Have you ever felt like a “difficult patient?” It might not be all in your head if you think a doctor is getting impatient or annoyed with you.
Often times we come across patients that we term as “difficult”, just as many patients can recall doctors whom they would say are difficult to work with as well. This kind of patients can evoke feelings of anxiety, dread, frustration, and even anger and seem to breakdown the doctor-patient relationship leaving the doctor feeling like the patient cannot be helped, does not want to be helped, or is sabotaging his/her care. “Difficult patients” can be seen as a problem to be tolerated or terminated from practice, though the real difficulty lies in the relationship, not simply the patient and there are techniques and strategies to help clinicians improve that relationship and retain its therapeutic nature.
Who are ‘difficult’ patients?
Angry – smileless faces, furrowed brows, clenched fists, and wringing of the hands are some of the signs that can show that something is wrong with the patient. When we see these signs, we try to uncover the source of anger for the patient and pay attention to the way his or her emotions relate to the medical issues at hand. For example, a patient who is in pain and has been waiting for an hour because the doctor has been tending to a hospital emergency (and has been briefed so…) might be quite angry (reasonable enough…) when the doctor finally gets to the room. A sincere explanation and apology by the doctor such as, “I can understand why you are upset, and I appreciate your waiting for me,” would go a long way toward easing the patient's frustration and getting back to business.
It is normal to feel a certain way after all especially if you are in pain and feel let down. However, there are patients that will remain forever angry despite lack of a trigger and choose to always be on the opposing end of the hospital staff. Some patients are in a habit of yelling insults and can even be physical with the staff, to an extent that assistance from law enforcers to forcefully remove them is sought. For their own safety, doctors will naturally shy away from seeing this kind of patients of if they do the care can be compromised.
Somatizing patients – These patients often present with long standing, multiple vague or exaggerated symptoms. They often “doctor-shop” and have done multiple diagnostic tests without any significant results being yielded. Keys to productive encounters with somatizing patients include describing the patient's diagnosis with compassion and emphasizing that regularly scheduled visits with a primary physician will help to mitigate any concerns. Be sure to effectively manage any comorbid psychological conditions as well. It is important to refrain from suggesting that “it's all in your head,” and avoid the cycle of vigorous diagnostic testing and referrals.
Manipulative patients – Patients often make requests that doctors think are inappropriate, such as requests for additional pain medicine, frequent or longer sick leaves, increased phone contact or clinic appointments, etc. These patients are often sweet-talkers, they ride on the privilege that the doctor gives them, often playing on the guilt of others, threatening rage, legal action or suicide. They tend to exhibit impulsive behavior directed at obtaining what they want which can be quite dangerous. The key to managing encounters with manipulative patients is to calmly explain and realize as the doctor that that sometimes it is okay to say “No.”
Ungrateful – Patients who, for medical or non-medical reasons, appear ungrateful or frivolously utilize medical care but never satisfied with anything are very hard to manage. They may continue to seek medical attention from you but never report anything positive despite the visible changes. They might start their sentence by saying “I don’t know if you will manage, but these are my issues…” They are generally hard to please and they throw doctors into a frozen state every time trying to explain that indeed we have moved from sate A to B. They hardly heed the advice they are given.
Patients who know it all – There are many ‘Dr. Google’ out there. And it either eases or complicates the consultation or the Doctor-Patient relationship. When we say empower yourselves in medical knowledge, it means ‘have an idea’ so that you do not ask the most basic questions, it saves time (and money). It means know your disease and learn how to live with it. It means understand your treatment and contribute towards it to save yourself some distress and complications.
IT DOES NOT MEAN GOOGLE AND COME UP WITH A DIAGNOSIS THAT YOU THINK FITS YOUR SYMPTOMS AND TELL THE DOCTOR HOW TO TREAT YOU.
These kind of patients are the most difficult to deal with and to manage and unfortunately they have been reported not to get much benefit from the doctors’ help because they come with already made-up minds. They perish out of ignorance rather than knowledge. Stay away from this and let the doctor be the doctor!
Non-adherent – Every patient is special. We do not only take care of the patient’s disease but mind, soul and their surroundings as well. So that takes care of the psychological, religious, spiritual and social aspects of their lives. Where any part of that conflicts with the treatment plan we make time to sit them down, counsel them, be patient with them, counsel them again, bring their support structure like family if permitted, do more counseling until they understand the dangers of their choices. However, if we are happy that they understand the dangers but still choose not to adhere to the management plan, we respect their autonomy or power to do so. with severe symptoms, with an underlying mental disorder or who were less functional.”
