truth (or part of it, at least) is that anger is a healthy emotion, just like any other emotion. It is when it gets out of hand or out of balance that problems arise. Anger in its early stages can act as a type of emotional messenger to alert us that something in life is not going well even if we may not be consciously aware of that fact. If ignored, anger will build up and become potentially harmful. If suppressed for too long, it can turn into depression. Anger springs from feelings of being mistreated, underappreciated, victimized, or treated unfairly in some way, to name a few. Realizing this should help practitioners understand the nature of this volatile emotion and help them to not take patient outbursts too personally. If you remember the five phase cycles, you can direct your treatments at the liver to help soothe an inflammatory situation.

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QUEST IO NS FOR C HAPTER FO UR : 1. What are some ways in which a practitioner might contribute to a patient’s anger? 2. Recall a situation in which you were angry at a health care provider. What made you angry? Was it handled well? If so, how? If not, how could it have been handled better? 3. Think of a case in which your own anger at a personal situation was taken out on someone else. How could you have prevented that from happening? What were the consequences? 4. What kind of patient behavior might make you angry? How would you manage that? 5. Scenario for discussion: Mrs. S. has been coming to your clinic for assistance with weight loss. Every time she comes, you have the sense that there is anger brewing just below the surface, though she has never expressed it. One time when she comes for her appointment, she embarks on a vehement (and potentially lengthy) tirade about some coworkers. She then also makes an offhand remark that your office “smells funny” that day and demands you do something about it. How would you handle this situation?

If we can safely determine that this patient truly has need of all of his/her providers and modalities, our job becomes that of supporting the patient to the best of our abilities within the scope of our own practice.

CHAPTER FIVE

The Patient with High Utilization of Health Care

“An apple a day keeps the doctor away,” but, is there a similar anecdote for keeping the patient away? That may sound cynical and counterproductive. Of course we want patients, and lots of them, to keep our practices full and thriving! But we must be discriminating and realistic at all times. Patients who are “frequent flyers,” those who overutilize the health care system, can become problem patients for us. There is often an underlying need for attention or an underlying anxiety that drives this type of patient to seek frequent treatment from health care providers. Very often, such patients will not discriminate between alternative and conventional practitioners but may very well seek help from a variety of sources. One of the difficulties in dealing with this type of patient is to differentiate between the person whose problems are so varied and complex that they truly do need to be seen quite often, and may even legitimately require several modalities and

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providers for optimal health, and the person who is simply habituated to the patient role. We never want to be in the position of dismissing a patient’s complaints, thereby risking missing a serious problem. All complaints and histories need to be taken seriously. It is a sad fact that many people in our society suffer from a number of maladies simultaneously. It is not uncommon to meet people who are under the care of several providers at once: the cardiologist, the pulmonologist, the primary care physician, and perhaps an endocrinologist as well. Unfortunately (or fortunately, depending on your point of view), health care in the United States has become incredibly specialized. There are “foot doctors” who will not look at an ankle, “hand doctors” who will not look at a forearm, etc. Therefore, sometimes a multitude of specialists may be necessary to completely cover the full range of a patient’s needs. However, if there is suspicion that high utilization of the health care system is not as necessary to full healing as the patient perceives it to be, we can run into problems. In these cases, our ability to set boundaries and clarify options for our patient will come to the forefront. C L I N I C A L P R E S E N TAT I O N : ■

Seeking care from multiple practitioners and modalities

■

Long history of various illnesses and/or complaints with questionable outcomes from previous therapies

■

Questioning other providers’ knowledge or recommendations

■

Taking multiple medications and/or medicinals/ supplements at once

■

Bringing in long narrative files or many test results for the practitioner to read

■

Difficulty making appointments because of other health care appointments

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C O N T R I B U T I N G FA C T O R S : Home base There are basically two types of patients who make frequent use of health care systems: 1) those who truly have a need for multiple providers and 2) those who do not have such a need but perhaps have a deeper underlying need or anxiety which compels them to seek frequent treatment. Both of these types of patients pose a challenge to the Oriental medicine provider but in differing ways. They will each be discussed in this chapter. Usually, someone who frequently utilizes the health care system has a long history of doing so. It is fairly safe to assume that the acupuncturist or Chinese herbalist is not the first practitioner this type of patient will see. More typically, he/she will have been to many conventional doctors for several years. Following that, there may be some ventures into alternative health care while still maintaining contact with previous providers. If we can safely determine that this patient truly has need of all of his/her providers and modalities, our job becomes that of supporting the patient to the best of our abilities within the scope of our own practice while at the same time ■ tailoring our treatments and recommenLikewise, you must dations so as not to interfere with any constantly be coexisting treatments. In this way, we truly aware, for legal become holistic practitioners. As we conand ethical tinue our examination of ourselves as practitioners, in this case we probably have reasons, of your not done much to contribute to the origiscope of practice nal problem. and what you can and cannot do to However, we may unwittingly contribute help someone. to the problem by not analyzing whether our services will be really useful to this

■

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patient. It is necessary to be on guard against becoming an enabler for this type of patient. If they really do need your services, that’s fine, but, if they are simply seeking attention and going in several different directions to attain it, it might be more prudent for you to help them determine their best course of treatment, whether it is Oriental medicine or something else. The case of the patient who displays a legitimate case for high utilization of health care poses more of an intellectual and perhaps even academic challenge for the practitioner of Oriental medicine. From our cubbyhole of Asian thought and treatment principles, we are now forced to look at what else the patient is using to assist with healing. A thorough intake is one of the keys to successful treatment and, in this case, is the number one tool we can use to discern the best course of treatment for the patient. The difficulty here lies not in patient personality or behavior, but in our ability to understand the coexisting treatments the patient is undergoing. Most schools of Oriental medicine in this country are incorporating classes in Western pathophysiology and pharmacology as well as in the interpretation of various test results. In California and New Mexico, this training has been so elevated that practitioners in these states have achieved the status of primary care physician, and their extensive academic and clinical training leads to that degree of expertise. In other states, the education may not be quite as extensive, but it can fulfill a basic level of knowledge needed to operate within the current health care system. The Oriental medicine practitioner must be constantly on guard regarding his/her knowledge, comfort level, and ability to decipher what the patient’s experience has been. Likewise, you must constantly be aware, for legal and ethical reasons, of your scope of practice and what you can and cannot do to help someone. Your intake form should include a line for the patient to list the primary care physician. Easy enough, right? Over the years, I

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have added more lines for “other health care providers” which can be anyone from a chiropractor to an MD to a psychologist. I have often been surprised at how many people really do need that extra space. You may also find it necessary, as I have, to provide several lines for the patient to list the chief complaint they are wanting you to address as well as for other existing medical problems, even if the patient is not seeking acupuncture for those complaints. As tedious as these forms can be, a thorough and accurate history is essential for providing the best care possible. Even if the patient is coming in for a simple case of tendonitis, do get a complete history. This can be beneficial on several levels. It may uncover another problem that could be simultaneously treated (e.g., insomnia), and it will also alert you to possible factors that may not be obvious contrib■ utors to the patient’s condition but may The first step, be playing a part nonetheless. Lastly, as always, knowledge of the patient’s medications is is to put ego absolutely necessary if you are prescriband personal ing herbs. Though herb/drug interactions are rare, it is always an issue and should opinion aside and not be taken lightly. act in the best interests of Let’s consider the case of the patient who the patient. has a legitimate need for multiple care■ givers, medications, etc. After interviewing the patient, you come to the conclusion that the patient is indeed in need of multiple care-givers and medications. You also determine that you feel you can help her with her chief complaint. But what about all that other information filling up your intake form? What to do about that? The first step, as always, is to put ego and personal opinion aside and act in the best interests of the patient. Your first thought might be something like, “What does he need all these doctors for? Too many cooks spoil the broth. All he really

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needs is some good Oriental medicine.” Or, “Doctors prescribe too many pills for people these days. She doesn’t need all this when a basic herbal formula could cover all her problems.” Again, these are only your opinions, no matter how true they may be. Unless you really do have a degree in Western medicine, you are not legally allowed to make suggestions to the patient regarding any care that is prescribed by a Western medical doctor. Keep in mind, also, that your patient may not share your opinions. Sure, some people will come to your office, stating they’ve had it with their doctors and medicine and want to pursue an entirely different route of treatment. On the other hand, many people have a great deal of trust in their physicians and in the drugs they’ve been prescribed. They may be quite content to utilize different health care systems simultaneously, and the beauty of Oriental medicine is that this is often a very plausible route. Still other patients may be very reluctant to contemplate changing a medication they feel has helped them for a long time. Your job in this situation is to keep yourself well informed and well educated. If there is something on the form you do not understand or are not familiar with, ask the patient. There are countless Western diagnoses out there and some of them are rare or confusing. Do not be afraid to ask the patient to explain a diagnosis you are unfamiliar with. They will appreciate your honesty and will be happy to provide you with what you need to know. This also furthers the patient’s role as an active participant in their own care and in the therapeutic relationship. Take a careful look at the patient’s medications. If you have had course work in Western pharmacology, you will most likely be familiar with most drugs the patient is taking, but again, if you are not, do ask them. However, do not be surprised if the patient doesn’t know. It is alarming how many people take pills that they really do not understand or even know the name of. If neither you nor the

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patient can figure out a particular medication question, it is time to refer to your PDR or other drug reference. Pharmacists are an often-ignored source of information and are usually more than happy to answer questions over the phone. You can call the patient’s pharmacy directly or any pharmacy in the area and you will more than likely get a great response. (Be sure to mention that you are an acupuncturist. It is just one more little way to get acupuncture into the mainstream awareness and, who knows, that pharmacist just might be wondering how to get hold of a good acupuncturist.) Once you have established a good working knowledge and understanding of your patient’s history and present condition, consider all the facts carefully. I suggest you ask yourself the following questions: 1. What can you help with and what is best left to another provider? 2. Will your treatment interfere with other treatments the patient is receiving? 3. Are there any potential herb/drug interactions you need to be aware of? It might at times be helpful to consult with the other health care providers the patient is seeing. This can sometimes be a little tricky. Some Western MDs will be quite open to speaking with you, while others will not give you the time of day. Sometimes going through the “back door” is a more productive option. Speaking with a nurse or an office manager first may facilitate your getting through to the physician. I have found that most physicians will not respond to a letter or other type of written communication, but a fax sent directly to the office may get you the attention you need. Send a simple fax with a patient Release for Information Form already filled out

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and a few pertinent questions for the doctor. Make sure your request is professional and polite. It is best sent on your own letterhead. It will probably be much easier to contact another alternative medicine provider such as a homeopath or a nutritionist. They are much more likely to return a simple phone call and are usually very happy to confer on a case with you. As always, get the patient’s written permission for any such consultations. Quite often in complex cases your best course of action will be to prioritize. We would all love to be able to cure all of our patients of all of their ailments in one fell swoop, but this is not realistic. You and the patient need to decide which problems will best be helped by Oriental medicine and which are best left to another provider. In all cases, even when you disagree with another provider ’s course of action, be respectful, do not badmouth another provider, and honor the patient’s wishes and feelings. Case in point: G. L. is a 45 year-old woman who made her first acupuncture appointment due to chronic pain in the neck and shoulders. She stated that she has had this pain for about 10 years and believes it was the result of a skiing accident. The acupuncturist’s specialty was musculoskeletal problems. He did notice on the intake form that the patient had been to an acupuncturist several years ago for the same problem and had also visited a chiropractor, had some Reiki work done, and had undergone some physical therapy. In addition, she had seen her primary care physician for the same problem. Nothing much had seemed to help her. In the space provided, the patient had also marked off some other conditions that were bothering her, but her chief complaint was the neck and shoulder pain. Since it seemed to be a pretty clearcut case, the acupuncturist did not spend much time on the history and proceeded to treat the chief complaint. After about eight sessions, both the acupuncturist and the patient were frustrated and bewildered by her lack of progress. The pain just

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wasn’t budging. At this point, the acupuncturist went back and reviewed the history and started asking the patient questions about her chiropractic care and what that practitioner had done for her. She smiled and grimaced a little and said,“He thought I had a Candida infection and put me on that ‘yeast diet.’ I hate to admit it, but that’s the only thing that ever helped this pain.”

■ What went wrong? There were a few oversights made in this case.The acupuncturist did not carefully read the history. Even though he noted the presence of a long history as well as several attempts at seeking relief, he did not adequately delve into this information, nor did he carefully go over the intake form.Therefore, he failed to notice that one of the other conditions the patient had listed was trouble with digestion.While the diet connection may not have been very strong or obvious in this case, a little more questioning at the outset of the treatments might very well have revealed this piece. The patient and acupuncturist could have been spared some wasted hours, and the patient could have been spared some cost as well.Also, the acupuncturist may have been a little too confident in his own abilities and not thought it necessary to inquire why others had also not been successful. He felt certain his skills were superior and that he would be able to get to the bottom of the problem. In this case, the patient had had a legitimate reason for frequent use of the health care system since several therapists had failed to correct her problem.

The other side of the coin The second type of patient in this category is more problematic. This is the patient who demonstrates high utilization of the health care system and may not truly require all the attention he or she is seeking. Oftentimes, this patient will have only one or two diagnoses, but there may be a type of fixation on his/her health in general or on the particular diagnosis itself that compels the patient to continually seek care for this problem. Very often, in

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spite of such a long history of journeying into the health care field, the patient will report that nothing ever really helps, yet continues to seek treatment. Often they will show reluctance to part from a practitioner or practitioners even though they do not appear to be benefiting from those particular services. Likewise, they may also be reluctant to give up a medication, herb, or supplement that does not seem to be providing relief. (This type of patient is frequently also a “needy patient,” and you will notice several overlapping qualities in these two chapters.) This type of patient will often have gathered quite a healthy collection of literature which may have been culled from the Internet, magazine articles, books, or handouts from various classes he/she may have attended. In addition, he/she may also have accumulated several months (or even years!) of printed test results from a variety of other health care providers. These may or may not be relevant to their present complaint. Sometimes it is helpful for you to read an MRI or lab result. Utilize this information if it is within your scope of experience, but do not agonize over information that is not pertinent to the present case or that may take you out of your legal scope of practice. This type of patient may also have a tendency to self-diagnose and to self-medicate whether or not such actions are compatible with other prescribed therapies. They often have a fairly stubborn outlook in that they are convinced their course of action is necessary, that the doctors are helpful, but don’t know everything. In some instances, in fact, they may not be forthcoming with their providers in disclosing everything they are doing. This is often the result of a mistrust or fear that their provider will not approve of what they are doing and may criticize their choices. These can indeed be quite difficult cases for Oriental medicine practitioners. In these cases, it is your job to efficiently (and as quickly as possible) wade through the history as well as any literature the patient may want to share. No matter what your

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opinion of your patient’s literature is or whether or not you agree with what they have been doing, you must show respect and dedicate an appropriate but reasonable amount of time to what they are showing you. It is important not to alienate the patient by dismissing their materials or telling them you don’t have the time to read through everything (even if this is true—which it usually is). You can simply let them know that you would like to focus on the interview or conversation with them and that you will read what they have brought later in the day when you have more time to concentrate on it. Do give at least a cursory glance at the material and do comment on it the next time they come, even if it is only to say something like, “That article on aliens practicing Oriental medicine was really interesting. I’d never heard of that before. Thank you for sharing that with me. May I make a copy?” These actions indicate to the patient that you have paid attention to what is important to them, even if it never results in a direct action on your part. The practitioner’s job here is to cut to the chase and figure out what the patient’s chief complaint is, what they are currently taking, what other practitioners they are currently seeing, and, most importantly, whether or not you can help them. Again, your intake form will be your greatest ally here. Sometimes these patients may waver off track and divert the conversation to include stories about their forays into health care that are not particularly relevant to what you need to know. Allow a few moments of this at most but then redirect the conversation as soon as possible, using the questions you have in front of you. D i fficulties may arise when you notice that something the patient is doing or taking may not be compatible with what you would like to prescribe. You should help the patient prioritize since he/she will most likely want to address multiple problems at once. It is helpful to point out to the patient that

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Oriental medicine involves the balancing of the patient’s energy and doing too much or treating too many diagnoses at once will be counterproductive and perhaps even harmful. Try not to let your sincere desire to help this person get in the way of reality. Be honest with them as well as with yourself regarding what you can and cannot do to help them. Do not disparage anything they are currently doing, but help them to figure out their own best direction. This course of action is often not possible to accomplish in one visit, so your first treatment may be a simple balancing protocol. Subsequent visits, should you decide to proceed with offering care to this patient, can be dedicated to uncovering more of the patient’s history and delving a little deeper into their Oriental medical diagnosis. Cases in point: Case 1. D. S., a 54 year-old insurance salesman, comes for acupuncture treatments as a last resort for his asthma. He is tired of taking his inhalers and hopes that acupuncture will offer him a viable alternative.However, he has several other medical problems including eczema, diabetes, obesity, and depression. He appears somewhat depressed at his initial visit but has filled out the health history questionnaire very thoroughly. In fact,he has even written some in the margins. Because of his presentation, the acupuncturist started interviewing him before looking carefully at the health history. The depression was forefront during their conversation,and the acupuncturist thought this was actually the chief complaint. She did a treatment to rectify the qi, resolve depression, and quiet the spirit. She also gave him a Chinese herbal formula in pill form,which he agreed to take.At the end of this first treatment, the patient stated he felt much better and made a second appointment. While talking to him at the follow up appointment, the acupuncturist asked how he had been feeling since the last appointment. The man replied that he wasn’t feeling quite so depressed but was still having a lot of

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trouble breathing and that his asthma had not seemed to improve at all.The acupuncturist was surprised to hear him mention the asthma, but when she glanced at the intake form,she realized he had indeed listed that as his chief complaint! He also mentioned that his blood sugar had been somewhat higher than usual the past few days. The acupuncturist was also surprised to hear him mention his blood sugar but,after looking at the form again, saw that diabetes was listed as part of his past medical history.

■ What went wrong? This acupuncturist was fairly new at her practice and was immediately caught up with the patient’s presentation and neglected to carefully peruse the entire form before deciding on a treatment strategy. She lost her own focus and treated the patient only for what was obvious at the time of the intake,thereby actually neglecting the patient’s chief complaint, which was, in fact, strongly contributing to his feelings of depression. More dangerously, however, she also overlooked the fact that he was diabetic, and she prescribed pills that contained some sugar as an additive. The pills may very well have raised his blood sugar. Had she focused more carefully on the whole picture, she would have prioritized correctly, treated the asthma, and avoided giving the patient a formula that was contraindicated for his diabetes. Case 2. Mr. M. made his first acupuncture appointment for persistent digestive problems. He had seen his primary care physician, a chiropractor, a medical intuitive, and a gastroenterologist for this problem. He tells the practitioner that all these things have helped him a little, but he still has gas, bloating,and diarrhea. He becomes very involved in relating his history and goes into great detail about his experiences with each of the above providers. The acupuncturist, noticing his long history and multiple providers, earnestly wants to understand the big picture and wants to make sure that whatever he prescribes will not be

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duplicated or contraindicated with his other treatments. So he allows the patient to describe these things in detail. The interview takes quite a long time, and there is barely enough time left for the actual treatment before the next patient arrives. The acupuncturist becomes a little flustered but gives the patient a peremptory treatment that is shorter than it should be.

■ What went wrong? The practitioner can be commended for his earnest desire to understand the complete patient history, but he neglected to sort out all the details. When he saw so many practitioners listed on the patient’s form, the first question should have been, “Are you currently seeing all of these practitioners?”The patient would have divulged that he rarely sees his chiropractor, that the gastroenterologist was a one-time referral from his primary care physician (PCP), and that he mostly goes with what the medical intuitive tells him. This information would have greatly reduced the interview time, leaving more time for a good treatment. It would have also given the acupuncturist a clearer idea of what types of treatments are important to the patient and which are secondary as well as who the patient is currently seeing.