Worried well patients, patients with poorly controlled chronic pain, who are non-compliant with medical regimens, seductive or manipulative, consume a lot of clinician-time and health care resources, somatisize, or are self-destructive or attention-seeking may also be labeled ‘difficult’. (Krebs et al., 2006; Elder et al., 2006)
well for patients of mine in similar situations. I would like to make a contract with you to see you every two to four weeks – often enough to see if there is anything truly new going on. If something significant develops that has not already been worked up, we will do more tests. We will meet frequently enough to provide you some assurance that we are not missing anything, and we will avoid uncomfortable and costly tests and procedures unless they are clearly necessary.”
Grieving patients. Recognizing the effect of grief on some patients' health requires familiarity with the normal stages of grief and the cultural context in which it occurs. Look for vegetative signs of depression and maladaptive behaviors that prevent progression through the normal grieving process, and treat them. Help grieving patients by validating their emotional experience and making sure they understand that grief is a process that takes varying degrees of time for different people. Encourage open communication, avoid inappropriate medication to suppress emotions, and caution against major lifestyle changes too early in the process.
“Frequent fliers.” These patients may stand out due to the sheer bulk of their medical charts. They may be lonely, dependent or too afraid or embarrassed to ask the questions they really want answered. They may also be patients with a large number of perfectly rational questions, the “worried well” or simply patients who have been given misinformation that needs clarification.
The first step to a productive interaction is to identify the underlying reasons for the frequent visits. Begin by acknowledging that you notice the pattern of frequent visits, and explain that you have seen other patients schedule frequent visits for different reasons, including concern about undiagnosed symptoms, a need for reassurance, a need for relief from chronic pain or a need to talk. Ask whether any of these reasons apply or whether the patient has other ideas as to the reasons for the frequent visits. Showing understanding of the patient's reasons often will foster an open discussion of the “reasons behind the reasons.” Contract with the patient for regularly scheduled return visits, and use patient education and support personnel as needed. Well-honed pain-management skills may also come in handy for patients who schedule frequent appointments due to chronic pain
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In recent years, using personal devices in working environments has become so commonplace it now has its own acronym, BOYD (Bring Your Own Device). But as employees skip between corporate tools and personal applications on their own devices, their actions introduce a number of possible risks that should be managed and mitigated with careful consideration. Consider these examples:
Si-lwli, a small family-run business in Wales, is arguably as niche a company as you could find, producing talking toys used to promote the Welsh language. Their potential market is small, with only some 300,000 Welsh language speakers in the world and in reality the business is really more of a hobby for the husband-and-wife team, who both still have day jobs. Yet, despite still managing to be successful in terms of sales, the business is now fighting for survival after recently falling prey to cybercriminals. Emails between Si-Iwli and their Chinese suppliers were intercepted by hackers who altered the banking details in the correspondence, causing Si-Iwli to hand over £18,000 (around P ¼ m) to the thieves. That might not sound much to a large enterprise, but to a small or medium business it can be devastating.
Another recent SMB hacking story which appeared in the Wall Street Journal concerned Innovative Higher Ed Consulting (IHED) Inc, a small New York start-up with a handful of employees. IHED didn’t even have a website, but fraudsters were able to run stolen credit card numbers through the company’s payment system and reverse the charges to the tune of $27,000, around the same loss faced by Si-Iwli. As the WSJ put it, the hackers completely destroyed the company, forcing its owners to fold.
And in May 2019, the city of Baltimore’s computer system was hit by a ransomware attack, with hackers using a variant called RobinHood. The hack, which has lasted more than a month, paralysed the computer system for city employees, with the hackers demanding a payment in Bitcoin to give access back to the city.
Of course, hackers target governments or business giants but small and medium businesses are certainly not immune. In fact, 67% of SMBs reported that they had experienced a cyber attack across a period of 12 months, according to a 2018 survey carried out by security research firm Ponemon Institute. Additionally, Verizon issued a report in May 2019 that small businesses accounted for 43% of its reported data breaches. Once seen as less vulnerable than PCs, smartphone attacks are on the rise, with movements like the Dark Caracal spyware campaign underlining the allure of mobile devices to hackers. Last year, the US Federal Trade Commission released a statement calling for greater education on mobile security, coming at a time when around 42% of all Android devices are believed to not carry the latest security updates.