Desperate times call for desperate measures We are a society that clamors for instant gratification. When people are plagued with discomfort, they do not want to know the cause, they just want relief, and fast! When one treatment modality fails to alleviate symptoms in a week or so, people become impatient and then want to seek another modality they hope will lead to a faster cure. Often they turn in desperation to a practitioner or therapy that advertises relief from their specific problem. They may be reluctant to let go of previous practitioners, however, fearing that the first modality might work eventually and not wanting to give up on that possibility. In this manner, they may easily end up with several providers and several treatments at once. The end result, of course, is that their own energy

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ends up getting scattered from too much information being thrown at them. One of your tasks in this situation is to assist the patient in finding his/her best course of action, realizing that the best course of action may or may not be Oriental medicine. At all times, the patient’s best interests should be your absolute primary concern, even if it means that a different type of practitioner might serve them better at the time. When you are faced with this type of patient, carefully go over the intake form with them, taking note of all they are doing. Make use of your teaching skills to help the patient understand that utilizing too many types of therapy all at once can be counterproductive and that, especially in energy work, patience is a virtue and the longer a condition has been present, the longer it is likely to take to heal. Ask the patient which current therapy seems to be helping the most. If he/she is dissatisfied with most of them, then suggest they put those modalities aside for a time while they try Oriental medicine. Reassure the patient that they can always ■ resume the other therapies if acupuncture At all times, the doesn’t work well for them. client’s best Also point out that when employing sevinterests should eral treatment types simultaneously, it is be your absolute almost impossible to determine which primary concern, therapy is the one that is actually proeven if it means ducing results. Instruct the patient to that a different choose one modality and stick with it for a certain amount of time, for instance, 4- type of practitioner might serve them 8 weeks, and only then move on if there better at the time. are no results. There may also be some kind of treatment that the patient has not ■ tried that you might feel is beneficial to them and you can make a suggestion to that effect as well. It is not uncommon for a patient (as well as ourselves) to confuse the tip or branch of the problem with the root.

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It is quite common for patients to see the branch as the main problem and seek treatment only for that manifestation. A little guidance can go a long way. Cases in point: Case 1. J. L. is a 60 year-old with late-stage lymphoma. His chemotherapy treatments are having a good effect at slowing down the cancer’s growth, but the treatments have left him weak and he also has chronic back pain as a result of some of the tumors. He and his wife have sought multiple avenues of relief to improve his quality of life while he undergoes his chemotherapy. They arrive at the acupuncturist’s office with a box filled with herbs and supplements as well as several articles on various therapies they have used to help him.They wonder what acupuncture can do for him.The practitioner takes the literature without commenting on it and sets it aside, telling them that she’ll look at it later. She then looks at the box of remedies they have brought along and says, “I really don’t know what any of this is. I guess you can keep taking it and I’ll see what I can do with acupuncture.” The patient comes for several treatments, but eventually stops, saying,“I’m feeling better, but I think it’s the supplements that are really working.My sister recommended them and they worked for her friend who had cancer. So I’ll just take them for now.”

■ What went wrong? In this case, the acupuncturist did not create a feeling of trust between herself and the patient.She should have at least commented briefly on the literature the patient showed her which would have made the patient feel she was interested in him personally. She also dismissed the supplements the patient was taking.Even if she did not know what they were, it is her responsibility to understand everything that the patient is doing that affects his health care.

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The real problem, however, is that the patient’s body-mind was experiencing too many things at once,and it was impossible to tell what was really working.A better course of action would have been to explain to the patient that if he continued to pursue so many modalities at once, it would be impossible to determine which of his remedies was most therapeutic for him.She should have helped the patient sort through all his supplements and decide if he might be willing to put them aside while trying acupuncture. Alternatively, she could have suggested he continue with the supplements for a while and if he still did not experience relief in a few weeks, to stop them and revisit acupuncture as a possibility. Case 2. Ms. W. is a pleasant 40 year-old with multiple medical problems. She has a urostomy as a result of bladder cancer, has fibromyalgia,arthritis, general weakness, and fatigue. She is currently seeing a psychic healer, a Reiki practitioner, her PCP, and a massage therapist, and wants acupuncture to help with the fibromyalgia. The acupuncturist agrees to work with her, but finds that the patient’s reactions to the treatments vary from week to week. Sometimes she gets relief, at other times she feels worse, and still other weeks she reports no change.The acupuncturist does not note an overall improvement and also notices that the patient is losing more and more weight.On the initial intake,the patient had listed what appeared to be a fairly healthy diet. Therefore, the acupuncturist continued to treat her, but eventually the patient stopped the acupuncture treatments without any significant improvement.

■ What went wrong? First, the patient had had so many health problems in her life that she was starting to lose sight of what her complaints and goals really were.The practitioner should have spent some time helping the patient prioritize what she wanted treated first and

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what was bothering her the most. Secondly, the acupuncturist failed to adequately assess the patient’s diet. It is a fact that many patients will tell you they have a good diet but will omit the fact that they eat junk food 2-3 times a week or skip breakfast every day. There is not much we can do about that, but, having noticed a gradual weight loss in this patient, the acupuncturist should have revisited the patient’s nutritional needs. Further assessment would have revealed that the patient had an eating disorder, which was, in fact, a crucial factor in exacerbating symptoms of her existing conditions. In this case, the eating disorder turned out to be fairly severe and was probably beyond the acupuncturist’s scope of practice to deal with.A referral to a psychiatrist, psychologist, nutritionist, or eating disorder clinic would have been appropriate.The acupuncturist could have let the patient know that once her nutrition was more balanced,acupuncture would then be an appropriate path for her.

The patient who cried wolf Almost all of us know or have known someone who suffers from hypochondriasis. A hypochondriac can be defined as a “patient who has a physical disorder but who, in actuality, suffers only from worry and not from any organic pathology.”1 It can be exasperating to deal with such a person as a friend or family member. They seem to always be in pain but not always with the same complaint. Simple physical sensations are seen as disastrous health problems. A common cold is leukemia, a headache is an inoperable brain tumor, a case of night sweats is HIV/AIDS. Knowing such a person on a personal level is one thing. We may have known this person for a long time and are aware that he/she is a hypochondriac. As practitioners, though, we are not always privy to this knowledge and are obligated to take all complaints seriously until we can prove that they are unbiased. The saying in the medical world is, “Sick until proven otherwise.” The first mistake a practitioner must avoid is misdiagnosing a patient or nullifying a complaint that is actually serious. However, it usually

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does not take too long to identify a hypochondriac because, quite often, there are identifying characteristics that become readily apparent after only a short time. Often, the complaints will change. Something that bothered the patient last week is of no consequence the following week, but a new problem has arisen. There may also be a fixation on the complaint and an insistence that something is dreadfully wrong, even though countless medical tests have proven otherwise. Logical explanations do little to assuage these patients, and they may bring up the same complaint, concerns, and questions over and over again. As practitioners, we must recognize the underlying need or needs that spur hypochondriasis. Psychologists point out many roots of this problem, including childhood neglect, feelings of insecurity, need for attention, and anxiety or panic disorders to name a few. It is pointless to try to convince this patient that they are not sick or to try to explain to them that their frequent complaints are due to unresolved psychological issues. They will often not respond well to such an explanation. Rather, the practitioner should take the complaint seriously and even try to treat the physical symptom in some way, but can also do some points to help quiet the spirit or soothe the flow of the depressed liver at the same time. It is worthwhile to also mention two related syndromes that are not commonly seen but are also not that rare. They are Munchausen’s disease and Munchausen’s by proxy. In primary Munchausen’s, the person actually creates a physical problem that must be treated or deliberately causes an exacerbation of an existing problem. The subconscious issue here is a need for attention that is so severe the person will cause harm to themselves. Some examples of this: 1. Awoman with leg ulcers who picks at the ulcers with dirty implements such as toothpicks to infect the wounds and worsen the condition.

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2. A man whose diabetes is well-managed with medications but who eats a large amount of candy to elevate his blood sugar to a dangerous level. 3. A young woman with allergies who spends time around animals she knows will amplify her symptoms. An even more insidious and difficult disease to understand is Munchausen’s by proxy in which a person, usually a parent, deliberately causes a health problem in another person, usually their own child, in order to seek frequent medical attention. The likelihood of an Oriental medicine practitioner encountering such a case in a private practice is extremely low. However, as our profession becomes more mainstream and integrated, our contact with this syndrome will also grow, and it is useful to at least be aware of its existence. If you do encounter such patients as these, realize that you may be in dangerous waters. Refer this patient for psychological help or consult a psychologist yourself for advice on how to proceed. Case in point: A .S . is a 47 year-old woman with chronic sinus congestion.When she arrives at the acupuncturist’s office for her first visit,she is visibly anxious and stressed. She has a hard time concentrating on the history form and only fills out the bare essentials. She tells the acupuncturist she would rather talk than write about her problems and proceeds to outline a long history of visiting doctors for her sinus problems. She says that antibiotics help sometimes but not all the time, so she is certain there is something else going on.She tells the practitioner she knew someone once who had leukemia that was misdiagnosed as a recurring cold, and she is convinced that is what is happening to her. She is very upset that no one has discovered this yet. The acupuncturist finds her demeanor and story somewhat comical and cannot help smiling a little as the patient talks. The patient is already hypersensitive and picks up

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on the acupuncturist’s facial expression, which upsets her even more. The acupuncturist then says,“Well, I can certainly treat you for your sinuses, but I can’t treat you for something you don’t have.” The woman becomes indignant and leaves without her treatment—and without paying.

■ What went wrong? In this case, it is fairly obvious that the cardinal error made by the practitioner was not taking the patient seriously. Admittedly, some people’s interpretations of their health problems can sometimes be comical to us, but we must remember it is not funny to the patient. At all times, the patient deserves our attention and respect, no matter how crazy we think their complaint is. In this instance, the acupuncturist could have explained that he was not qualified to diagnose leukemia but that a routine blood test will often show this illness. He could have recommended that the patient request blood work from her PCP (not an unreasonable request) and wait until the test results were back before jumping to conclusions. He could have also told the patient that sinus congestion can be so severe at times, it may seem like something more serious and that acupuncture can often allev i at e

■ At all times, the patient deserves our attention and respect, no matter how crazy we think their complaint is. ■

these symptoms quite dramatically. A little extra sympathy might have been enough to reassure this patient, at least for the duration of that visit.

THE INSIDE STORY: Most people abhor going to the doctor and shudder at the thought of going to more than one medical provider for their needs. The health care system is so complex and can be so difficult to navigate, that most of us avoid it as much as possible. Why, then, are

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there so many people whose lives seem to revolve around getting attention for their health? Aside from the obvious case of someone who really does require multiple medical avenues for their care, there are those who are lonely, who feel deprived of attention, or ignored by family, friends, or society in general. There is a certain comfort in seeking medical attention and knowing that you will at least get someone to pay attention to you for some period of time. Recognizing loneliness or even a feeling of neglect in a patient can help us to understand the motives for such behavior. Some people simply need someone to lend an ear and hear their story. In our “high tech,” fast-paced, compartmentalized society, there is often no room left over for plain old human contact, and some people may be driven to find attention where they can, even at a doctor’s office. If you have been able to successfully treat a “frequent flyer” patient in your clinic, he/she may let you in enough to tell you they are lonesome or have no one to talk to. This can open the door for you to help them solve this condition by suggesting social activities at a local recreation center, adult education classes, or joining a club. Once again, healing does not have to be limited to just the complaint the patient originally came in with. True healing takes place on many levels, and helping someone to help themselves can be the greatest healing gift of all. QUEST I ONS FOR C HA PTE R F IV E: 1. What are some of the various reasons a person might have to be a high utilizer of the health care system? 2. What dangers does this pose for the patient? What dangers does it pose for the provider? 3. What are some of the problems inherent in treating this type of patient? 4. What are some tools that the Oriental medicine practitioner can use to help treat this patient?

The Patient with High Utilization of Health Care

5. Scenario for discussion: Mr. B., a 30 year-old shop owner, comes to your office because of long-standing irratible bowel syndrome (IBS). He brings in several medical reports from his PCP, his gastroenterologist, and his nutritionist, along with three articles on IBS, including one that talks about a “rice only” diet for this condition. He also lists about seven different supplements he is taking and says, “I think there are more, but I can’t remember right now.” Under his chief complaint, he also states that he suffers from low back pain and frequent headaches, but that nothing he has tried has helped either of these problems. Because he runs his own business, he is often pressed for time and wants to know how long it might take for you to treat all his complaints. How would you handle this situation?

Endnote: 1

Hooberman & Hooberman, op. cit., p. 235.

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Successfully managing this patient will require an equal measure of empathy and detachment as well as an ability to set boundaries.

CHAPTER SIX

The Needy/ Dependent Patient

In the previous chapter, we discussed patients who frequent the health care system to a fault. Many of these patients display characteristics of neediness, though not all needy patients over-utilize the health care system. In fact, some patients who are needy will latch on to one practitioner and expend a lot of energy trying to get help and attention from that one person. The patient/practitioner relationship can sometimes be like a parent/child relationship, with the practitioner in the role of comforter, adviser, and caregiver and the patient in the role of a dependent receiver. Whether or not the practitioner is a parent, this type of patient can evoke maternal or paternal feelings, and this role can at times be detrimental. A needy patient may also bring out the “rescuer” in the practitioner, and he/she may find him or herself desperately wanting to help this patient. In a case like this, it is easy for the provider to lose sight of the focus or diagnosis for the treatment and a kind of emotional tango can result. 99

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It is especially important to have a good grasp of your own emotional agenda when treating a needy patient in order not to become entangled in an emotional web yourself. In fact, part of the healing of this patient is to assist him/her to become more confident and independent over a period of time. Needy patients may also frustrate a practitioner since they are prone to asking countless questions, requiring repetition of follow-up instructions, or making frequent phone calls to the office. These patients can also bring their personal problems to the clinic, and the practitioner must avoid the temptation to give advice on these matters or, indeed, on any matters not directly connected to the treatment itself. Always keep in mind that you are hearing only one side of the story, and very likely a skewed version at that. Also remember that your words carry an incredible amount of power; any advice you give is bound to be taken more seriously than you may think and may ■ even result in worsening the patient’s Always keep in problems. In this instance also, you need mind that you are to be able to attain a certain level of detachhearing only ment to avoid becoming angry or irritated one side of the with patient behavior. story, and very Your staff may also have difficulty with likely a skewed this patient. The patient may foster a relaversion at that. tionship with the front desk staff as well ■ as yourself and expect certain “favors,” such as “squeezing them in” for appointments or forgiving lastminute cancellations. Successfully managing this patient will require an equal measure of empathy and detachment as well as an ability to set boundaries, a delicate balance to be sure! C L I N I C A L P R E S E N TAT I O N : ■

Disclosing personal information not related to the diagnosis

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Seeking advice on personal matters not related to the treatment

The Needy/Dependent Patient

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Frequently complimenting the practitioner and/or staff

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Bringing gifts for the practitioner and/or staff

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Frequent calls to the office for a variety of reasons

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In some cases, calling the practitioner at home

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Inviting the practitioner and/or staff to social functions with them

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C O N T R I B U T I N G FA C T O R S : Home base Compassion, empathy, and a sincere desire to help people are the fundamental requirements necessary to becoming a good healer. However, sometimes these very qualities, along with your own unmet needs, may contribute to or enhance neediness in your patients. Some practitioners may also have a need to be controlling or to rescue. Either of these characteristics can come into play in the therapeutic relationship. When confronted with neediness in a patient, you must be willing to make an honest self-appraisal as to your own motives and actions in the situation. As mentioned in the introduction to this chapter, the therapeutic relationship can often mimic that of the parent/child relationship. Aneedy patient may move you to want to do any thing to help them, just as you would want to help a child in need. This patient may also move you to indulgent actions just so you can placate them and get them “off your back” (just as you might a persistent child). Like a real parent, though, you must maintain an air of confidence and caring, while at the same time setting limits. Unlike some of the other patient types in this book, the needy patient will often show him/herself to be so from the start. It is likely that this patient will be very thorough in filling out the intake form and may well include information that is not necessarily pertinent to the chief complaint. During the interview, he/she may start talking about their personal problems, or ask

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a lot of questions, or try to solicit your opinion about actions they have taken in the past, especially those related to health issues (but not limited to such). This is tricky ground indeed, and care must be taken not to offend the patient or dismiss their conversation as unimportant while at the same time proceeding with the interview in an efficient manner. The focus should always be kept on the chief complaint. When or if the patient diverges from the topic, allow a short amount of time for them to talk, make a comment on what they’ve said to show your interest. Then, gently steer the interview back to the problem most concerning the patient. If the patient starts asking you questions about information, tests, or diagnoses given to them by other practitioners, be aware that this may be a subconscious tactic to try to win your favor, and you may find yourself wanting to provide the answers to them. This is especially so if the question is presented in such a way as to make you feel that other practitioners are incompetent and you are the one who can solve all the problems. Be honest when you do not know the answers and encourage them to consult the original practitioner with their questions. If it is simply a matter of explaining what a certain word means or what a certain medication is used for and you do indeed know the answer, there is usually no harm in providing that information, but be sure you do not linger on the subject. Remain in your own territory and you will stand on solid ground. After what would seem a normal course of treatment, if the patient is not getting better but still wants to come for treatments, it is time to re-evaluate with them what you can do for them. This, too, is a delicate matter. He/she has placed trust in you and you have developed a good rapport. For any number of reasons, the patient may be afraid or reluctant to end the therapeutic relationship and may want to cling to the attention they are getting. It is important not to be too curt with the patient or to tell them that there is nothing further you can do for them so you cannot

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see them anymore. Rather, help them to see the progress they have made, congratulate them for their perseverance, and suggest other practitioners who you think may be able to help them. You can ease them into detaching from you by starting to schedule visits further and further apart. If they were coming weekly, tell them it is time to cut back to every other week or even once a month. On these visits, try to accentuate whatever positive aspect of their situation you see to help them have a more independent outlook. Also reassure them that ■ you will always be there if another problem arises. If they do agree to seek other It is an unfortunate reality that you treatments, ask them to give you a call and will not be able to let you know how it worked out for them. Do not offer to call them, however, as this help everyone will only foster the neediness. who comes to you. You will recognize Conversely, you need to be aware youryourself maturing self when the treatments are no longer as a practitioner therapeutic. Especially in the beginning when you can of your practice, you will be searching for really embrace patients and your appointment book may this truth and seem a little thin. It is never all right to continue treating a patient who you feel accept your own you are not helping just in order to keep limitations. them on the books. You may also find ■ yourself feeling frustrated or that you have let the patient down. But it is not all right to continue treating this type of patient because of your own need to help them and your own fear or frustration in disappointing them. It is an unfortunate reality that you will not be able to help everyone who comes to you. You will recognize yourself maturing as a practitioner when you can really embrace this truth and accept your own limitations. Oriental medicine is a holistic and deeply personal field. As an

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Oriental medicine practitioner, you want and need to get to know your patient and their history as thoroughly as possible. As the therapeutic relationship develops, you may also find yourself sharing personal information with the patient. This is a fairly gray area, and different practitioners have varying levels of comfort regarding how much of their personal lives to share with their patients. Of course, this is an intensely personal decision, but keep in mind that you are there to help them and not vice versa. Giving out your personal phone number and/or address may serve to invite the needy patient to call you or to even stop by your house. (While this is uncommon, it is not unheard of.) It is best to let the patient have only your business phone number. If your private number is listed in the phone book and the patient looks it up and calls you at home, be very clear with them that you do not accept business calls at home and that you will be more than happy to speak with them during regular business hours. If your office is in your home, the patient will of course know where you live. Try to keep your treatment/office area separate from the rest of your home and try not to allow the needy patient to explore too much of your private area. If they start asking questions about your home, lifestyle, etc., short, simple, and polite answers are the best. You are a healer, but you are also human and have your own needs. Be alert to any factor in your own life that may lead you to become a “needy practitioner.” You may have just ended a relationship or experienced some other difficulty and have a need to share your feelings with someone. Apatient who is needy may try to engage you into divulging personal information to them. This actually strengthens their position because now not only do they need you, but you need them as well. If you have developed a good rapport with the patient, you may well be tempted to unload, but resist this temptation. Of course, there is no harm in sharing some minor details, but, for the big issues,

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rely on family, friends, and support groups. The therapeutic relationship should not be a forum for the practitioner’s needs. It is the patient’s space in which to heal. Also, needy patients often try to develop some kind of relationship with office staff. If your staff answer phones, make appointments, handle insurance information, and process paperwork, the patient will most likely have a fair degree of contact with them. Advise your staff to maintain a professional demeanor at all times. Instruct them not to accept invitations to lunch, shows, or other social functions so as not to get too personally involved with the needy patient and to avoid the patient becoming dependent on them. This is especially true of patients who live alone or feel isolated for whatever reason. Though you and/or your staff may sympathize with the patient, a better solution is to assist them to find activities in the community that can facilitate meeting other people in their peer group. Cases in point: Case 1. Ms. B. is a 45 year-old woman recently diagnosed with breast cancer. Someone had recommended acupuncture as a support therapy while she underwent chemotherapy. Ms. B. was a licensed social worker (LSW) and was also working on a Ph.D. She initially presented as very self-assured, but,on the second visit,she became quite tearful and shared her fears about her diagnosis with the acupuncturist.She had also done quite a bit of research on her illness and, on subsequent visits, started discussing the results of her searches with the acupuncturist.Her recent divorce and financial difficulties started coming into the conversation and taking up appointment time. In addition,the chemotherapy treatments had made her skin very sensitive ,a n d she often verbally expressed discomfort during the needling, sometimes whining a bit about the whole pro c e d u re . The acupuncturist gave the patient her home phone number and

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told her to call her any time she needed to vent or talk things over. The patient took her up on this suggestion and even invited the acupuncturist out to lunch. As things progressed,the practitioner felt she was losing her place in the therapeutic relationship and found herself asking the patient what she thought she needed at every visit.The patient also began asking advice on matters other than her health,many of which the acupuncturist did not feel qualified in answering. Eventually, the acupuncturist ended the relationship when the patient finished her chemotherapy treatments.

■ What went wrong? In this case, the acupuncturist saw the patient as her professional equal.Furthermore,she was impressed by the patient’s obvious intelligence and professional achievements. Subconsciously, the practitioner wanted to impress the patient with her own knowledge and degree of professionalism. As the patient displayed a greater neediness, the practitioner felt even more pressed to help her and found herself entering a type of codependent relationship. In the end,her treatments, though helpful, were not as e ff e c t i ve as they could have been and her confidence was somewhat shaken. No matter what patients’backgrounds or credentials are, it is important for practitioners to maintain a healthy degree of confidence in themselves to be able to represent the profession and serve patients to the highest degree possible. Case 2. Mrs. S. was receiving acupuncture treatments for urinary stress incontinence. She was an older woman living alone without any close family nearby. The acupuncture treatments had been extremely helpful for her, and she continually praised the acupuncturist and his staff. They initially felt sorry for her because of her social situation. During the course of her treatments, she made frequent calls to the office between appointments, often telling the staff she needed “the doctor” to call her right away, that something was terribly wrong. When the acupuncturist

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returned the calls, there was never a very real problem, but the patient kept him talking on the phone for a long time. In addition,she often brought treats for the staff when she came for her visits. After her visits, she would sometimes linger in the office and ask the acupuncturist and his staff about their personal lives and even about other patients she would see in the office.Eventually, the acupuncturist and his staff became impatient with her, started answering her questions rather abruptly, and even cutting her visits a little short. The patient soon became offended by the lack of attention and tearfully told the staff and practitioner that she felt very let down and disappointed. Of course,they all felt somewhat guilty about this attitude and had a very hard time ending this therapeutic relationship.

■ What went wrong? The acupuncturist and his staff failed to recognize and act on the patient’s neediness fast enough and the situation was allowed to get somewhat out of hand. When the acupuncturist and his staff finally realized that the patient was becoming something of a burden, it was too late to handle the situation in an optimal way. It is important not to confuse sympathy with wanting to correct what is wrong in a given patient’s life. The practitioner and staff had no control over the patient’s social situation, but their innate sympathy led them to want to soothe the patient’s feelings of loneliness and isolation which only led to greater dependence on the patient’s part. The acupuncturist should have instructed his staff to ask the patient the specifics when she placed her “emergency calls” and for them to inform the patient that the practitioner would get back to her as soon as possible. It was the acupuncturist’s responsibility to curtail his phone conversations with the patient when he did return her calls. The office staff should have given only very short answers to personal questions or even could have stated

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that they do not discuss their personal lives in the office. Of course, the patient should have been immediately informed of HIPAA requirements and that no information about other patients could be divulged.Short, final, but polite answers would have helped stem the needy behavior of Mrs. S.

The devil made me do it Sometimes the devil really is the culprit; in this case, the devil being the person’s illness itself. Long illness creates dependency out of necessity. The patient may very well have become dependent on friends, family members, and/or health care providers because of limiting symptoms such as chronic pain, debilitating weakness and fatigue, or plain old age. Even if the patient was previously independent, their illness has forced them into a dependent position. They may have lost their driving privileges, may need others to do shopping or household chores for them, or may need help getting dressed. Further complicating matters are family members or friends who become overly solicitous in trying to help the patient and end up promoting neediness unwittingly. In these cases, a vicious cycle can easily develop in which the caregivers soon become resentful of the very neediness they helped to create. The patient is now fully ensconced in the “sick role” and often relinquishes more and more responsibility and independence to others. By the time they reach your office, they may be fully engaged in this type of dependency. Family dynamics and role hierarchy in the patient’s social and family circumstances may fuel problem behavior. The lines between what the patient can actually do for themselves and what they cannot do become blurred and they become committed to a dependent lifestyle. In other cases, it is the symptoms of the illness that may create neediness. This is especially evident in emotional/spiritual diseases, which can dictate behavior the patient might otherwise not display. A depressed patient may find it difficult to complete

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tasks that they were once efficient at and, at the same time, crave attention for their depression. A bipolar patient in the manic phase may be beyond distinguishing what is and is not socially acceptable behavior, and their compulsions may lead them to frequent visits, phone calls, or other contact with practitioners. Medications may also contribute to unhealthy behavior. Prolonged steroid use, especially at high doses as prescribed for people with respiratory or rheumatoid conditions, may make a patient prone to emotional lability, which may lead them to needy behavior. And let’s not forget good old hormones. If you treat women in menopause, you will most likely run into your fair share of tears and even hysteria. In all these cases, the patient’s illness and not his/her intentions dictate needy behavior, but the behavior must still be efficiently managed. Case in point: H .L . is a 36 year-old woman who recently underwent a complete hy st e re c t o my due to endometriosis. ( U n fo rt u n at e l y, she was unaware that Oriental medicine can be effective in tre at i n g endometriosis.) The sudden drop in her hormone levels had caused a severe emotional depression characterized by frequent crying jags and,on some days, an inability to go to work because of her depression.She was also prone to some hysterical behavior, which caused her to make mountains out of molehills. Her gynecologist had prescribed an antidepressant but that had done little to curb the emotional storms, and she desperately wanted to try some “natural”treatments to help restore her to stability. Before the surgery, she had been quite competent in the business world, running her own clothing store and generally being quite socially active. She told the herbalist that she had never experienced this type of behavior in herself and did not know what to do. She was also having some marital problems that she

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found herself incapable of getting a rational perspective on. Because the herbalist was the same age and sex as the patient and had just come out of a difficult phase in her own relationship, she identified with the patient very strongly. On the first visit, she allowed the patient to cry for quite a while and to vent about her problems. The herbalist even found herself giving the patient some advice on how to speak to her husband and related similar problems that had occurred in her own relationship. The patient bonded very strongly with the herbalist and started calling between visits to give her a blow-by-blow description of her latest encounters with her husband.The herbalist soon became frustrated with these frequent calls and also noticed that the visit time for this particular patient was becoming longer than the allotted time and was interfering with the timeliness of her other scheduled visits.

■ What went wrong? The herbalist made the common mistake of identifying too closely with the patient and losing sight of her therapeutic role. She also failed to fully recognize that the patient’s emotions were a byproduct of her physical condition and that this physical condition was itself partly responsible for the problems the patient was having at home. Of course, she needed to allow the patient some venting time. A patient who is tearful in the office needs to be allowed a few moments to compose herself. The practitioner should have offered her a tissue,some tea, or even just a glass of water as a comfort measure, allowed a few minutes of venting, but then proceeded with the treatment without dwelling on trying to find solutions to the patient’s personal problems. The herbalist would have been correct in teaching the patient that her hormonal situation was making her unduly emotional and that realization of this fact should help the patient refrain from rash actions or decisions for the time being. She could have also suggested that the patient and her husband seek counseling for their issues.

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Part of her treatments should have also included reassurance that the treatments were the best way to restore balance to the patient and that such treatment would be far more effective than talking endlessly about her problems.The treatment room should have provided as relaxing an atmosphere as possible and the practitioner could have also worked with the patient on relaxation breathing, guided imagery, or other methods to help calm the mind and quiet the spirit.

High anxiety There is an awful lot of free-floating anxiety in our society, and any kind of illness or compromised lifestyle is likely to create or exacerbate that anxiety. Many people you will see have an underlying anxiety or even panic disorder for which they may or may not be receiving treatment. In some cases, the anxiety disorder is itself the reason they come to you. In other cases, the patient’s health issues create the anxiety or intensify the existing anxiety disorder. Practitioners must not underestimate how anxiety affects a person. It often actually reduces the person’s field of perception to their immediate surroundings. In advanced cases, they may not be able to “see the forest for the trees,” may not be able to see rational angles to their situation, or may not be able to perceive simple and reasonable solutions which would otherwise be obvious. Anxious patients can frequently become fixated on a certain subject, especially their health, and may need a great deal of reassurance that they are not deathly ill or in immediate danger of a dire health crisis. Panic disorders are an advanced form of anxiety and can interfere with a person’s ability to perform their daily duties. People who suffer from panic disorders often say they have a feeling of impending doom, that the world is going to end, or that they are going to die. These feelings may be accompanied by physical manifestations such as shortness of breath, heart palpitations, or headaches. Patients with this presentation often ask frequent and repetitive questions about the practitioner’s instructions in a

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desire to do everything just right and avoid aggravating their situation. For example, they may be fearful that missing one dose of herbs will have a devastating effect on their health or, conversely, that the herbs will somehow cause a new health problem. It is the practitioner’s job again to provide reassurance and extremely accurate information to assist the patient in relaxing and in complying with the treatment. In fact, I believe that points such as Shen Men (Ht 7), Nei Guan (Per 6), Shen Ting (GV 24), and Yin Tang (M-HN3) should be part of their treatment to help mitigate the effects of the anxiety. Case in point: B. C. is a 26 year-old male with an underlying anxiety disorder. He had also just finished treatment for Hodgkin’s lymphoma. Fortunately, his prognosis was excellent, and his oncologists were quite optimistic that he would make a full and lasting recovery. B.C.decided to get some acupuncture treatments to help him fortify his immune system, which had been devastated by his lymphoma as well as by the chemotherapy. Like many cancer survivors, he had an abject fear of the cancer returning,and his anxiety led him to believe that any new physical manifestation was a sign of the cancer’s return.He was also anxious that if he did not do everything exactly right, the cancer would recur. He voraciously collected info rm ation on the Internet and often printed out articles about anything and everything that would possibly harm him.He also started bringing these articles to the acupuncture office.At every visit,he found new concerns to discuss and would often ask the acupuncturist if a certain feeling was indeed a sign that the cancer had returned. The practitioner was at first patient with this patient,understanding how his recent bout with cancer could exacerbate his anxiety, but, as this pattern continued over the course of several

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treatments without signs of abating,the acupuncturist became weary of the constant questions and worrying to the point that he started dreading this patient’s visits. The patient’s attitude was especially exasperating to the practitioner because the patient could not see the excellent progress he was making with his acupuncture treatments. The practitioner soon adapted a rather curt manner with this patient that eventually led the patient to believe that the acupuncturist was aware of some problem with his health that he was not sharing with the patient.

■ What went wrong? This is a very difficult situation. The acupuncturist here should not have underestimated the power of this patient’s anxiety. As mentioned earlier, it would have been very ap p ro p ri at e and even essential for the practitioner to treat the anxiety concurrently with the supplementing treatment for the immune system. A pre-existing anxiety disorder should always alert the perceptive practitioner to its effects on the whole person and should be addressed along with the chief complaint. The practitioner must also be extremely cautious about falsely reassuring the patient. Since the acupuncturist was not an oncologist,he should have advised the patient to consult his oncologist with any concerning symptoms. It is possible that this patient could have had a symptom of clinical significance, one that the acupuncturist may have simply attributed to his anxiety level. Again, it is paramount for practitioners to remain within their scope of practice. The practitioner might have also found occasion to recommend counseling of some sort for this patient.The practitioner could have pointed out to the patient that the healthiest attitude he could take would be one of positive thinking and that dwelling on negative outcomes could actually create unfavorable results.

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■

THE INSIDE STORY:

Recognizing fear and powerlessness as the primary issues underlying most needy behavior can give us an insight into the patient’s state of mind, and we can use this information to help the client heal on many different levels.

Patients who are needy and dependent can easily become a source of vexation and frustration for any practitioner. Childlike behavior, repetitive questions, and entangled conversations can certainly sabotage a treatment. Neediness does not exist in a vacuum. It is borne of life situations over which we may have no control. It may even stem from childhood experiences, both positive and negative. We are generally never so secure as when we are young children, dependent yet having all of our needs met. When, as adults, we become frightened or anxious, it is understandable how some people may revert to this ■ childhood behavior in hopes of finding a safe haven. Recognizing fear and powerlessness as the primary issues underlying most needy behavior can give us an insight into the patient’s state of mind, and we can use this information to help the patient heal on many different levels. QUES TI ONS FOR C HA PT ER SI X: 1. Can you think of a situation in your life in which you felt needy or dependent? Can you identify the underlying cause of your feelings? How were your expectations of yourself and others affected? 2. How might a practitioner actually foster or encourage neediness in a patient? 3. What are some examples of setting limits for a needy patient? 4. How can a person’s illness create or contribute to dependency?

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5. Scenario for discussion: Mr. T. reluctantly sought acupuncture for chronic back pain resulting from an automobile accident. He had tried narcotic therapy, hypnotherapy, and over-the-counter medications for relief, all to no avail. His wife suggested acupuncture since her sister had found relief from pain using Oriental medicine. She accompanied her husband to the office and answered many of the practitioner ’s questions instead of letting the patient answer for himself. The patient was sweaty and nervous and told the practitioner that he was deathly afraid of needles stemming from a traumatic childhood incident at a doctor’s office. At each visit, he required an unusual amount of time in which to get relaxed enough to “endure the treatments,” thought up some “rituals” to help him relax (which were time-consuming), and asked the practitioner countless questions about the safety of acupuncture. How would you handle this situation?

The danger here lies in you losing control over the effectiveness of the treatments and having your own thoughts and energy become scattered as you try to accommodate the patient’s wishes.

CHAPTER SEVEN

The Manipulative Patient

As practitioners of Oriental medicine, we do not always want our practitioner/patient relationships to resemble those of a Western MD’s office. We would like to think of our therapeutic relationships as true partnerships in which both parties exchange information and ideas and strive to reach a treatment plan that is acceptable to both. Although it may be a partnership, that does not mean both parties have access to the same information. There are two different roles in this special relationship. The practitioner has the knowledge of his/her field backed by years of study and training. The patient has knowledge of his/her body, illness, and wants and needs backed by years of experience. Both sides of this relationship carry equal importance, but the parties involved cannot cross the boundaries of their respective roles within the relationship. It is not the practitioner’s job to dictate to the patient what he/she needs or to determine what is the best course of action without taking the patient’s opinions into consideration. Likewise, it is 117

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not the patient’s role to direct the course of treatment or to presume to have enough knowledge of Oriental medicine to feel that he/she is capable of making professional decisions about the treatment. Both parties need to understand and abide by these differing roles in order for the relationship and treatment to be successful. It is not uncommon to encounter patients who will be manipulative and will try to either outsmart the practitioner or to direct the course of their treatment by telling the practitioner what to do. Manipulation can also occur when the patient feels entitled to special treatment, attempting to get treatments at a lower cost, or to arrange appointment times that may not be compatible with the clinic’s schedule. At times, the patient may even try to make the practitioner feel guilty and thus give in to the patient’s wishes. When faced with this type of patient, the practitioner must rely on his/her training, knowledge, and, above all, self-confidence in order for everything to proceed smoothly. C L I N I C A L P R E S E N TAT I O N : ■

Comparing the current practitioner or treatments with past practitioners or treatments

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Suggesting specific points or herbs that the practitioner “should” use

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Asking the practitioner to incorporate ideas from fields other than Oriental medicine

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Bargaining with the practitioner about fees or appointment times

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Wanting to continue treatments even after no improvement is being noted

C O N T R I B U T I N G FA C T O R S : Home again Lack of self-confidence is probably the biggest obstacle standing

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in a practitioner’s way when faced with a manipulative patient. As they say, “Alittle knowledge is a dangerous thing.” Some of your patients will have had previous experience with Oriental medicine or may have done some reading on the subject. Others will have heard or read about a certain treatment or cure that they may tell you they want you to incorporate into the treatment. Especially at the beginning of your practice, you will be eager to please and even impress your patients. You will lack experience, the great teacher upon which you will eventually build your treatment strategies, and this lack of experience may induce you to yield some of your control over to the patient. The danger here lies in you losing control over the effectiveness of the treatments and having your own thoughts and energy become scattered as you try to accommodate the patient’s wishes. It is important not to be intimidated—even on your first day as an acupuncturist or herbalist. There is no shame in not knowing a fact or not being sure of what to do or how to proceed. However, the patient need not be aware of your doubts. It is not necessary and certainly not desirable to let the patient know you feel unsure of yourself, but, at the same time, you also do not need to feel intimidated by the patient. If you truly do not know how to proceed, you can simply tell the patient that there are several treatment options for them and you will research each one and present this information at the next visit. Meanwhile, for the present treatment, you can always treat based on what is before you: the history, the pulse, and the tongue signs. In my experience, these will give you enough preliminary clues to begin a good initial treatment. When faced with a manipulative patient, it is easy for practitioners to feel challenged and even “put upon.” These patients do not always react well when their suggestions or demands are not heeded. At times, the patient may use tactics such as guilt or ingratiating behavior to try to manipulate the practitioner ’s actions. If they do not get their way, you may even lose the patient

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■ As always, you need to find that middle ground on which you can show respect for your client’s opinions, yet retain your place as the practitioner.

completely, but it is still better to lose a patient than to lose control of your practice! Fortunately, it is often the case that the patient will remain with you even if you cannot comply with their suggestions. In many cases, you will increase your patients’ respect for you by standing your ground, especially when they experience the positive results of your work.

As stated throughout this book, it is not okay to get angry with the patient or to a rgue with them. In fact, arguing will ■ only aggravate the situation. As always, you need to find that middle ground on which you can show respect for your patient’s opinions, yet retain your place as the practitioner.

One of the dangers of acquiescing to a manipulative patient is that it makes it even easier for them to manipulate in the future. Dealing with manipulative patients does require establishing boundaries and setting limits. It also involves the great tool of education. You must find a way to educate your patients as to why their suggestions will not fit into your treatment plan. If possible, you might try to find some common ground whereby the patient will be satisfied, even if their original wishes are not met. Case in point: M. D. is a 50 year-old woman with a long history of insomnia that started during the illness and eventual death of her eight yearold daughter. She also suffers from an anxiety disorder that at times borders on panic. She is a chiropractor who often uses Applied Kinesiology (AK) in her practice. She contacted an Oriental medical practitioner in hopes of finally finding a solution for her insomnia and anxiety. When she initially called for

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the appointment, the acupuncturist’s staff was put off because she insisted on being seen the next day, even though the practitioner’s schedule was full. The staff scheduled her for the day after that. When she came for her appointment, she informed the practitioner that she was disappointed she could not have taken her the day before, especially since her problem was quite pressing. She told the practitioner, “I have a friend who is an acupuncturist,and she would never make someone wait to see her.”The practitioner took this comment as something of an affront but continued with the appointment. The practitioner prescribed an herbal formula based on the patient’s presentation, but the patient insisted that she “test”the formula with kinesiology before taking it.The practitioner reluctantly agreed, but the patient then stated that she could not take the formula because it did not “test right”and asked for another formula. The practitioner then prescribed a second, though in her opinion less appropriate, formula. This second formula “tested” to the patient’s satisfaction.However, on the return visit, the patient was again dissatisfied because the formula she was given was not having the desired effect.