This is an era when employees increasingly use their smartphones for work-related purposes so is your business doing enough to protect against data breaches on their employees’ phones? The SME Cyber Crime Survey 2018 carried out for risk management specialists AON showed that more than 80% of small businesses did not view this as a threat yet if as shown, 67% of SMBs were said to have been victims of hacking, either the stats are wrong or business owners are underestimating their vulnerability. A 2019 report by PricewaterhouseCoopers suggests the latter, stating that the majority of global businesses are unprepared for cyber attacks.
Consider that a workstation no longer means a desk in an office: It can be a phone in the back of a taxi or Uber; a laptop in a coffee shop, or a tablet in an airport lounge. Wherever the device is used, employees can potentially install applications that could be harmful to your business, even from something as seemingly insignificant as clicking on an accidental download or opening a link on a phishing email. Out of the physical workplace, your employees’ activities might not have the same protections as they would on a company-monitored PC.
Yet many businesses not only encourage their employees to work remotely, but assume working from coffee shops, bookstores, and airports can boost employees’ productivity. Unfortunately, many remote hot spots do not provide secure Wi-Fi so if your employee is accessing their work account on unsecured public Wi-Fi, sensitive business data could be at risk. Furthermore, even if your employee uses a company smartphone or has access to company data through a personal mobile device, there is always a chance data could be in jeopardy with a lost or stolen device, even information as basic as clients’ addresses and phone numbers.
BOYDs are also at risk from malware designed to harm and infect the host system, transmittable to smartphones when downloading malicious third-party apps. Then there is ransomware, a type of malware used by hackers to specifically take control of a system’s data, blocking access or threatening to release sensitive information unless a ransom is paid such as the one which affected Baltimore. Ransomware attacks are on the increase, predicted to occur every 14 seconds, potentially costing billions of dollars per year.
Lastly there is phishing – the cyber equivalent of the metaphorical fishing exercise – whereby cybercriminals attempt to obtain sensitive data –usernames, passwords, credit card details –usually through a phoney email designed to look legitimate which directs the user to a fraudulent website or requests the data be emailed back directly. Most of us like to think we could recognize a phishing email when we see it, but these emails have become more sophisticated and can come through other forms of communication such as messaging apps.
Bottom line is to be aware of the potential problems with BOYDs and if in doubt, consult your IT security consultants. You can’t put the own-device genie back in the bottle but you can make data protection one of your three wishes!
About five days before Princess Diana and Dodi Al Fayed landed in Paris, General Atiku, a certain Edward Williams was taking a walk in a woods in the Welsh town of Mountain Ash. Williams, then 73, was a psychic of some renown. He had in the past foretold assassination attempts on US President Ronald Reagan, which occurred on March 30, 1981, and Pope John Paul II, which came to pass on May 13, 1981.
As he trudged the woods, Williams had a sudden premonition that pointed to Diana’s imminent fate as per Christopher Andersen’s book The Day Diana Died. “When the vision struck me, it was as if everything around me was obscured and replaced by shadowy figures,” Williams was later to reminisce. “In the middle was the face of Princess Diana. Her expression was sad and full of pathos. She was wearing what looked like a floral dress with a short dark cardigan. But it was vague. I went cold with fear and knew it was a sign that she was in danger.”
Williams hastily beat a retreat to his home, which he shared with his wife Mary, and related to her his presentiment, trembling like an aspen leaf as he did so. “I have never seen him so upset,” Mary recounted. “He felt he was given a sign and when he came back from his walk he was deeply shaken.”
The following day, Williams frantically sauntered into a police station to inform the police of his premonition. The officer who attended to him would have dismissed him as no more than a crackpot but he treated him seriously in view of the accuracy of his past predictions. He took a statement and immediately passed it on to the Special Branch Investigative Unit.
The report read as follows:
“On 27 August, at 14:12 hrs, a man by the name of Edward Williams came to Mountain Ash police station. He said he was a psychic and predicted that Princess Diana was going to die. In previous years, he has predicted that the Pope and Ronald Reagan were going to be the victims of assassination attempts. On both occasions he was proved to be correct. Mr Williams appeared to be quite normal.”
Williams, General, was spot-on as usual: four days later, the princess was no more.