■ What went wrong? This relationship started off on the wrong foot with the staff being challenged to find an appointment time that would suit the patient even though it was not in keeping with the office schedule.Things went from bad to worse when the patient made a comparison in which the present practitioner did not appear fa vo r ab l e . Although the practitioner was somewhat insulted by the remark, she also could not help taking it to heart and feeling that she would like to prove to the patient that she, too, was a caring healer. This herbalist was a believer in AK but had misgivings about the way the patient was using it. In the end,she chose to try to please and appease the patient but with less than satisfactory results. She should have stuck to her guns and given an

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explanation to the patient as to why the first formula was her primary choice and why the second formula would probably not be effective.If the patient still refused to try the first formula, the herbalist might have had to suggest another practitioner or another type of discipline.

The upper hand Sometimes patients will try to manipulate things other than the treatment itself. In fact, they may have nothing to say about the treatment but plenty to say about time or money. Time and money, as we all know, carry tremendous power and can be used as tools of manipulation by patients trying to get reduced fees or special time considerations. Again, as the practitioner, you must be willing and able to set limits and stand your ground. The person who truly does not have the funds to pay for their treatments will usually find a fairly forthright way of requesting a payment schedule, or they simply will decide to put off treatment until they can afford it. In a manipulative situation, however, the patient may very well be able to afford the treatment. Money or lack thereof is not the actual issue. It is more a kind of bargaining chip, and what they are bargaining for is “the upper hand,” a chance to feel they have “gotten their way,” or even that they have “pulled one over” on someone. Time can also be a bargaining chip. Some patients will try to maneuver their way into a busy schedule or try to talk the practitioner into staying late or coming in early just for them. They may also try to linger or prolong their treatment time. If there are other patients waiting in the office, the manipulative patient may even try to use their presence as a means to their ends. This is often done by complimenting the practitioner in front of these patients or trying to engage them in the situation. When this happens, the pressure on the practitioner is doubled, and it is usually then necessary to draw the patient into a private area to discuss the matter away from the influence of others.

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Cases in point: Case 1. An acupuncturist had been treating a terminally ill man for some time at a reduced rate because the gentleman’s finances were a problem. The acupuncturist had had no trouble working out a payment schedule that was acceptable to all concerned.During the course of the treatments, the practitioner had been introduced to several of the man’s family members. Unfortunately, the man passed away but,a few months later, his daughter called for an appointment for a case of tendonitis. When she showed up for the appointment, the first thing she asked was how much the treatment would cost. The acupuncturist quoted her his usual fees. The patient balked a little and stated that she thought she should be treated at a reduced rate like her father had been. The acupuncturist told her that that had been a special consideration and reiterated his usual fees. The patient was quite persistent, however, and started complimenting the practitioner profusely, saying how his treatments had prolonged her father’s life and enhanced his quality of life. She stated that, since she was a close relative and was still grieving, she should also be given “a break” on the fee. When the acupuncturist held firm, the patient actually started a kind of bargaining process. The acupuncturist had become quite fond of the patient’s father when he was treating him, and the daughter’s insistence started wearing on him. Because time was being wasted on this topic, the acupuncturist finally gave into the patient’s wishes and did agree to treat her at a lower rate.

■ What went wrong? This patient was quite skilled at emotional manipulation and knew what would tug at the acupuncturist’s heartstrings. She actually was able to afford the treatments but felt that she wanted the upper hand for some reason and so persisted until she was able to get her way. Even though the acupuncturist had an

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emotional attachment in this situation, he would have been wiser not to argue with the daughter. The fact that they already knew each other did not help since he wanted to maintain the same professional and caring image he had created when treating the father. He should have clearly and firmly explained that the father had received a reduced rate because of extenuating circumstances that did not apply across the board. He could have asked the daughter if she was having any financial problems that would interfere with her paying for the treatments or could have simply stated the fee and let the patient decide if she wanted to continue or not. Case 2. After a treatment,a patient approached the front desk to make her next appointment.There were two other patients in the reception area at the time. Patient: I’d like to make an appointment for next Friday at

6:00 PM. Receptionist: You know that [the practitioner’s] last appointment on Fridays is at 5:00. I could get you in at 4:30 or 5:00. Patient: Oh no, that won’t work. I have to come in next week,

but it has to be Friday after 5:00. I’ve been coming here so long. Don’t you think she could make an exception just this once? Receptionist: I’m sorry. She won’t be able to do that. Is there

any other time you can make it next week? Patient: (turning to the others in the waiting room) I just can’t

believe it. She is usually so great, isn’t she? I mean, she has done so much to help me. Don’t you think I deserve a little slack here?

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Receptionist: Well, I don’t know. Let me get [the practitioner]

for you. The receptionist then called the acupuncturist to the front desk and explained the problem.The acupuncturist relented slightly and told the patient she could come in at 5:30 if she wanted to.

■ What went wrong? Several errors were made in this scenario. First, the receptionist had perhaps not been fully instructed by the acupuncturist on how to handle this type of patient.Second, the receptionist should have spoken to the acupuncturist privately in order to allow her the time to assess the situation and make a decision about how to handle it.When the acupuncturist came to the front desk,she was immediately thrown into a situation in which the patient had tried to gain support from the other patients and the situation could have escalated had the acupuncturist not compromised. However, this type of action only paves the way for further future manipulation. If the patient had not been willing to schedule during normal hours of operation, she should have been told that she could have the first available appointment after Friday.

Driving with the brakes on Other forms of manipulation may not always be so obvious. Sometimes a patient will use his or her lack of progress as a form of control. These are the patients who come to you week after week with the same complaint that does not seem to improve, yet they do not show discouragement with the treatments. Instead, they continue to make their appointments and are visibly shaken if the practitioner indicates that the treatments are not working and that it might be best to pursue another plan. Patients who demonstrate this type of behavior are often afraid to end the relationship with the practitioner. The fact that they are not getting better is not their fault; so they are absolved of that responsibility.

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In addition, the relationship with the practitioner gives them a much-needed sense of being cared for. The attention they receive is important to them and may also be filling a void in their lives. Nonetheless, you as the prac■ titioner must realize that that is not your Manipulative role. These cases can be emotionally very clients will challenging and difficult for a practiembrace your tioner. You see a hurting individual and suggestions and s i n c e rely want to help them. You do even try to prove everything in your power towards that end, yet you see no pro g ress and you to you how become frustrated. they’ve tried to follow up on your advice, but somehow it just did not work out in spite of their best efforts.

Most of these patients do not express anger or any type of blame towards the practitioner. In fact, in most cases, they may be overly grateful and try to reassure you that they think you are doing all you can to help. They may even blame their lack of progress on themselves with comments ■ such as “I know you’re doing all you can to help me. It’s just me. I’m so messed up that no one can help me.” The self-pitying attitude is hard to brush off and will often make a practitioner feel that he/she wants to do even more to assist the patient. Manipulative patients will embrace your suggestions and even try to prove to you how they’ve tried to follow up on your advice, but somehow it just did not work out in spite of their best efforts. When dealing with these patients, there is bound to come a time when you need to end the relationship. When this time comes, it is paramount to offer the patient some choices for what they can do next. Sending them away with no hope is extremely detrimental. However, it must also be made clear that the ultimate decision lies with them and that, if they do not like what you have offered as follow up advice, there is not much more you can do.

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Case in point: N.K.sought acupuncture treatment for a case of long-standing, severe depression at the suggestion of a friend. The initial interview went well with the patient expressing a sincere desire to get well. The acupuncturist noticed that she was already taking some prescription antidepressants, but the patient st at e d they really were not helping. When asked how long she had been on the medication, she gave vague answers. When asked why she continued on the medication even though she did not feel it was helping, she gave even more vague answers. The acupuncturist proceeded to administer twice-weekly treatments for depression and was encouraged by the patient’s optimistic attitude towards acupuncture. After about four weeks of treatment, the patient demonstrated no noticeable improvement and, at times, told the acupuncturist that she thought the depression was getting wo rs e . The acupuncturist was becoming frustrated and referred the patient to a Five Elements practitioner. The patient took the information, but never called. When asked why, she put on a sad face and said,“What could she do that you can’t? You already know me and I feel comfortable here.” The acupuncturist also referred this patient to a local support group and suggested she also try Trauma Touch therapy. Again the patient seemed eager to try these avenues but came back stating she so far had not had time to go to the support group. She also stated she had done some research on Trauma Touch massage and felt that it would not help her. The practitioner eventually became exasperated and told the patient there was not much more she could do for her and that the patient would have to try to find other sources of help. The patient left the office rather tearfully but did not return.

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■ What went wrong? The patient gave a hint early on in the treatments that she might be somewhat manipulative when she gave vague answers regarding her antidepressants. It might have been worthwhile for the acupuncturist to pursue this information in a little more detail and perhaps to consult with the doctor who prescribed the antidepressants if the patient would have agreed to that.As the treatments continued with no progress, the acupuncturist should have tried to gently taper off the frequency to once a week, then twice a month, etc. instead of abruptly ending the relationship. When it became clear to the practitioner that the patient needed another means of treatment, the acupuncturist should have reiterated her original suggestions and given them to the patient in writing. In the gentlest way possible, she needed to let the patient know that, just because acupuncture was not working for her, there was still hope and the patient had not exhausted all her options. She needed to acknowledge the patient’s tearfulness and express sympathy but still hold firm to her own advice.

T HE I NSI DE ST ORY: Manipulative patients can often prove to be frustrating and even annoying at times. Their desire to control the treatments can be a real challenge to any practitioner. It is helpful to understand that underneath this behavior is a person who has likely been manipulated themselves, either in a present situation or in a past instance from childhood. In more serious cases, there may be a history of sexual, physical, or emotional abuse. They feel out of control, yet also have a need to exert control. In so many cases, the only way they know how to do this is by mimicking the way they have been or are being treated. Many of these patients may also have been somewhat neglected as children. Their behavior can often seem quite childlike, and

The Manipulative Patient

they may be seeking a kind of surrogate parent or caregiver role from their health care providers. However, even though they seek to exert control, there is also a feeling that they have a deep need to be cared for and taken care of. If they have not been able to find this in their personal relationships, the health care provider is a logical choice to pursue.

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■ It is helpful to understand that underneath this behavior is a person who has likely been manipulated themselves, either in a present situation or in a past instance from childhood.

Of course, these motives are usually quite subconscious, and it is not the job of the Oriental medicine practitioner to analyze the patient or find answers to deep-rooted problems, but just being armed with a basic ■ understanding of this type of patient can help the practitioner develop an effective treatment strategy that will benefit both the patient and the therapeutic relationship. QUEST I ONS FOR C HAPTE R SEVEN : 1. Can you think of an instance in which you yourself used manipulative behavior? If so, what were your motives? What did you hope to achieve and were you successful? 2. Have you ever been in a situation in which someone manipulated you (or tried to)? How did it make you feel? How did you handle that situation? 3. What are some clinical presentations of a manipulative patient? 4. What are some of the underlying issues that may cause a person to be manipulative? 5. Scenario for discussion: J. W. is a 25 year-old woman with a history of irritable bowel syndrome (IBS). She is very squeamish about acupuncture needles, but has a large number of tattoos

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and body piercings. She often complains and even whines about how much the acupuncture needles hurt and that, when she had her piercings and tattoos, she did not feel much pain. She also mentions that she had had acupuncture “a long time ago” and that the needles did not hurt then. She often tells the practitioner which points not to needle and also requests the practitioner needle other points that she says “don’t hurt so much.” How would you deal with this patient?

It is important not to show impatience with either the “Rambler” or the “Vague Complainer.” This behavior is difficult to change since it is often part of the person’s basic personality and diagnosis.

CHAPTER EIGHT

The Patient with Communication Problems (The Rambler & the Vague Complainer)

Effective communication is critical in a healthy therapeutic relationship. It is the only way the practitioner can attain the knowledge that he/she needs to be an effective healer. Patients need to be able to convey their symptoms succinctly and as accurately as possible. It is important for them to be able to give an accurate medical history as well and it is helpful if they have a fair working knowledge of their medications. They also need to be able to convey their comfort level with the treatment and to inform the practitioner of any true discomfort. Practitioners on the other hand, must be able to explain their treatments in vernacular terms. They need to be able to offer timely and coherent explanations about a medicine not native to the culture they practice in and incomprehensible to much of the general public. The practitioner also must develop skillful interviewing techniques

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and learn how to ask critical questions from the history the patient gives. In this way, both parties can proceed in a positive and therapeutic manner. However, not everyone is an effective communicator, and there will be some patients who make their way to your office who will pose problems in this area. I have divided these patients into two basic types for the purposes of this book, but you will probably be able to identify other types of communication problems not mentioned here. In my experience, the two most problematic patients regarding communication are the “rambler” and the “vague complainer.” The Rambler is familiar to almost anyone in or out of a health care situation. This is a person who loves to talk, especially if they are the focus of the conversation! Conversations with such people are often one-sided. The listener is hard-pressed to get a word in edgewise and finds him or herself looking for an escape. Ramblers relish telling others personal anecdotes about themselves, at times in excruciating detail. They rarely let the listener express an opinion, nor do they ask for one. This type of person usually does not seem to mind whether they are talking to a stranger or to someone they know well. Everyone is a potential audience. The Vague Complainer is more likely to be seen more often in a health care setting. He or she knows something is wrong but cannot define what it is. Even when asked specific questions, they are often unable to come up with clear answers. Common responses from these people are statements such as, “I don’t know,” “I’m not sure,” “I can’t really describe it,” and “I guess so.” In this case, the listener has no trouble getting into the conversation. In fact, the listener often finds him or herself trying to draw the patient into the conversation with varying degrees of success. Such a patient can prove difficult because of their diminished participation in the therapeutic relationship. Fortunately, Oriental medicine affords us tools such as pulse

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and tongue signs that become absolutely critical when dealing with a Vague Complainer. C L I N I C A L P R E S E N TAT I O N : ■

“Stream of consciousness” talking with little or no opportunity for the listener to talk

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Giving long-winded descriptions or explanations

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Frequently changing the subject or an inability to stay on one subject for any length of time

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Inability to give accurate descriptions of what is bothering them

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Insufficient answers to practitioners’ questions

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An intake form that is either overly detailed or not filled out enough

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Lack of eye contact

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Hyperactivity or hypoactivity

C O N T R I B U T I N G FA C T O R S : Home again There is not much in the office setting that will enhance or deter someone with a communication problem, but there are always some areas to explore. A Rambler can sometimes pose problems for the front desk staff when the practitioner is busy with another patient. They will often try to engage the staff or other patients in conversation. This is an area in which having some good reading material can be helpful. If a talkative patient in the waiting room is disturbing the staff or other patients, the staff can try pointing out an interesting magazine or article for them to read while they wait. (Of course, this can also be an effective strategy for any other unwitting audience members to use as a distraction and deterrent.) If the Rambler persists in conversation with the staff, the staff can simply but politely state that they need to attend to their work. Of course they should honor the patient

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with all the normal courtesies but, beyond that, should discourage long-winded conversation. It is usually the practitioner who bears the brunt of dealing with this patient, however. You may sometimes feel that you are trapped in the room with no way out. The intake form may be your greatest ally in this situation. It is important to allow the person a little leeway to express themselves, but this needs to be limited to just a minute or two. You need to be alert to the inevitable but fleeting break in the conversation, which will allow you to ask a crucial question or to redirect the conversation to the subject at hand. You must also check yourself to make sure you are not unwittingly engaging the patient. Although some Ramblers are boring and monotonous, others are interesting and have stories to tell that may pique your interest. Resist the urge to pursue the topic because it is certain you will get what you asked for. Remember, your primary purpose is professional, not personal. ARambler will often fill out the intake form in painstaking detail. It is the practitioner’s job to sort through the information and distill only what is pertinent. The Vague Complainer will rarely pose a problem in the reception area. They will often be quiet and keep to themselves. They may pose a problem to the staff in that they may not be able to be decisive about when they want their next appointment. They may even want the staff or the practitioner to help them decide when a good time to come in would be. Their intake form may look pretty sparse. They may tell you that, “I just didn’t know how to answer the question.” Your challenge here is to elicit more detailed responses from them. In some cases, you may not be as successful as you’d like in this area and may need to rely on data such as pulse and tongue examination, facial color, voice timbre, and complexion to assist you in your treatment plan. It is important not to show impatience with either of these types

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of patients. This behavior is difficult to change since it is often tied up in the person’s basic personality. Instead, you need to find ways to allow just enough time to get the information you need without having the appointment time be devoted solely to that end. Cases in point: Case 1. Ms. W. made an appointment with an herbalist because of a persistent rash on her upper torso that had been refractory to Western dermatological treatment.When she called to make her initial appointment, she went into considerable detail on the phone and the herbalist found herself spending quite a bit of phone time fielding questions she could not possibly answer without examining the patient in person.When Ms. W. came in for her appointment, she asked for an extra sheet of paper to supplement her responses on the intake form.When asked how long she had had the rash, the patient gave details dating back 20-30 years, including the names of various doctors she had been to and the years she had received treatment from them. She also diverged from the main question and started telling the practitioner how her mother had had similar problems and then delved into stories about her dysfunctional relationship with her mother. At one point she became quite emotional and started crying.After 45 minutes, the herbalist realized they were still only about halfway through the interview! By the end of the interview, the herbalist felt that she had too much information but did not have a good grasp on the chief complaint.

■ What went wrong? Needless to say, the original phone conversation was the star ting point of the trouble. It was easy to see that this patient had a lot to say, but the practitioner should have obtained the basic information and then quickly but politely told the patient that

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there would be plenty of time at the first appointment to discuss her issues. When the patient showed up for her appointment,she should not have been given extra paper to write on.The practitioner could have told her that whatever would not fit on the form could be discussed afterwards. When the herbalist realized the patient was diving back several decades, she needed to wait for that opportune opening in the conversation to insert a statement like,“How long have you had the rash this time?”When the patient started discussing her mother, the practitioner should have immediately interjected, stating something like ,“ W h at I really want to hear about is you.” This type of statement serves the purpose of keeping the focus on the patient while at the same time keeping the interview on track. Case 2. A .K . is a 60 year-old man who had recently been diagnosed with cancer. He called the acupuncturist to see if Oriental medicine could help him. The patient was not sure of his exact diagnosis or even what type of cancer he had. He was also unable to name any of the chemotherapy agents he would be receiving and was very unsure of his chemotherapy schedule. He was also unable to fully describe his symptoms. His responses were statements such as, “Sometimes my neck hurts, but not always. Well, it really doesn’t hurt. I think it’s the headaches that bother me the most.” The acupuncturist was incredulous at the patient’s lack of knowledge and found it hard to hide his disbelief. At one point he said, “How can you not know what kind of cancer you have or when you start your chemo?” The patient became intimidated and clammed up even more. The acupuncturist felt frustrated and at a loss as to how to help this gentleman.

■ What went wrong? This patient is a man who is quiet by nature and unaccustomed to talking about himself. The fear he had over his cancer diagnosis made him even less willing to talk. He did not fully understand what chemotherapy could do for him, but he also had

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never had acupuncture and did not know what to expect or even what to ask for. The acupuncturist would have found it helpful to briefly broach the subject of how the cancer diagnosis was affecting this man.When questioning him about specific symptoms, he could have used broad questions such as,“What is bothering you the most right now?”or “How do you feel now that is different from the way you normally feel?”These questions may have helped the man pinpoint his objectives as well as helped the acupuncturist to divine the information he required.In addition, the acupuncturist should have paid even closer attention than normal to the pulse and tongue signs to help him understand where this patient was experiencing imbalances.

It’s a cultural thing Culture can be a huge factor in communication difficulties. Earlier in Chapter One, we discussed situations in which the patient and practitioner do not share the same primary language. Even when both parties are speaking the same language and have a good working knowledge of that language, culture can still affect communication. In some cultures, it is common for a person to talk a lot and share their difficulties, even to the point of being overly dramatic. This type of communication is sometimes a feature in some Mediterranean cultures. It can be frustrating to deal with this type of person if the practitioner is not familiar with this culture or is from a culture that does not promote expressive dialogue. Other cultures such as Asian cultures encourage people to be taciturn. It is seen as a sign of selfishness or even shame to talk much about oneself. People from these backgrounds may only give one-word answers to questions and may deliberately leave out very personal information such as the emotional or sexual history. If the communication difficulty is indeed due to cultural influences, it is even more important for the practitioner to try to understand the patient. Hopefully there will be some obvious

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sign that the person is from a different culture. They may speak with an accent, have different colored skin, or even wear clothing that identifies their cultural background. Noticing these signs is important on so many different levels. Of course we do not want to stereotype anyone, but a healthy recognition of differences is vital to successful communication. Cases in point: Case 1. J. D. is a 38 year-old man with Crohn’s disease who wants acupuncture treatments to help decrease abdominal spasms. When he came for his first treatment, he was accompanied by two family members. He had no trouble revealing personal details; in fact he did so to the point that the acupuncturist was somewhat embarrassed. The family members did not share this discomfo rt . In fa c t ,t h ey chimed in quite often, sometimes disagreeing with the patient or with each other. Before the acupuncturist could realize what was happening, the conversation had strayed to an entirely different topic. The acupuncturist became frustrated and annoyed with the patient and his family. He requested that the family step into the waiting room for a while, but the patient explained that,“There are no secrets in my family.” The family members were offended that they were being requested to leave and the feeling in the room became rather uncomfortable.

■ What went wrong? This patient was indeed from a Mediterranean culture in which family input was expected, even in very personal situations. The acupuncturist failed to recognize this as a cultural factor and merely thought the patient and his family members were overly demonstrative and talkative. The patient’s family name as well as several comments made by him and his family members should have tipped off the acupuncturist to the culture of origin. Even if he could not identify the exact culture, he could have

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determined that culture was a factor. Whenever this is suspected, all angles of patient behavior must be held up to that light and benefit of the doubt given. The acupuncturist should not have discouraged family participation but should have set boundaries so that only one person at a time was talking. When the topic changed,he should have indicated an interest in the new topic very briefly but brought the conversation back around to the patient’s health as soon as possible. He could have said something like,“I wish we had more time to talk about that, but right now I need to know what I can do to help.” Case 2. K. M. is a 48 year-old Asian woman referred to an acupuncturist for menopausal symptoms. Although the patient spoke with a slight accent, she spoke English fluently. The patient was extremely polite,friendly, and cooperative until the acupuncturist started asking questions about her menstrual cycle. The woman became very quiet and gave only vague answers. She did not make any eye contact at all.For some questions, all she would say was,“Oh, I can’t answer that.”The acupuncturist began to suspect that the patient was malingering and became upset when further questioning was met with further evasiveness. Finally, the acupuncturist told the woman she did not know if she could help her since she was unable to give her the information she needed. The patient smiled and quietly left the office.

■ What went wrong? This is a similar situation to the preceding one, only instead of being too talkative, this patient was not talkative enough. Although it was obvious she was from a different culture,she had lived in this country quite a while and spoke very good English.Therefore, the practitioner did not immediately recognize the woman’s hesitation as a cultural factor. In fact, the woman was unprepared to be asked questions of a personal nature. Although she had lived in this country for quite some time,her ties to her own culture were quite strong and she adhered to mores she had learned

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as a child,including not discussing personal matters, even with an acupuncturist.In fact,she expected the acupuncturist to be able to determine her needs just from her pulse and tongue. In this case, the acupuncturist’s options were very limited. She could have suggested that the woman come again with a close friend or family member if that would have made the patient feel more comfortable.The other person could have assisted in giving answers. Ultimately, the acupuncturist might have had to rely on pulse or tongue diagnosis, or she might have had to refer the patient to a practitioner who was of the same background or at least more familiar with that culture.

A case of nerves Anxiety and fear can also impede effective communication. Many times this is seen when someone has been given a frightening diagnosis. It may also just be a way of dealing with an unfamiliar setting. Even though Oriental medicine is gaining popularity, there are still scores of people who have never tried it. They may be victims of misconceptions or misunderstanding. They may also be at the appointment under duress. Perhaps a wellmeaning wife or husband pushed them to come. Anxiety may make them “run off at the mouth” as a way to express their nervousness. On the other hand, these same emotions can also make someone “clam up.” Anxiety can cause shortness of breath. Fear can be paralyzing. The patient may truly not know what to say. In these cases, you must use your skills to help alleviate the patient’s distress. Allow them some time to discuss what may be making them nervous. Reassure them with simple explanations. Assure them that they can ask questions at any time and that they should tell you if they are uncomfortable with any aspect of the treatment. If you suspect that their health concern is the source of their inability to communicate, it might be worthwhile to allow them a little time to discuss how they are feeling about their condition.

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Cases in point: Case 1. W. S. is a 32 year-old who had been in perfect health until he started having numbness and tingling in his limbs as well as some double vision. Although tests were inconclusive, his Western doctor had indicated that the diagnosis might be multiple sclerosis (MS). When asked about his symptoms, the patient began talking very rapidly in a “stream of consciousness” fashion. Whenever the practitioner tried to steer the conversation back to the topic, the patient had trouble focusing and would start talking about something else.This situation continued until the acupuncturist asked the patient exactly why he was there since he would not stay on the subject. This made the patient more nervous and he felt that the acupuncturist did not want to help him.

■ What went wrong? The acupuncturist in this case was not as sensitive as he should have been to the overwhelming impact the patient’s symptoms and possible diagnosis were having. Working in health care can sometimes make us a little hardened to what a patient may be feeling. We know that there are thousands of people with debilitating illness, and we see them on a regular basis. However, a person diagnosed with such a condition cannot help but be upset and feel as if their whole world is crashing in. They may have heard dire things about the condition. They may know someone with a similar diagnosis who did not do so well.There are countless thoughts rushing around inside their heads and they may have insufficient information to develop a clear understanding of what is happening to them. Talking quickly and changing the subject can be methods of avoiding a topic that is too frightening to discuss outright. Noticing the chief complaint, the acupuncturist should have been more sensitive to the patient’s emotional state and devoted

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some time to asking the patient how this new development was affecting him. That in itself might have been enough to soothe the patient and help slow him down a little. Case 2. P. C. is a 62 year-old woman who comes to the acupuncturist for relief from indigestion and bloating after meals. While reviewing the patient’s medical history, the acupuncturist noted that the patient had had breast cancer several years ago. When questioned about this, the patient stated she was in complete remission and was not currently receiving any cancer treatment. She also said,“Once you have had cancer, nothing is ever the same.” When the acupuncturist started asking the patient about her digestive symptoms, the woman gave only brief, one-word answers and was not able to provide details about her symptoms. She was also unable to maintain eye contact and continually looked out the window instead of at the practitioner. The acupuncturist gave up trying to elicit responses from her and relied on her pulse and tongue diagnoses. She was able to provide the woman with some relief from her symptoms, though they did not resolve completely. The woman continued to have problems communicating on all her subsequent visits.

■ What went wrong? In this case, the acupuncturist was not so put off by the patient’s reluctance to talk, but her treatments were not as effective as they should have been. The acupuncturist should have taken the patient’s statement about cancer as more than just a passing remark.Further discussion would have revealed that, even though she was in remission, she was terrified of a recurrence and suspected that her current symptoms were, in fact,indicative of the cancer’s return. She was so afraid of this possibility, however, that she could not bring herself to say it out loud. Her fear made her turn to silence. In her silence, she found a place where she did not have to reveal or acknowledge her fears. If she had been given a chance to express her true inner feelings, she might have actually felt relief in being able to talk about them.

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It’s not all in your mind Physical or emotional illness often has a profound impact on behavior. When faced with a communication problem patient, the practitioner should also be alert to any disease process that might affect the patient’s communication. A bipolar patient in the manic stage might have a tendency to talk nonstop and have trouble staying on one subject. Someone who is very depressed may find it difficult to engage in a conversation. More and more adults are being diagnosed with a type of attention deficit disorder (ADD). Attention deficit disorder may manifest as hyperactivity, including “hyperactive speech.” Stroke victims may have expressive or receptive aphasia. In expressive aphasia, the patient knows what he/she wants to say but cannot make the correct words come out. In receptive aphasia, the patient recognizes the words being spoken to him/her but cannot make sense of them. Someone afflicted with Bell’s palsy or any kind of facial deformity may also have trouble conveying their ideas. These types of patients require extra attention. In many such cases, the reason for the communication problem may also be the reason the patient is seeking help. The origin of the problem will be very obvious, but sometimes it may be difficult for a practitioner to know how to deal with it. It is always helpful if a friend or family member can accompany the patient and help facilitate communication. Cases in point: Case 1. R. B. is a 65 year-old gentleman who suffered a mild stroke several months ago. His daughter had heard that acupuncture can be effective in treating the sequelae of st ro ke and brought him in for an appointment.After she helped the patient fill out his paperwork, she stated that she had to leave and run some errands but would be back to pick the patient up in an hour. Although the patient did appear to have some difficulty conveying his thoughts, he also appeared to manage fairly well. After the daughter left,however, the acupuncturist had difficulty

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trying to get some further information from the patient. The patient appeared to want to participate very much, but, every time he opened his mouth, the words that formed did not make sense. The acupuncturist was able to proceed with the tre at m e n t nonetheless, but both he and the patient felt frustrated.

■ What went wrong? This acupuncturist was new to practice and had not had much experience with stroke victims. When he witnessed the rapport between the patient and the daughter, he felt that the patient was able to make himself understood. After the daughter left, the situation became more difficult. The fact is that the daughter had become accustomed to her father’s aphasia and had developed effective ways to understand and communicate with him. Of course, the acupuncturist did not have this benefit. It would have been more appropriate for the daughter to stay for the treatment to help everyone have a more beneficial experience. The acupuncturist would have been well within reason to request this. If the daughter were unable to stay, he could have asked her advice on how well the patient could communicate and what he could do to assist him. If the patient had use of his writing hand, the practitioner could also have had him write down some information or even some questions he might have had. Case 2. J. S . is a 45 ye a r-old woman seeking acupuncture treatment for chronic depression. She was rather quiet during the interview and gave mostly one-word answers to the practitioner’s queries. In addition, she had a tendency to mumble when speaking which sometimes made her speech difficult to understand. Her body movements were slow and even laborious, and she had trouble making eye contact. She sighed often and sometimes had a delayed response to quest i o n s. T h e acupuncturist recognized the severity of the woman’s condition

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but had trouble finding the patience to bear with her. She even found herself wishing the patient would seek help elsewhere.

■ What went wrong? Although the acupuncturist was aware of the severity of the patient’s depression, she had trouble understanding how deeply the depression affected everything the patient did, including conversation. Severe depression is an emotional disorder that often has somatic effects, including slow movements, laconic speech, and inability to fully engage with another person. The acupuncturist could have facilitated this encounter by keeping questions very simple and using “yes/no”questions for the most part. When the patient had delayed responses, the acupuncturist could have used this as an assessment tool, and could have also evaluated the patient’s body language as a diagnostic measure as well.This would have helped the practitioner herself to stay engaged.

THE INSIDE STORY: We take the power of speech for granted, but it is essential to our interactions with others. Abnormalities or difficulties in this area have a profound effect on relationships, and the health care relationship is no exception. There are many factors that affect the way any given individual communicates. Sometimes difficulty in communication is a symptom of an emotional or physical syndrome. At other times, cultural factors weigh in. Family history also affects the way a person interacts with others. Similar to cultural considerations, some families are quite demonstrative within the family unit, while others are more reserved. Upbringing often dictates how we behave in the larger social arena. Social isolation may also make someone overly talkative or withdrawn. In spite of all our high-tech ways to communicate in this society, loneliness is rampant. In fact, technology can often make people feel isolated. E-mail instead of phone conversations, telephone

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menus, answering machines, and caller ID allow us more choices for communication but, at the same time, reduce actual human contact. Someone who is lonely, lives alone, and has little contact with other people may take the opportunity of a doctor ’s visit to engage in conversation. Because of their social situation, they may not be aware of boundaries and may have a tendency to talk too much or to linger after appointments just to have someone to relate to. Conversely, social isolation may also cause someone to retreat to the point that they lose some of their social skills and become overly withdrawn in the company of others. As practitioners of Oriental medicine, it is part of our job to help people feel connected and more complete. Understanding the underlying causes of communication difficulties can go a long way to achieving this goal. QUES TI ONS FOR C HA PT ER EI GHT: 1. Has there ever been a time in your life when you felt you talked too much or not enough? If so, what was going on with you at the time? Were you aware of how other people reacted to you? 2. List three factors that contribute to rambling speech. List three factors that contribute to vague complaints. 3. What are some illnesses that can affect the way a patient communicates? 4. What are some social factors that contribute to communication difficulties? 5. Scenario for discussion: Mr. J. arrives at your clinic for his acupuncture appointment. He is being treated for HIV/AIDS. You have seen him twice before and never had any problems, but today he is unusually talkative. It is hard to get the treatment started because he starts a lively conversation with the

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receptionist. Once in the treatment room, he laughs inappropriately and starts talking about problems he is having with his pet dogs. He has trouble staying on the subject, and his speech is rapid. When you ask him a question, he is unable to give a direct answer. How would you handle this situation?

We must always be on guard and be aware of what is happening in our own personal lives that may cloud our judgment and drive us to feel some kind of attraction toward a particular patient.

CHAPTER NINE

The Seductive Patient

The American Heritage Dictionary defines seduction as “1. enticing into wrong behavior; corruption. 2. The act of inducing to have sexual intercourse.” 1 The word “seduction” is most often associated with sexual attraction and/or exploitation. The practitioner/patient relationship is definitely not exempt from this type of seduction. In fact, it can sometimes invite seductive behavior in the patient as well as in the practitioner just by the very nature of the relationship. So many of our patients are vulnerable. They need and are seeking to be cared for. Perhaps they are lonely or feeling rejected or were not sufficiently cared for as children. Finding a health care provider who shows them empathy and compassion can certainly foster feelings of emotional and physical attraction. The therapeutic relationship, though professional, is also intensely personal. Patients share feelings and information with us that they may never share with another human being. The lines between professional intimacy and personal intimacy can often 149

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become blurred. Too often, the attraction in this situation is a false type of attraction. Either party is attracted not so much to the person but to what the person represents. If an actual involvement should ensue, the relationship is often doomed to failure because it is based on unmet needs and realizations rather than on true attraction to the actual person. Of course, practitioners are by no means exempt from this type of feeling, either. We must always be on guard and be aware of what is happening in our own personal lives that may cloud our judgment and drive us to feel some kind of attraction toward a particular patient. Seduction need not only be of a sexual or romantic nature, however. Sometimes a practitioner and patient find they have a common interest, hobby, or lifestyle. What starts out as small talk or polite conversation can quickly grow into a more intimate bonding. The patient or practitioner may find themselves wanting to take their relationship further than the clinic. The patient may invite the practitioner to some kind of social event that has to do with a shared interest. Gifts may also be presented to the practitioner. The practitioner, on the other hand, may find him or herself accepting such invitations or gifts and perhaps even reciprocating in kind. The practitioner may also find that, during the appointment time, he/she and the patient end up discussing common interests and losing focus on the reason that the patient is actually there. The treatment then becomes secondary and ethical issues arise. Atoo-personal relationship with a patient may also predispose the patient to asking for or expecting favors or special considerations from the practitioner. Of course, there are times when a true friendship or even a serious romantic relationship may arise between a practitioner and patient. In these cases, each party needs to seriously consider how they wish to proceed. It is usually not advisable to bring a friendship into a therapeutic

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relationship as the professional relationship may lose its power and integrity to underlying emotional issues and expectations. It is never appropriate to continue treating a patient if sexual attraction is a concern, whether it is mutual or not. C L I N I C A L P R E S E N TAT I O N : ■

Wearing skimpy or revealing clothing

■

Inappropriate physical contact with the practitioner

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Complimenting the practitioner on his/her looks, personal appearance, etc.

■

Flirtatious behavior

■

Gifts or invitations to social events

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Conversation that leads away from the patient complaint or from the treatment in general

C O N T R I B U T I N G FA C T O R S : Home again Although this chapter is titled “The Seductive Patient,” you as the practitioner can also be the seducer, or you may unwittingly invite seductive behavior by your actions. As discussed in the first chapter, a practitioner must always be aware of how he/she is presenting themselves to their patients. Wearing skimpy or revealing clothing is not appropriate under any circumstances. Not only is it highly unprofessional, but it conveys a message you may not be intending to convey. (If the intention is there and is conscious on your part, then a whole new discussion needs to take place!) It is very likely that you will find yourself being physically or otherwise attracted to one or more of your patients during the course of your practice. This is normal and can be controlled with a modicum of self-restraint. It is when the feelings of attraction lead to action that the danger occurs. Mind your words, your dress, and even your body language at all times in order to avoid a potential powder keg in your clinic.

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Be aware of your own life situation. Practitioners can be just as vulnerable as any one else. If you have recently ended a relationship, divorced, or are unhappy in your present relationship, you may find yourself looking for attention outside your personal life. You have access to a wide variety of people in your practice and may find someone attractive. Or, if you sense that one of your patients is attracted to you, you may be flattered by the attention and be tempted to respond in a like manner. Likewise, if you are new in town, are feeling lonely, or are feeling overburdened by starting a new practice or maintaining an existing one, a patient’s affection may be very appealing. It is easy to lose perspective in a situation like this. Take advantage of a good friend or a trusted colleague to get a more realistic picture of what you are feeling. So often, an objective party can shed light on truths that are obvious but to which we are blind when we let our emotions take hold of us. Be mindful of your conversations with patients when you are treating them. Small talk is a way to break the ice and also a way of letting your patient know you are interested in them as a whole person. If you and your patient happen to discover a common interest, it is very easy to get swept away in a conversation that focuses on that interest instead of on the treatment. Always remember that you are there for the patient and not the other way around. Also remember that the patient is paying you for the time you reserve for them and they deserve the best possible care during that time. Another danger of getting too closely involved with a patient is that it may lead to a situation whose outcome is less than desirable. You may find that someone with whom you seem to be compatible in the clinic is not really the person you thought they were. While patients confide a great deal in us, they may also hide a great deal from us as well. Furthermore, this type of involvement can lead to actions which then present a problem in the

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more personal relationship and this problem may carry over into the therapeutic relationship. It is crucial for the practitioner to be able and willing to set boundaries when the therapeutic relationship involves seduction of any kind. As they say, silence implies complicity. As with any undesirable behavior, the longer the behavior is allowed to go on, the more the situation intensifies. Nipping it in the bud is always the best course of action. Cases in point: Case 1. W. H. went to see an acupuncturist for hip pain that he had had for a number of years. Due to the location of the pain, he had to remove his lower body clothing in order for the acupuncturist, a female, to treat the affected area. The acupuncturist explained everything she was doing and gave the patient a sheet with which to drape himself. The patient made some offhand remarks such as, “I bet you get to see lots of guys without their clothes on.” The practitioner brushed off these remarks and continued to keep the sessions professional.Eventually, the patient started commenting on her wardrobe, stating,“I love those cute dresses you always wear. They really accent your figure.” At this point, the practitioner became a little uncomfortable, but did not say anything to the patient. On subsequent visits , however, he started comparing the practitioner to his wife, saying things like, “I wish my wife could understand me like you do,” and “I always feel so good when I leave here.” The acupuncturist and this patient had discovered earlier in the clinical relationship that they both shared a passion for rock climbing, and the patient started asking the practitioner to meet him at the rock climbing gym. At first, she tried to laugh off these invitations, but the patient persisted until she finally had to tell him she did not socialize with patients at all. He continued coming for treatments, but the practitioner always felt uncomfo rt able with him and found herself rushing through his appointments.

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■ What went wrong? In this case, the acupuncturist did her best to maintain a professional attitude, but the patient was persistent in his seductive b e h a v i o r. The mist a ke here was that the behavior was not addressed before it progressed to an uncomfo rt able place. When the patient first started making inappropriate remarks, the practitioner should have immediately discouraged such remarks. When the remarks then crossed over to her personal appearance, a serious discussion needed to take place. Failing to set boundaries allowed this situation to get to a level in which neither party was benefiting and the patient’s care was compromised. Case 2. D. B. was a long-time patient who relied on acupuncture to help her with symptoms related to rheumatoid arthritis (RA). She and the practitioner were approximately the same age and had a lot of things in common.Over the course of time,her visits took progressively more time because she and the acupuncturist would spend about 20 minutes in social chatter. One of their shared interests was horses. The acupuncturist was also an avid rider and was in the market to look for a new horse.The patient stated that she knew several people who were selling horses and that she could help the practitioner out.They met several times, but the practitioner never found a horse she liked. The patient spent time seeking out horses she thought would be good for the practitioner and soon the practitioner started feeling obligated to see all these animals, even though she was becoming discouraged with the search and also was realizing that her riding ability was not as advanced as the patient had thought.While she at first appreciated the patient’s efforts on her behalf, she ended up feeling resentful and a little embarrassed and had a hard time figuring out how to tell the patient she was no longer interested in pursuing those avenues.

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■ What went wrong? The acupuncturi st was well-meaning but did not re c o g n i z e when the therapeutic relationship started to get offtrack. She should have checked herself when she found her appointment times with this patient getting longer and longer, but she allowed it to continue because she herself was benefiting from the personal conversations. She did not have many other friends who shared her hobby. Therefore, she enjoyed the mutual interest she shared with the patient. When the relationship spilled over into non-clinical areas, she became aware that she and the p atient we re really not on the same level re ga rding hors emanship and her discomfort eventually infiltrated her clinical relationship with this patient.

Sexual abuse It is an unfortunate and incomprehensible aspect of our society that abuse of all types is rampant. You will meet many people who are victims of physical, verbal, emotional, and/or sexual abuse. You yourself may have experienced these types of abuse in your life. It is certain that many of your patients will have abuse in their histories. Some will freely admit this to you and will even seek treatment as a means of healing from past pain. Others may be too embarrassed to discuss the issue or they simply may not have the level of trust required to share this with a health care provider. Still other people will have repressed their memories of abuse so deeply that they may not be aware of it. It lies buried deep within the subconscious. And yet others will be able to tell stories about abuse but may not see their story as serious or as true abuse, no matter how obvious it may be to an objective observer. Sexual abuse is especially difficult for some people to define or discuss. Its effects may manifest in a variety of ways. Some

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survivors of sexual abuse may become shy and withdrawn and may shun social contact. They may exhibit an extreme fear of intimacy or of relationships in general. Feelings of mistrust are common. However, a victim of sexual abuse may also exhibit a heightened overt sexuality, even if they are inwardly feeling awkward or afraid. It is not uncommon for sexual abuse victims to dress provocatively or to be flirtatious or promiscuous. Of course, some people display this characteristic even if there is no history of abuse. It may not always be easy to determine if someone is simply sexually expressive or if their behavior is stemming from a painful past. Nonetheless, in any patient who displays overt sexual behavior, the influence of abuse must at least be suspected. How to deal with this situation is not easy or clear cut. On one hand, this patient has many unmet needs and is, in many aspects, quite fragile, although they may appear self-confident and even aggressive. They may very much need help but may not even be aware themselves of what has happened to them. In these cases, you must be careful and use your intuition to determine whether a discussion is possible. You may want to include on your intake form a space about possible abuse. Some people will be honest, others may not be able to be that honest and may leave that space blank or openly deny any significant history. If you do suspect a history of abuse and the patient does not indicate this in writing, you might try to find a way to weave the topic tactfully into the interview. In some cases, you can ask the patient outright, if that feels comfortable and appropriate. In any case, it is important to realize that the outward manifestation of their sexuality might be a cry for help. Outright rejection can be extremely detrimental. You must proceed with caution. If you do discover that the patient has had an abusive encounter and has not received help, refer them to a mental health practitioner and urge them to get counseling.

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Case in point: B. M. is a 20 year-old woman who comes to the acupuncture clinic for digestive problems. On her first visit,she is dressed in a flimsy and revealing dress. She is openly flirtatious with the (male) acupuncturist. The acupuncturist does not comment on her dress or behavior. As part of the treatment, he needles Tian Shu (St 25). The patient immediately starts crying but, at the same time, becomes even more flirtatious, taking the practitioner’s hand and telling him she needs a shoulder to cry on.At this point,the acupuncturist becomes quite distressed. He does not understand the sudden tears and is taken aback by the patient’s apparent need for his affection.He becomes quite stern with her and tells her that her behavior is not appropriate for a clinical setting and that he feels they should end the treatment and perhaps continue another time.

■ What went wrong? Obviously, the acupuncturist here was not attuned to signs of possible abuse. Acupuncture is a gentle healing form, but to some people, it can also seem quite invasive. It is also a very personal form of healing. This patient had been sexually abused by her uncle, and the needles at Tian Shu (St 25) were close enough to the abdominal area to bring on memories of her past trauma, but she did not know how to express this. Her tears we re an invo l u n t a ry reaction to painful memories that had been re s u r rected during the tre at m e n t . The acupuncturi st needed a heightened level of sensitivity to understand that the young woman’s behavior was masking a deeper and more s e rious pro b l e m . When she st a rted cry i n g , he should have stopped the treatment but attempted to discover exactly what was upsetting her so much. Even if she had not been able to state her feelings or history directly, she might have dropped

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some clues regarding her background. The acupuncturist might have been able to pick up on these enough to gently broach the subject of abuse. In any case, any further treatments would be futile until the patient could be assisted to recognize the true problem. In most cases, a history of abuse can lead to physical symptoms such as digestive problems later in life.

Hey, look at me! The above situations reflect some serious problems and issues. However, sometimes seductive behavior is simply nothing more than another means of trying to get attention. Loneliness and social isolation are common afflictions in our society. People may feel they are ignored or unappreciated. Pressures at work or home may contribute to such feelings. Some people’s self-esteem is low enough that they feel the only way any one could like or pay attention to them is through their physical appearance. Of course, the media is no help here, as we are inundated on a daily basis with messages that tell us we can get what we want by being sexy. Cars, food, movies, and television all advertise with sexual images, and the general public is eager to respond and to take the message to heart. Women seem to be especially vulnerable to this type of hype. Case in point: L. M. is a 50 year-old woman who wanted acupuncture for her back pain. When she showed up for her first appointment, she was dressed quite stylishly and wore quite a bit of make-up. The acupuncturist, a male, assumed this was her usual attire for work. However, she acted a little coy during the intake,not openly flirting with the acupuncturist but making some generally suggestive remarks. Her behavior was similar on subsequent visits, and the acupuncturist told her, in a gentle way, that her comments were not appropriate for the clinic.She seemed genuinely startled by his comments and insisted that she was not deliberately trying to imply anything and that she was “just trying to make

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small talk.” However, she also became a little teary at the same time and seemed as if she were holding back tears.The acupuncturist then became somewhat uncomfortable himself and was a little unsure as to how to proceed from there.

■ What went wrong? In truth, nothing truly went wrong here. The acupuncturist handled the situation appropriately but did have some trouble dealing with the patient’s emotional response to his remarks about her behavior. During the interview, she had revealed that she was new in town and had relocated after getting divorced.Sometimes practitioners have to be detectives . An astute practitioner may have realized that this woman was simply lonely and grieving the loss of a relationship. He may have been able to find a way to help her find some social activities in town. He could have also complimented her on some achievement in her life, perhaps even giving her positive feedback regarding her ability to start over again.He could have mentioned that starting over takes a lot of courage and effort.Non-suggestive compliments such as these may have helped alleviate a sense of isolation and helped her see more positive aspects of herself.

THE I NS IDE ST ORY: Sexual energy carries a lot of power. Most of us are not fully aware or equipped enough to deal with the ramifications of our own sexuality, let alone that of others. Because sexual imagery is so prevalent in our society, we all fall prey to its messages. In addition, the darker side of society is the abuse that so many people suffer when they are young, innocent, and vulnerable. Although we are becoming more able to discuss sexual issues openly, there is still a level of discomfort and misgiving among many people. Sexual energy can also be fraught with misunderstanding and mixed messages. So many people have a “come hither” attitude when all they really want is a little attention, recognition, or friendship. It is imperative that we, as practitioners, are comfortable

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with our own sexual nature in order to 1) provide safe and effective treatment for our patients, 2) to maintain an optimal clinical environment and, 3) above all, to do no harm. Recognizing the underlying behavior that leads to flirtatiousness or other seductions is the first and most important step in helping patients achieve their best and most effective healing. QUESTIONS FOR CHAPTER NINE: 1. What kinds of patient behavior can be considered seductive? 2. What are some of the dangers inherent in becoming too personally involved with a patient? 3. What are some of your own attitudes towards sexuality? Are you comfortable with your own sexuality? Are there any issues in your past that you feel you might need to explore more in depth? 4. What are some methods a practitioner can use to assess whether or not a patient may be a victim of sexual abuse? 5. Scenario for discussion: A patient of your same age and sex comes to you for acupuncture treatment for abdominal cramping. You develop a good rapport with this patient over the course of several treatments. On about the fifth treatment, however, the patient appears reluctant to leave the office. Finally, he/she discloses that he/she finds you very attractive and has been thinking that he/she would like to become more involved with you. How would you handle this situation?

Endnote: 1

American Heritage Dictionary, Davies, Peter, editor, 2003, NYDell Publishing Co., Inc.

Remaining steadfast to your policies and remaining true to yourself are paramount qualities to acquire in order to maintain as smooth a practice as possible.

CHAPTER TEN

The Chronically Late/ No-show Patient

When operating your own practice, time and money are the most important practical issues you will face. In these last two chapters, we will deal with both of these topics and how they play into the therapeutic relationship. In this chapter, our focus is time. In general, most patients are conscientious about showing up on time. In fact, many patients will arrive quite early for their appointments. However, there are those who prove themselves to be chronically late. Then there are the most vexatious and, perhaps, most difficult to understand; the patients who simply do not show up. They do not call before or after the appointment to let you know what happened. They just do not show up. You will see a good deal of these types of problem patients, and it is a good idea to decide from the outset what your policies should be and how you are going to handle these situations when they arise. Remaining 161

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steadfast to your policies and remaining true to yourself are paramount qualities to acquire in order to maintain as smooth a practice as possible. C L I N I C A L P R E S E N TAT I O N : ■

Consistently arriving over 10 minutes late for appointments

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Not calling to inform practitioner of lateness

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No excuse or a profusion of excuses

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Making no apologies or being overly apologetic

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Not showing up for appointment at scheduled time

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Not calling to explain the reason they did not show up

C O N T R I B U T I N G FA C T O R S : Home again 1. Lateness Deciding what your policies regarding lateness and no-shows will be will depend quite a bit on how your office is set up. If you have only one treatment room, patient punctuality will be a critical issue. If one patient is late, that may upset the schedule for the entire day in a kind of domino effect. You may want to leave 15-30 minutes or so between each appointment in order to allow a little room for unavoidable lateness (i.e., due to traffic, weather, etc.). In this case, you may also want to inform all of your patients of the situation on their first visits so that they will have a clear understanding of the office dynamics and the importance of being on time. Your policy may include having to cut the appointment short if the patient shows up late. This information can and should be clearly stated in your disclosure form. It is a good idea to verbally discuss this with each patient, since a lot of people do not take the time to really read through what they are signing. Even if you have more than one treatment room and can accommodate lateness, you do not want to give your patients the idea that lateness is all right.

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Tardiness is disruptive, even if you can accommodate it, and it also shows a lack of respect for the practitioner as well as for the treatment itself. Of course, there are very legitimate reasons for a patient to be late. They may have had an unexpected situation at home or work that delayed them. Weather and/or traffic may be a factor. The patient’s children or other family members may have a lastminute need that detained the patient. Most practitioners allow at least a 10-minute window. Tell patients that, if they are going to be much later than 10 minutes, they should call so you know they are on their way. If the patient shows a tendency to be chronically late, however, you may want to ask them why they have such a hard time showing up on time for their appointments. It is possible that you may be able to help them problem solve or find ways to better manage their time to prevent future problems. If this fails and the patient continues to show up late, you may have to curtail treatment time or have a more serious discussion with the patient regarding this bad habit. 2. No-shows A ”no-show” is just that, a patient who makes an appointment and then simply does not show up at the designated time. There is no phone call or other explanation. This is perhaps one of the most exasperating experiences a practitioner can have, and you will find that it happens fairly often. Again, it is best if you have your policy regarding no-shows set ahead of time so you do not feel as though you are fumbling your way through a difficult situation. Some practitioners give patients reminder calls the day before the treatment. This is not a bad idea. Some people are just plain forgetful or disorganized, and a friendly reminder call may be the boost they need to remember that they have an appointment. For others, it may present the opportunity to cancel ahead of time. Even though this is not really an ideal situation, it is still

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better to know in advance if someone is not going to be there than to sit around waiting and wondering. Surprisingly enough, there are more than a few people who will acknowledge the reminder call and still not show up. ■ Unfortunately, these types of patients The truth is that come with the territory. time is money. You must learn Most practitioners have a cancellation policy that specifies that the patient needs to to view your give a 24-hour notice of cancellation. If own time this is not done, there is a full or partial as a valuable fee required. Unfortunately, there is little commodity. Even we can do to actually enforce this policy. if the patient Hopefully, patients will comply and that does not show up, will help to stem future no-shows, but if you showed they don’t, there is not much recourse. up and reserved Again, point out your cancellation policy that time slot to the patient and discuss it at the first especially visit, even if they seem to have read the disclosure form thoroughly. for them. ■

Do not make a big issue out of it. That might alienate or offend the patient. But it doesn’t hurt to point it out in a gentle way. The real problem with cancellation policies is that many practitioners have a hard time adhering to them. Most people who gravitate towards the healing professions have little or no interest or aptitude regarding business management. Most of us would volunteer our services if we could and if we did not have to make a living ourselves. Some practitioners feel guilty enforcing the cancellation policy. They feel they are taking someone’s money but haven’t done anything to earn it. The truth is that time is money. You must learn to view your own time as a valuable commodity. Even if the patient does not show up, you showed up and reserved that time slot especially for them. It is very likely that you showed up early and did some

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prep work too, such as preparing the treatment room or researching that patient’s particular problem. You deserve to be compensated for your time and effort. Enforcing the policy is a way of letting patients know you are serious about what you do and that you expect them to respect you and the healing process. It is quite acceptable to waive the policy on the first occurrence, but to let the patient know in a gentle way that if it happens again, you will need to charge them for a missed visit. If a patient does not show up for an appointment, a telephone call is in order. There are several reasons for this. First of all, it lets the patient know you care about them. After all, an accident or other unforeseen event may have occurred. A telephone call will let the patient know you care and will also give them a chance to explain what happened. The call is also another way of letting the patient know you do take your appointments seriously and do follow up on them. If the patient has a legitimate reason for not showing up, express understanding and ask if they would like to reschedule. If it is not the first time the patient has not shown up, try to determine the reason for this. The patient themselves may not always understand their own actions, but it won’t hurt to ask, and it may give the person pause to consider what they are doing. Review the cancellation policy with them. If the patient continues to not show up, you may have to refer them to someone else or to a different modality and terminate your relationship with them. Although taking a stern stance can be difficult for someone who works from the heart, in the end it will boost your practice, increase patients’ respect for you, and raise your own self-esteem. Being compassionate does not mean you need to be a martyr. In addition, we all must be representatives of our profession. There are still many people who do not view Oriental medicine as a serious discipline but rather as a novelty or a side-kick to Western medicine. Whenever we take ourselves seriously, we help the public to do the same and so benefit not only ourselves, but our profession as a whole.

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Cases in point: Case 1. R. J. is a 65 year-old man who suffers from low back pain and intermittent sciatica.He was referred for acupuncture care by a friend of the practitioner’s.Although he experienced improvement in his condition as a result of his treatments, he often showed up about 20 minutes late for his appointments. At first,the practitioner said nothing since the man was apologetic and seemed to sincerely regret his lateness. However, he usually did not offer an excuse for the lateness and soon he began showing up even later for appointments and wreaking havoc with the clinic schedule. On one or two occasions, other patients were kept waiting in order for R. J. to receive his full treatment time. Finally, the acupuncturist informed him that his lateness was keeping other people waiting and that he would have to make an effort to show up on time. He expressed understanding, but the next time he came, he showed up a half hour late. The acupuncturist told him he would not be able to treat him in the remaining time and he would have to reschedule. The patient then became quite sad and upset that he could not get his treatment and stated that,“My pain flared up last night, and I really need some relief today.” The acupuncturist relented and gave him an abbreviated treatment, but was upset with the man’s behavior.

■ What went wrong? The acupuncturist’s main mistake here was not addressing the problem seriously from the start.As we have seen in previous situations, bad behavior that is allowed to continue will do just that. And the longer it goes on,the more difficult it is to correct.When the patient showed up a half hour late, the acupuncturist should have remained strong in telling the patient he would have to reschedule.Giving a shorter and less effective treatment,especially when the practitioner was feeling upset with the patient is

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not good practice and does not benefit either party. In addition, it merely reinforces to the patient that if he shows up late,he will be seen and does not give him much incentive to arrive on time. It is also not fair to other patients who do show up on time to be kept waiting or to be inconvenienced in any way. Case 2. E.S.is a 28 year-old man who has been coming to the acupuncturist for a few years on and off for various problems. He had recently taken a high-stress job position and called the acupuncturist to schedule some appointments to help him deal with his stress. He did not show up for the first appointment,and, when the practitioner called him, he was profusely apologetic and rescheduled for the next week. He did show up for that appointment but then missed the next two after that.Each time the practitioner called him to find out what happened, he again apologized profusely but had one or two more no-shows. The acupuncturist did not review her cancellation policies with him, and then felt awkward confronting him with the situation.

■ What went wrong? One of the main difficulties in the above scenario is that the patient had been coming for acupuncture for quite some time, and the acupuncturist felt kindly toward him. They had developed a good rapport over that period of time and she was afraid to “make waves” or to seem too harsh to the patient.When he repeatedly failed to show up on time,she was reluctant to mention the cancellation policy also and the behavior continued. This young man needed some guidance with time management.Although his attitude towards his treatments was sincere, he was allowing other obligations to eclipse his responsibility to himself and to the practitioner. The acupuncturist could have used this situation as a teaching opportunity to help the patient assess his new lifestyle and set

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his priorities. It is understandable that she was hesitant to enforce her cancellation policy with a loyal patient, but, when the behavior started to follow a pattern, she should have sat down with the patient to discuss the inappropriateness of his no-shows. She also could have offered to give him a reminder call the day before his appointments to help keep him on track.

■

THE I NSI DE ST ORY:

Chronic lateness can be seen as a person’s exerting their will or control over a situation when other aspects of their lives may seem to be careening out of control.

Time management is a big problem for a lot of people. Many people have so many things going on in their lives that they find it difficult to keep track of everything they need to do. It is easy to see how someone could be late or even forget to show up for an appointment. The pace of today’s society barely allows any breathing room. Realizing that people may be overwhelmed by their life’s activities can be a starting place to under■ standing a seeming lack of re g a rd for health care treatments. Practitioners can use their skills in teaching lifestyle changes and time management to patients as part of the treatment itself. For other people, time is a means to gain and exercise some control over circumstances in their lives. Chronic lateness can be seen as a person’s exerting their will or control over a situation when other aspects of their lives may seem to be careening out of control. People who do not show up for appointments may be exhibiting a similar desire for some control over their lives. If illness has forced them to curtail some activities or they are faced with caring for an ill family member, they may also feel that they have little freedom in their lives. In some cases, not showing up for appointments or being

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chronically late may also be a sign of mounting frustration. As always, a good practitioner must be aware of these hidden factors and be willing and able to assist the patient in understanding themselves as well as promoting respect for their health and for the practitioner. In other instances, it is the sad truth that patients may not be taking alternative health care appointments as seriously as other obligations they may have. They may regard Oriental medicine as something that is not really that important or even as a kind of frivolous luxury that they do not have a real need for. Our job as practitioners is to continually educate the public about the benefits as well as the seriousness of our profession. QUESTI ONS FOR CHA PT ER T EN: 1. Examine your own time management behavior. Do you tend to be punctual or are you consistently late? If you tend to be late, can you think of any reasons why this is so? 2. How does it make you feel when other people are late in meeting you, whether in a professional or personal relationship? 3. How can a patient who is chronically late or a chronic no-show disrupt a clinical practice? What are some reasons patients may exhibit this type of behavior? 4. Design a policy for your practice that addresses lateness and no-shows. What difficulties do you foresee in adhering to these policies? 5. Scenario for discussion: J. D. is a 52 year-old patient with lung cancer who started acupuncture treatments a few weeks ago to help with the side effects of her chemotherapy. While she generally arrived on time for her appointments, there were a

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few occasions on which she was over 15 minutes late. More upsetting than that, however, is that on a few occasions she did not show up for her appointment at all. Follow-up phone calls revealed that the patient had simply forgotten the appointment, and she always apologized and always rescheduled. How would you handle this situation?

Examine your own views, feelings, and relationship with money from the outset of your practice.

C H A P T E R EL E V E N

The Nonpaying Patient

As much as most of us would like to think that money is not our main objective in choosing a healing profession, we must admit that we, too, have to make a living. You have spent a large amount of time, energy, and money in serious pursuit of your training so that you can be the best practitioner you can be. During the course of your practice, you will have patients who are quite wealthy as well as patients who are barely making ends meet. In many cases, insurance may help to cover a patient’s costs, and, if you decide to accept insurance, part of your problem is solved. However, depending on where you live and what your views on insurance are, this may not be an option for your practice. It is important to remember that money lends value to things. That is just the way our society operates, and, whether we like it or not, we do have to operate within that paradigm at least part of the time, especially if we want to seriously pursue and maintain our business.

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Most people do not want a hand-out. In fact, many people feel uncomfortable if they think they are being treated like a “charity case.” Offering free treatments reduces the value of the treatment itself and may negatively, though unwittingly, affect a patient’s self-esteem. Of course, there is definitely an appropriate time and place to do pro bono work. This is one way members of the Oriental medical profession can make a positive and selfless contribution to our world. There is no shortage of need, and each practitioner must decide for him or herself how much time and service to donate and what causes to focus on. This chapter is not about pro bono work. It is about people who, for whatever reason, fail to pay for the service provided and how you as a practitioner can handle such cases. While the majority of your patients will be happy to pay for your services, there are those who may ask for some kind of leniency or who may not pay you at all. You will have to seriously review your own relationship with and feelings towards money in order to have a clear idea not only of what your fees will be, but when you may wish to do some pro bono work and when you may need to insist on payment. C L I N I C A L P R E S E N TAT I O N : ■

Hinting that they do not have enough money to pay for treatments

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Telling the practitioner stories of personal financial trouble, but not necessarily saying they cannot pay

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Asking to be billed rather than paying up front at time of appointment

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Not sending payment in after receiving a bill

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Remarking on how expensive treatments are

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C O N T R I B U T I N G FA C T O R S : Home again In my experience, money is a bigger issue than you might imagine when you first start out. When you are consumed with studies, making a living while going to school, getting used to a whole new way of thinking and living, and memorizing more material than you thought possible, the logistics of starting, building, and maintaining a practice may not be foremost on your mind. Many aspiring Oriental medical practitioners have a vague and foggy notion that, if they practice from the heart ■ with integrity and compassion, the money The bottom line is will follow. that your patients While this may be true in some cases, the are your source of income. They are majority of experienced practitioners will tell you that the money does not flow where the money effortlessly and that it requires continual comes from! When effort to keep a good cash flow. It is wise faced with a to seek out advice from someone who is patient who does experienced who can guide you regardnot pay or has ing practice-building and marketing stratetrouble paying, gies. The bottom line, however, is that your you must keep patients are your source of income. They in mind that are where the money comes from! When that is money out faced with a patient who does not pay or of your pocket. has trouble paying, you must keep in mind that that is money out of your pocket. ■ As stated above, many people entering this profession have some conflict with money. We are, for the most part, compassionate humans who sincerely want to help others, and the thought of doing this for profit may make us feel selfish or mercenary. Examine your own views, feelings, and relationship with money from the outset of your practice. If possible, try to identify areas

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where you feel uncomfortable with money. Do you feel guilty or ill at ease taking money from people for your service? Are you comfortable with your fees? Do you feel you deserve to make a good living? Sometimes views of what we perceive as our own inadequacies make us feel we do not deserve to be paid what we are worth. Beginning practitioners may be especially vulnerable to such feelings, viewing their lack of practical experience as a liability. While you may initially want to charge a little less than a seasoned practitioner, do not sell yourself short either. Your time, energy, and training are worth a lot. If you are experiencing difficulty in your own relationship with money, it might be a good idea to seek some counseling so you can attain a reasonable level of comfort. Conversely, if all you see are dollar signs, then you might need to seriously consider your priorities and the reason you chose this profession in the first place. Setting your fees is, of course, an essential step in starting a practice. The best way to do this is to see what other practitioners are charging. By the time you graduate, you will have a fairly good idea of typical fees for Oriental medicine in your area. You may want to start at the low end of this scale but do not undersell yourself. Our society values money and charging too little may give people the idea that your services are not quite up to par, that you are struggling and desperate, or that you lack confidence. Charging too much at the outset can also be detrimental. You need to be honest with people about your actual level of experience. Many people will find it hard to pay a novice the same fees as a senior practitioner, but they also do not expect to pay peanuts for legitimate service. Once you determine what your fees will be, assess your comfort level with them. If you feel your fees are reasonable but, for some reason, you do not feel comfortable with telling people what they are, consult with other practitioners for advice. You can also

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practice with an imaginary patient in front of your mirror. Try saying your fees out loud to this imaginary patient or practice with a friend until the uneasiness wears off. When you do tell people your fees, use a confident voice. Wavering will only make you look unsure of yourself. Part of setting your fees is deciding whether or not to treat at a discount, to use a sliding scale payment system, or to treat some patients for free. If you decide to set discount fees or to use a sliding scale, decide ahead of time exactly what type of patient would qualify for this benefit. Also look at your own overall costs and what you need in order to make a decent living for yourself and to cover your monthly expenses. If you are not skilled at accounting or bookkeeping, it is a good idea to seek the help of someone who does this for a living. Free treatments really should be reserved for extreme cases, promotional events, or demonstrations. Bartering is often a good alternative to actual monetary exchange if a patient really does not have the cash to pay. Bartering should be an equal exchange. So be sure that what you are bartering for has the same value as your treatments. It is a fact that, if someone receives something for nothing, the value of what they receive lessens. Patients will take you and themselves more seriously if they pay in some way for what they are getting. Case in point: V. B. recently graduated from Oriental medical school and has started her own practice. She set her fees at $70.00 for initial visits and $60.00 for follow-ups, which is in keeping with the standards of her community. She gets a call from someone inquiring about her services. She explains her practice and what she can do for this person. Then the potential patient asks about the cost of a treatment. She tells the person what her fees are. There is some hesitation on the other end of the line, and the acupuncturist

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quickly states, “I can offer a discount if that’s a problem.” The person on the other end then asks what the discount is. The new practitioner stutters a little, then says, “I can offer you the first treatment at $60.00 and the follow-up visits for $50.00.” The new patient takes her up on this offer. However, when she hangs up, the practitioner feels frustrated, confused, and unhappy.

■ What went wrong? V. B.,as a new practitioner, had not yet reached a comfort level with her own fees. Even though she initially stated her actual fees, the caller’s hesitation threw her off. She should have allowed the caller to indicate whether or not she could pay those fees. She assumed that the caller’s hesitation meant that the caller was troubled by the stated fees when it might just as well have had nothing to do with the call itself or might have simply been the caller reviewing her own finances to see if she could afford the treatment.Instead, the practitioner’s insecurity led her to a hasty decision to offer a discount she did not feel comfortable with. A little practice with a friend or in front of a mirror might have helped her feel more at ease with what she was charging which was, in fact, competitive and quite reasonable to begin with.

The cupboard is bare One of the most difficult situations you will face regarding payment of fees is the patient who sincerely wants and needs your help but honestly cannot afford it. People’s finances can be poor for any number of reasons. Some people work at low-paying jobs and do not have the means or desire to do anything that would get them better employment. There are too many families out in the world who are struggling. The cost of raising a family can be astronomical. Add to that unexpected medical bills or legal fees and the situation can quickly become a crisis. When the economy is down, layoffs are rampant, and many people who had good incomes find themselves looking at financial hardship.

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In short, most people do not suffer lack of finances because of sheer laziness. There is often some sort of misfortune or socioeconomic disability behind the money situation. The difficulty facing the practitioner is how to accommodate these patients while fostering respect and value for your services. Some practitioners decide to maintain a fairly stalwart attitude towards their fees and insist on payment; if a person is unable to pay, the person will not receive the care. However, I feel that these practitioners are in the minority. Most practitioners are more than willing to find some way to get these patients good care. These are the situations in which you might want to consider your sliding scale or discount rates. Always measure the patient’s perceived need and sincerity when calculating these matters. Most practitioners would not want to turn these types of patients down. Remembering that “something for nothing” usually is not a good policy, you can offer some sort of trade or barter if that is an option. You can also offer the sliding scale or discount rate dependent on the patient’s actual income. Even a fee of $10.00 will be significant to a patient who is scraping the bottom of their barrel. The upside of this is that these patients will often find a way to pay the full fee if given enough time or may reimburse you at a later date when their situation improves. Even if you find yourself balking at the lower fee, keep in mind that this patient may be so appreciative of your generosity that he/she will become a good referral source for you! Case in point: C.V. is a 62 year-old woman with chronic fatigue syndrome (CFS). She does not know much about acupuncture, but is desperate to find some help for her condition.She is on Medicaid and has a very limited budget for out-of-pocket expenses, and is dismayed to find that she will need a series of at least weekly treatments for at least 10 treatments. The acupuncturist quotes her his fee of $75.00 for the first visit and $65.00 for the follow-up visits.

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The patient explains her financial situation and the “vicious cycle” she is in. Even though she is on Medicaid, she is working parttime. She would like to work full-time, but the CFS prevents her from doing so. This acupuncturist does not adhere to any kind of discount policy and regretfully tells the patient he cannot treat her unless she can pay the full fee.The patient expresses understanding but leaves the office feeling frustrated and disappointed.

■ What went wrong? In this case, the acupuncturist felt a necessity to not offer any reduced rates, which is certainly his prerogative. However, in being so rigid, he denied care to a truly needy individual who was willing to pay what she could. A better choice in this situation would have been for the practitioner to work with the patient within her means. Of course, he had every right to abide by his own policies, but he could have also checked around for her and helped her find another practitioner who would off e r reduced fees. This would have left the patient feeling cared for and would have sent her away with some options instead of a heart full of discouragement. What he did not know was that this woman did find an acupuncturist who was willing to work with her financially, and she was able to refer three new patients to that acupuncturi st .

The check is in the mail Unless a particular patient is under an insurance plan, most of your fees will or should be expected at the time of service. Most practitioners would feel very uncomfortable asking for the fee up-front before the treatment is given. It is much more common and acceptable to collect your fee after the treatment is done. In most cases, your patients will pay by check or cash. You may have the means to collect fees from credit cards, too, which is a convenience for your patients and can help eliminate the “forgotten checkbook” syndrome (unless they’ve forgotten their credit card, too).

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Generally, patients are happy to pay for the service they have received. However, once in a while, a patient may be caught off-guard with no means to pay. In the majority of cases, this oversight is real and no malingering is intended. Not everyone carries their checkbooks around all the time, and some people only like to carry a limited amount of cash. It is entirely possible and not uncommon for someone to forget their checkbook or even the wallet they carry their credit cards in. In other cases, however, it might be that the person really is trying to get away without paying. At other times, simple forgetfulness might again be the culprit. You will have to assess each situation individually and decide how to handle it. If it is a known and trusted patient, you can tell them they can pay you at the next visit or can send the payment in the mail. If it is a relatively new patient ■ or someone you don’t have complete The important trust in, make sure you have their corthing here is not rect address and tell them you will send to let a missed them a bill. It is a good idea to get that payment slide. bill in the mail to them as soon as posIt is what is due sible. If 3-4 weeks pass and you still do you for your not receive payment, send a second bill honest work or make a “friendly reminder” telephone and effort and call requesting payment as soon as possible. There are a few practitioners who patients need do enlist the services of a collection to be held agency if the patient persists in not payaccountable for ing, but many other practitioners find their part in that this problem is so small it does not the therapeutic warrant this avenue. Depending on relationship. where you practice, your patient, and ■ how large a practice you are managing, you will have to make that decision for yourself. If you do not choose to use a collection agency, there is really no means to force the patient to pay. You may end up forfeiting that fee, but, if the

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same patient calls again for an appointment, remind them of their outstanding balance and let them know you cannot treat them again until the balance is settled. The important thing here is not to let a missed payment slide. It is what is due you for your honest work and effort and patients need to be held accountable for their part in the therapeutic relationship. Case in point: D. M. is a 45 year-old woman who has been coming for acupuncture treatments for migraine headaches. She has a developmentally disabled son at home and has been coming to the same practitioner for several months. She looks forward to her treatments, but, for the last four treatments, she tells the acupuncturist she has forgotten her checkbook.The acupuncturist has a lot of compassion for this patient because of her home and social situation and decides to allow a balance to add up each week, trusting that the next week, the patient will pay in full. However, each week progresses without full payment and before long, the balance is up to $300.00 and the patient states that she cannot pay it all at once. The acupuncturist reluctantly tells the patient she cannot treat her until the balance is paid.

■ What went wrong? This is another case in which some preventive action could have stemmed a situation from getting out of hand.While the practitioner was within reason to let the patient “off the hook” initially, after two or three missed payments, the fee needed to be frankly discussed with the patient. Although this patient was dealing with a difficult home situation as well as migraine headaches, many other people are also suffering hard times. If the practitioner allows all of these patients the same leeway, she will find herself very short of cash. Addressing the situation earlier would have allowed the patient to make more reasonable payments and

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would have also solidified the practitioner’s stance on payment options. The patient’s unintentionally neglectful behavior would not have had a chance to get out of hand, and both the practitioner and patient would have felt more at ease.

THE INSIDE STORY: It is true that, “Money makes the world go round,” no matter how much we would like to deny this fact. Money means different things to different people. Some people have feelings of guilt or resentment around money, while others simply do not have enough. Some people who have more than enough money may horde it and not share it with others, while some of the poorest folks can often be the most generous, sharing the last of what they have to help others. You as a practitioner must find out what your own feelings around money are and find a way to feel comfortable with accepting money as tender for your services. Your patients also have their own views on money. For some, money may represent control or a degree of comfort and security. They may be reluctant to part with something that gives them this sense of satisfaction. When money or lack thereof is an issue, you must be able to determine patients’ sincerity and future ability to pay and set realistic expectations both for yourself and for them. It is not your responsibility to teach anyone financial maturity, but you do need to feel confident enough in yourself to be able to collect the payment you deserve. QUE STI ONS FOR C HA PT ER EL EVEN : 1. Think about your own relationship with money. What are some of your feelings about money that may affect your practice? 2 . What are your views on the system of bartering? A re there any limits you would set on this practice in your clinic?

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3. What are some of the underlying factors that might make a patient miss one or more payments? 4. What are your views on pro bono work and how can you incorporate that into your practice and still make a living for yourself? 5. Scenario for discussion: L. M. is a student in his mid-20s who cannot come for acupuncture treatments but is willing to take bulk herbs on a consistent basis for his IBS. After a few months of taking the herbs, his symptoms are starting to resolve very nicely, but he has missed two payments so far and, on the last visit, states he lost his job and does not know when he will be able to pay you again. He suggests some bartering arrangement, but he is a little unclear as to what he may actually be able to exchange for the herbal therapy. How would you handle this situation?

CONCLUSION Being part of a healing profession is not only a career goal, it is a privilege, and one that all of us should take with the utmost respect and due care. Illness, pain, and suffering induce people to behavior that can be troubling for a practitioner. It is part of the art of our medicine to see the patient as a holistic being, including any type of behavior that is manifested. Problem behavior can in itself help diagnose what is wrong and can point the way to areas of need. It is the practitioner’s responsibility to see beyond the surface of the behavior and to recognize the causes of the problem behavior, and then to take measures to assist the patient to grow beyond this stage. Although dealing with such patients may not be the highlight of your day, it is still imperative to treat them with the same respect and consideration as anyone else. Remember that, beneath the puzzling and sometimes annoying behavior, there is a hurting human being, exactly the kind of person you went into practice to help.

Being a health care practitioner is an awesome responsibility. The work is rewarding and, most of the time, enjoyable, but you must never forget that you have an ethical, moral, and legal obligation to render the best care possible to each and every client.

C H A P T E R T W E LV E

Terminating the Therapeutic Relationship

One of the most difficult crossroads a practitioner can come to is the realization that a therapeutic relationship is no longer therapeutic and should be terminated. There are many reasons why this situation may manifest and, unfortunately, no easy solutions. In most cases your relationship with a client will have a natural beginning, middle, and end point. When the patient’s condition improves to the satisfaction of both parties, the patient generally does not schedule future appointments or schedules maintenance appointments appropriate to his/her condition. In some cases, however, the patient demonstrates a need or desire to continue to come for treatments, even when it is apparent to the practitioner that the patient is either not receiving benefits from the treatment or is hanging on for some kind of dysfunctional reason. I have touched briefly on this subject in some of the individual preceding chapters, but would like to explore this 183

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issue in a little more depth. It is a topic that most practitioners would prefer to avoid because it is unpleasant and we would rather not deal with it unless it actually occurs. However, it is always best to be prepared for an eventuality rather than to find oneself at a loss for action in the midst of a difficult situation. ■

Being a health care practitioner is an awesome responsibility; the work is rewarding and, most of the time, enjoyable, but you must never forget that you have an ethical, moral, and legal obligation to render the best care possible to each and every client. The majority of these clients will be delightful to work with, and those who are difficult may prove to be amenable to various strategies, some of which have been discussed in this book. It is not a given that you will like all of your patients. It is, in fact, a given that there will be patients you do not like. Simply not liking a patient, however, is not reason ■ enough to terminate your relationship with them. Your responsibility is to help them heal, not to like them. As Oriental medicine gains greater acceptance, expectations of Oriental medicine practitioners will increase. We must hold ourselves to the highest standards of patient care.

As Oriental medicine gains greater acceptance, expectations of Oriental medicine practitioners will increase. We must hold ourselves to the highest standards of patient care.

REASO NS NO T TO EN D T H E T H E R A P E U T I C R E L AT I O N S H I P 1.“I can’t stand this person!” It would be wonderful if we could truly embrace every person on their own terms and accept them completely. But just as we want to acknowledge the humanity of our clients, it is important to realize that we, too, are human! Personality differences abound everywhere, and the clinical setting is no exception. You may encounter clients whose basic personality grates on your nerves.

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Perhaps you don’t like the sound of their voice, their mannerisms or the way they dress. Nonetheless, you owe them as much time, effort, and consideration as any other client. This is a time when a practitioner may need to practice a healthy form of detachment; in other words, to provide the necessary service but not to become emotionally entangled in your feelings for the person. It might be helpful to call on a colleague to vent some of your feelings or to ask for helpful coping strategies. It is always possible to refer the client to another practitioner, but if he/she prefers to stay with you, is compliant, pays and shows up on time, you do not have much legal leg to stand on if you want to end your professional relationship with them. 2. “I can’t figure out what to do!” It is common for Western-trained practitioners of Oriental medicine to have little or no clinical experience in dealing with difficult diseases before graduating and going into independent practice. Unfortunately, our Western society is a fertile ground for complex diseases manifesting several patterns of disharmony all at the same time. Signs and symptoms seem to pile up and contradict each other. Pulse and tongue diagnosis do not match, symptoms do not fit easily into patterns of differentiation, and the practitioner feels like he/she is floundering. It is tempting to throw one’s hands up and say, “I just don’t want to deal with this anymore!” It is encounters such as these, though, that provide some of the best learning experiences. If you are baffled by a client’s presentation, it is time to do research, to hit the books, to confer with others in your field, and to decipher the meaning beneath the complexity. With persistence and honest intent, this task is possible, if not always easy. By plowing through the unknown, you will shed light on areas you need to strengthen. If you really get stuck in this type of situation and have truly tried everything you feel is at your disposal, then a referral to someone more experienced may be in order. Most patients will appreciate your honesty in this matter (and so will

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the other practitioner!). If it is a case of treating a condition you do not feel drawn to or interested in, the simple answer is: do not take the case in the first place! At the beginning of your practice, you will be eager to accept any client ■ that is willing to come to your office and Remember, be treated, but it is important to learn disthough, that cretion and to discern the kinds of cases each situation is you really do want to attract. unique and R EASO NS TO EN D THE each individual’s characteristics and T H E R A P E U T I C R E L AT I O N S H I P There are several valid cases in which a personal situation practitioner may ethically, legally, and must be taken morally end a relationship with a patient. into account. It is important to remember that this can No matter how never be done lightly. In most cases, a sinnegative or gle incident is not enough to warrant terunpleasant a mination. Usually, the practitioner must particular client demonstrate that there has been a consismay be, tent pattern of unacceptable behavior that it is in everyone’s has not been amenable to suggestions best interest for and/or attempted solutions. the practitioner Following are some of the most common to remain reasons a therapeutic relationship may be professional, justifiably terminated: caring and as pleasant as Noncompliance: A patient who delibpossible during erately and repeatedly fails or refuses to comply with practitioner advice and the termination i n s t ruction places him or herself in a process. potentially dangerous situation. A prac■ titioner cannot reasonably be expected to assist a person who will not comply with medical advice. If a patient is showing a pattern of noncompliant behavior and the practitioner begins to feel that the relationship should be

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terminated, the practitioner should start documenting the specific details of the client’s noncompliance as well as all measures the practitioner has taken to address the problem. The situation should be reviewed with the patient at intervals during the course of the treatment. If the problem continues, the practitioner may well have reason to end the relationship. Anger/Abuse: As discussed in the chapter on the angry patient, anger usually masks a variety of unexpressed emotions. With a little compassion and a lot of patience, a compassionate practitioner can often assist a client to work through feelings of anger, uncover the source of the anger, and facilitate emotional as well as physical healing. However, there are those people whose anger is so deep rooted that it may not be possible for the practitioner to assist them. In fact, they may require the help of a mental health expert. This type of anger may involve abusive language or behavior towards the practitioner, staff, and even other clients.

This type of behavior is not acceptable and if the strategies in Chapter Four prove to be unsuccessful, the practitioner may have sufficient grounds to terminate the relationship. In this case, it is of the utmost importance to explain fully to the client the reasons he/she cannot continue to be seen in your clinic. You yourself may want to consult with someone in the mental health profession to assist you with finding the best possible way to deal with a dysfunctionally angry client. It is a good idea to have someone else present when you talk to this patient to help diffuse tension if the situation looks like it might escalate or if the client has difficulty accepting what you are conveying. Seduction: Sexual advances, physical attraction, or outright

harassment are not appropriate at any time in the health care setting. If the attraction is mutual, the practitioner and client must agree to end their clinical relationship in favor of the personal one, and the client can then seek health care elsewhere. If it is a one-sided attraction initiated by the patient or experienced

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by the practitioner, the clinical benefits of the relationship are in danger and the relationship cannot continue. This can be a touchy (no pun intended!) subject to broach with a client but temporary embarrassment or discomfort is better than an unhealthy clinical partnership. Your disclosure form should include your policy about sexual relationships in the clinic, and you can refer to this as a starting point if you find yourself in this situation. Nonpayment: You are providing a fee for service. This should be clear and apparent at the outset of every client encounter. Fee schedules must be included in your disclosure form, and it is a good idea to discuss fees with each client in person to avoid misunderstanding. Most practitioners expect full payment at the time of service. If there is third party reimbursement, then payment will be made according to the insurance policy. If a client refuses payment even after a series of bills, reminders, etc. have been sent, the practitioner is not obligated to continue treatments until the bill is paid in full.

There may be other cases in which a practitioner decides it is in the best interests of all concerned to discharge a patient from care. The above list includes the most common cases. Unfortunately, there is no easy formula to guide a practitioner in ending a professional relationship with a client. The individual chapters in this book provide some strategies specific to each type of patient behavior. Remember, though, that each situation is unique and each individual’s characteristics and personal situation must be taken into account. No matter how negative or unpleasant a particular client may be, it is in everyone’s best interest for the practitioner to remain professional, caring, and as pleasant as possible during the termination process. It is wise to check with your state’s regulatory agency regarding policies about ending a patient/practitioner relationship. In some cases, the practitioner may be charged with patient abandonment

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if there is not sufficient evidence to warrant termination of a patient. If your state’s regulatory agency does not have a clear policy, it is best to adhere to the standards to which Western medical practitioners are generally held. This usually includes the following: 1. Documenting a consistent pattern of unacceptable, difficult, or problem behavior and all measures the practitioner and staff have taken to resolve the problem. 2. A 30-day written notice sent to the patient’s home outlining the problem and the reason the professional relationship is to be terminated. It should be made clear in this notice that you will continue to assume care of the patient during this 30-day period while he/she seeks out another source of health care. You should also offer to assist the client to this end in any way feasible. 3. Alist of other practitioners to whom the patient can be referred. This list can also include any appropriate community resources you feel might benefit the client. 4. Offering to forward the client’s medical records (with proper release, of course!) to the client’s new practitioner. Hopefully, with your instinctive compassion, personal resources, and the suggestions in this book, you will never find yourself in the position of having to terminate a patient relationship. If you do, keep in mind all the legal, ethical, and moral ramifications and take every necessary precaution to protect yourself and your client. CONCLUSION Like everything else in life, your career as a practitioner of Oriental medicine is a journey. This journey will take you to many thrilling and rewarding places, and will also present you with constant challenges along the way. I hope this book will be one of the tools you use along this journey. Most of the patients you will see over

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the course of your career will be delightful, cooperative, appreciative, and responsive. There will, of course, be those who frustrate and confound the practitioner. Instead of regarding these “difficult” patients as pesky problems to be avoided and dodged at every turn, we should accept them with open arms and greet the challenge they present. Indeed, you ■ will probably discover at some point that The most these difficult patients have something to important thing teach you. In any case, you need to treat to remember them with increased compassion and realis that beneath ize that the problem behaviors they prethe annoying sent have deeper meanings. Above all, practitioners should never take these chalbehavior, the lenges as personal affronts. In a world as confusing hectic and abrasive as ours, everyone messages, and needs understanding, and some people the frustrating need more than others! presentations, the difficult patient is Some of the problem behaviors studied a hurting human in this book include noncompliance, being—exactly anger, dependency, and seduction as well the kind of patient as practical issues such as timeliness and finances. In all cases, the practitioner you went into should always look first to him or herself practice to help! to see if he/she is in any way contribut■ ing to problem situations. In order to help others heal, we must be willing and able to look at ourselves and to find healing for what ails us, as well. In addition, a practitioner must realize the importance of not being a martyr and of taking care of our own well-being. Appropriate rest, diet, and recreation are essential for the practitioner as well as for the patients he/she counsels. Taking care of yourself will make you better able to care for others. In most cases, with a little understanding and some extra care, a difficult patient can be successfully treated and can even become a treasure for you.

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Your patience and attention will be rewarded when you see this client healing, making positive lifestyle changes, and progressing towards fulfillment of their own personal goals. There may, however, be those clients whom you cannot assist fully, who continue to abuse your care no matter how patient and understanding you are, who refuse to pay, do not respect clinic hours, etc. These are probably the most difficult situations since they often involve the painful decision on the part of the practitioner to end the therapeutic relationship. If you find yourself in such a situation, be sure you follow all the legal routes outlined by your state so you avoid liability. No matter how difficult the client may be, you are still responsible for providing care until an alternate solution can be reached. Difficult patients are part of the territory of being in the public arena and assuming the responsibility of being a health care provider. There are numerous ways to assist even the most challenging patient. The most important thing to remember is that beneath the annoying behavior, the confusing messages, and the frustrating presentations, the difficult patient is a hurting human being—exactly the kind of patient you went into practice to help!

■ Bibliography ■

Beinfield, Harriet, L.Ac. and Korngold, Efrem, L.Ac. OMD, 1991, Between Heaven and Earth, NY, Ballantine Books Davies, Peter, editor, 2003, American Heritage Dictionary, NY, Dell Publishing Co. Desmond, Joanne and Copeland, Lanny R., MD, 2000, Communicating with Today’s Patient, San Francisco, Jossey-Bass Hooberman, Robert E., Ph.D, and Hooberman, Barbara M., MD, 1998, Managing the Difficult Patient, Madison CT, Psychosocial Press Kaptchuk, Ted J., OMD, 1983, The Web that Has No Weaver, NY, Congdon and Weed, Inc. Platt, Frederic W. and Gordon, Geoffrey H., 1999, Field Guide to the Difficult Patient Interview, Philadelphia, Lippincott, Williams, and Wilkins Sohr, Eric, MD, 1996, The Difficult Patient, Miami, Medmaster

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OTHER BOOKS ON CHINESE MEDICINE AVAILABLE FROM:

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CHINESE MEDICAL PSYCHIATRY A Textbook and Clinical Manual by Bob Flaws and James Lake, MD ISBN 1-845891-17-9 CHINESE MEDICINAL TEAS: Simple, Proven, Folk Formulas for Common Diseases & Promoting Health by Zong Xiao-fan & Gary Liscum ISBN 0-936185-76-7 CHINESE MEDICINAL WINES & ELIXIRS by Bob Flaws ISBN 0-936185-58-9 CHINESE PEDIATRIC MASSAGE THERAPY: A Parent’s & Practitioner’s Guide to the Prevention & Treatment of Childhood Illness by Fan Ya-li ISBN 0-936185-54-6 CHINESE SELF-MASSAGE THERAPY: The Easy Way to Health by Fan Ya-li ISBN 0-936185-74-0 THE CLASSIC OF DIFFICULTIES: A Translation of the Nan Jing translation by Bob Flaws ISBN 1-891845-07-1 CLINICAL NEPHROLOGY IN CHINESE MEDICINE by Wei Li & David Frierman, with Ben Luna & Bob Flaws ISBN 1-891845-23-3 CONTROLLING DIABETES NATURALLY WITH CHINESE MEDICINE by Lynn Kuchinski ISBN 0-936185-06-3

CHINESE MEDICAL OBSTETRICS by Bob Flaws ISBN 1-891845-30-6

CURING ARTHRITIS NATURALLY WITH CHINESE MEDICINE by Douglas Frank & Bob Flaws ISBN 0-936185-87-2

CHINESE MEDICAL PALMISTRY: Your Health in Your Hand by Zong Xiao-fan & Gary Liscum ISBN 0-936185-64-3

CURING DEPRESSION NATURALLY WITH CHINESE MEDICINE by Rosa Schnyer & Bob Flaws ISBN 0-936185-94-5

CURING FIBROMYALGIA NATURALLY WITH CHINESE MEDICINE by Bob Flaws ISBN 1-891845-09-8

FIRE IN THE VALLEY: TCM Diagnosis & Treatment of Vaginal Diseases by Bob Flaws ISBN 0-936185-25-2

CURING HAY FEVER NATURALLY WITH CHINESE MEDICINE by Bob Flaws ISBN 0-936185-91-0

FU QING-ZHU’S GYNECOLOGY trans. by Yang Shou-zhong and Liu Da-wei ISBN 0-936185-35-X

CURING HEADACHES NATURALLY WITH CHINESE MEDICINE by Bob Flaws ISBN 0-936185-95-3 CURING IBS NATURALLY WITH CHINESE MEDICINE by Jane Bean Oberski ISBN 1-891845-11-X CURING INSOMNIA NATURALLY WITH CHINESE MEDICINE by Bob Flaws ISBN 0-936185-86-4 CURING PMS NATURALLY WITH CHINESE MEDICINE by Bob Flaws ISBN 0-936185-85-6 THE DIVINE FARMER’S MATERIA MEDICA A Translation of the Shen Nong Ben Cao translation by Yang Shouz-zhong ISBN 0-936185-96-1 DUI YAO: THE ART OF COMBINING CHINESE HERBAL MEDICINALS by Philippe Sionneau ISBN 0-936185-81-3 ENDOMETRIOSIS, INFERTILITY AND TRADITIONAL CHINESE MEDICINE: A Laywoman’s Guide by Bob Flaws ISBN 0-936185-14-7 THE ESSENCE OF LIU FENG-WU’S GYNECOLOGY by Liu Feng-wu, translated by Yang Shou-zhong ISBN 0-936185-88-0 EXTRA TREATISES BASED ON INVESTIGATION & INQUIRY: A Translation of Zhu Dan-xi’s Ge Zhi Yu Lun translation by Yang Shou-zhong ISBN 0-936185-53-8

FULFILLING THE ESSENCE: A Handbook of Traditional & Contemporary Treatments for Female Infertility by Bob Flaws ISBN 0-936185-48-1 GOLDEN NEEDLE WANG LE-TING: A 20th Century Master’s Approach to Acupuncture by Yu Hui-chan and Han Fu-ru, trans. by Shuai Xue-zhong ISBN 0-936185-789-3 A GUIDE TO GYNECOLOGY by Ye Heng-yin, trans. by Bob Flaws and Shuai Xue-zhong ISBN 1-891845-19-5 A HANDBOOK OF TCM PATTERNS & TREATMENTS by Bob Flaws & Daniel Finney ISBN 0-936185-70-8 A HANDBOOK OF TRADITIONAL CHINESE DERMATOLOGY by Liang Jian-hui, trans. by Zhang Ting-liang & Bob Flaws ISBN 0-936185-07-4 A HANDBOOK OF TRADITIONAL CHINESE GYNECOLOGY by Zhejiang College of TCM, trans. by Zhang Ting-liang & Bob Flaws ISBN 0-936185-06-6 (4th edit.) A HANDBOOK OF CHINESE HEMATOLOGY by Simon Becker ISBN 1-891845-16-0 A HANDBOOK OF MENSTRUAL DISEASES IN CHINESE MEDICINE by Bob Flaws ISBN 0-936185-82-1 A HANDBOOK of TCM PEDIATRICS by Bob Flaws ISBN 0-936185-72-4

THE HEART & ESSENCE OF DAN-XI’S METHODS OF TREATMENT by Xu Dan-xi, trans. by Yang Shou-zhong ISBN 0-926185-49-X

THE PULSE CLASSIC: A Translation of the Mai Jing by Wang Shu-he, trans. by Yang Shou-zhong ISBN 0-936185-75-9

HERB TOXICITIES & DRUG INTERACTIONS: A Formula Approach by Fred Jennes with Bob Flaws ISBN 1-891845-26-8

SHAOLIN SECRET FORMULAS for Treatment of External Injuries by De Chan, trans. by Zhang Ting-liang & Bob Flaws ISBN 0-936185-08-2

IMPERIAL SECRETS OF HEALTH & LONGEVITY by Bob Flaws ISBN 0-936185-51-1 INSIGHTS OF A SENIOR ACUPUNCTURIST by Miriam Lee ISBN 0-936185-33-3 INTRODUCTION TO THE USE OF PROCESSED CHINESE MEDICINALS by Philippe Sionneau ISBN 0-936185-62-7

STATEMENTS OF FACT IN TRADITIONAL CHINESE MEDICINE by Bob Flaws ISBN 0-936185-52-X STICKING TO THE POINT 1: A Rational Methodology for the Step by Step Formulation & Administration of an Acupuncture Treatment by Bob Flaws ISBN 0-936185-17-1

KEEPING YOUR CHILD HEALTHY WITH CHINESE MEDICINE by Bob Flaws ISBN 0-936185-71-6

STICKING TO THE POINT 2: A Study of Acupuncture & Moxibustion Formulas and Strategies by Bob Flaws ISBN 0-936185-97-X

THE LAKESIDE MASTER’S STUDY OF THE PULSE by Li Shi-zhen, trans. by Bob Flaws ISBN 1-891845-01-2

A STUDY OF DAOIST ACUPUNCTURE & MOXIBUSTION by Liu Zheng-cai ISBN 1-891845-08-X

MASTER HUA’S CLASSIC OF THE CENTRAL VISCERA by Hua Tuo, trans. by Yang Shou-zhong ISBN 0-936185-43-0

THE SUCCESSFUL CHINESE HERBALIST by Bob Flaws and Honora Lee Wolfe ISBN 1-891845-29-2

MASTER TONG’S ACUPUNCTURE by Miriam Lee ISBN 0-926185-37-6 THE MEDICAL I CHING: Oracle of the Healer Within by Miki Shima ISBN 0-936185-38-4 MANAGING MENOPAUSE NATURALLY with Chinese Medicine by Honora Lee Wolfe ISBN 0-936185-98-8 POINTS FOR PROFIT: The Essential Guide to Practice Success for Acupuncturists by Honora Wolfe, Eric Strand & Marilyn Allen ISBN 1-891845-25-X

THE SYSTEMATIC CLASSIC OF ACUPUNCTURE & MOXIBUSTION A translation of the Jia Yi Jing by Huang-fu Mi, trans. by Yang Shou-zhong & Charles Chace ISBN 0-936185-29-5 THE TAO OF HEALTHY EATING ACCORDING TO CHINESE MEDICINE by Bob Flaws ISBN 0-936185-92-9 TEACH YOURSELF TO READ MODERN MEDICAL CHINESE by Bob Flaws ISBN 0-936185-99-6

THE TREATMENT OF CARDIOVASCULAR DISEASES WITH CHINESE MEDICINE by Simon Becker, Bob Flaws & Robert Casañas, MD ISBN 978-1-891845-27-6 THE TREATMENT OF DIABETES MELLITUS WITH CHINESE MEDICINE by Bob Flaws, Lynn Kuchinski & Robert Casañas, M.D. ISBN 1-891845-21-7 THE TREATMENT OF DISEASE IN TCM, Vol. 1: Diseases of the Head & Face, Including Mental & Emotional Disorders by Philippe Sionneau & Lü Gang ISBN 0-936185-69-4 THE TREATMENT OF DISEASE IN TCM, Vol. II: Diseases of the Eyes, Ears, Nose, & Throat by Sionneau & Lü ISBN 0-936185-69-4 THE TREATMENT OF DISEASE, Vol. III: Diseases of the Mouth, Lips, Tongue, Teeth & Gums by Sionneau & Lü ISBN 0-936185-79-1 THE TREATMENT OF DISEASE, Vol IV: Diseases of the Neck, Shoulders, Back, & Limbs by Philippe Sionneau & Lü Gang ISBN 0-936185-89-9 THE TREATMENT OF DISEASE, Vol V: Diseases of the Chest & Abdomen by Philippe Sionneau & Lü Gang ISBN 1-891845-02-0 THE TREATMENT OF DISEASE, Vol VI: Diseases of the Urogential System & Proctology by Philippe Sionneau & Lü Gang ISBN 1-891845-05-5 THE TREATMENT OF DISEASE, Vol VII: General Symptoms by Philippe Sionneau & Lü Gang ISBN 1-891845-14-4

THE TREATMENT OF EXTERNAL DISEASES WITH ACUPUNCTURE & MOXIBUSTION by Yan Cui-lan and Zhu Yun-long, trans. by Yang Shou-zhong ISBN 0-936185-80-5 THE TREATMENT OF MODERN WESTERN MEDICAL DISEASES WITH CHINESE MEDICINE by Bob Flaws & Philippe Sionneau ISBN 1-891845-20-9 THE TREATMENT OF DIABETES MELLITUS WITH CHINESE MEDICINE by Bob Flaws, Lynn Kuchinski & Robert Casañas, MD ISBN 1-891845-21-7 UNDERSTANDING THEDIFFICULT PATIENT: A Guide for Practitioners of Oriental Medicine by Nancy Bilello RN, L. Ac. ISBN 1-891845-32-2 70 ESSENTIAL CHINESE HERBAL FORMULAS by Bob Flaws ISBN 0-936185-59-7 160 ESSENTIAL CHINESE HERBAL PATENT MEDICINES by Bob Flaws ISBN 1-891945-12-8 630 QUESTIONS & ANSWERS ABOUT CHINESE HERBAL MEDICINE: A Workbook & Study Guide by Bob Flaws ISBN 1-891845-04-7 230 ESSENTIAL CHINESE MEDICINALS by Bob Flaws ISBN 1-891845-03-9 750 QUESTIONS & ANSWERS ABOUT ACUPUNCTURE Exam Preparation & Study Guide by Fred Jennes ISBN 1-891845-22