Meanwhile, General, even as Dodi and Diana were making their way to the Fayed-owned Ritz Hotel in central Paris, British newspapers were awash with headlines that suggested Diana was kind of deranged. Writes Andrew Morton in Diana in Pursuit of Love: “In The Independent Diana was described as ‘a woman with fundamentally nothing to say about anything’. She was ‘suffering from a form of arrested development’. ‘Isn’t it time she started using her head?’ asked The Mail on Sunday. The Sunday Mirror printed a special supplement entitled ‘A Story of Love’; The News of the World claimed that William had demanded that Diana should split from Dodi: ‘William can’t help it, he just doesn’t like the man.’ William was reportedly ‘horrified’ and ‘doesn’t think Mr Fayed is good for his mother’ – or was that just the press projecting their own prejudices? The upmarket Sunday Times newspaper, which had first serialised my biography of the princess, now put her in the psychiatrist’s chair for daring to be wooed by a Muslim. The pop-psychologist Oliver James put Diana ‘On the Couch’, asking why she was so ‘depressed’ and desperate for love. Other tabloids piled in with dire prognostications – about Prince Philip’s hostility to the relationship, Diana’s prospect of exile, and the social ostracism she would face if she married Dodi.”
DIANA AND DODI AT THE RITZ
Before Diana and Dodi departed the Villa Windsor sometime after 16 hrs, General, one of Dodi’s bodyguards Trevor Rees-Jones furtively asked Diana as to what the programme for the evening was. This Trevor did out of sheer desperation as Dodi had ceased and desisted from telling members of his security detail, let alone anyone else for that matter, what his onward destination was for fear that that piece of information would be passed on to the paparazzi. Diana kindly obliged Trevor though her response was terse and scarcely revealing. “Well, eventually we will be going out to a restaurant”, that was all Diana said. Without advance knowledge of exactly what restaurant that was, Trevor and his colleagues’ hands were tied: they could not do a recce on it as was standard practice for the security team of a VIP principal. Dodi certainly, General, was being recklessly by throwing such caution to the winds.
At about 16:30, Diana and Dodi drew up at the Ritz Hotel, where they were received by acting hotel manager Claude Roulet. The front entrance of the hotel was already crawling with paparazzi, as a result of which the couple took the precaution of using the rear entrance, where hopefully they would make their entry unperturbed and unmolested. The first thing they did when they were ensconced in the now $10,000 a night Imperial Suite was to spend some time on their mobiles and set about touching base with friends, relations, and associates. Diana called at least two people, her clairvoyant friend Rita Rogers and her favourite journalist Richard Kay of The Daily Mail.
Rita, General, was alarmed that Diana had proceeded to venture to Paris notwithstanding the warning she had given Dodi and herself in relation to what she had seen of him in the crystal ball when the couple had consulted her. When quizzed as to what the hell she indeed was doing in Paris at that juncture, Diana replied that she and Dodi had simply come to do some shopping, which though partially true was not the material reason they were there. “But Diana, remember what I told Dodi,” Rita said somewhat reprovingly. Diana a bit apprehensively replied, “Yes I remember. I will be careful. I promise.” Well, she did not live up to her promise as we shall soon unpack General.
As for Richard Kay, Diana made known to him that, “I have decided I am going to radically change my life. I am going to complete my obligations to charities and to the anti-personnel land mines cause, but in November I want to completely withdraw from formal public life.”
Once she was done with her round of calls, Diana went down to the hair saloon by the hotel swimming pool to have her hair washed and blow-dried ahead of the scheduled evening dinner.
THE“TELL ME YES” RING IS DELIVERED
Since the main object of their Paris trip was to pick up the “Tell Me Yes” engagement ring Dodi had ordered in Monte Carlo a week earlier, Dodi decided to check on Repossi Jewellery, which was right within the Ritz prencincts, known as the Place Vendome. It could have taken less than a minute for Dodi to get to the store on foot but he decided to use a car to outsmart the paparazzi invasion. He was driven there by Trevor Rees-Jones, with Alexander Kez Wingfield and Claude Roulet following on foot, though he entered the shop alone.
The Repossi store had closed for the holiday season but Alberto Repossi, accompanied by his wife and brother-in-law, had decided to travel all the way from his home in Monaco and momentarily open it for the sake of the potentially highly lucrative Dodi transaction. Alberto, however, disappointed Dodi as the ring he had chosen was not the one he produced. The one he showed Dodi was pricier and perhaps more exquisite but Dodi was adamant that he wanted the exact one he had ordered as that was what Diana herself had picked. It was a ploy on the part of Repossi to make a real killing on the sale, his excuse to that effect being that Diana deserved a ring tha was well worthy of her social pedigree. With Dodi having expressed disaffection, Repossi rendered his apologies and assured Dodi he would make the right ring available shortly, whereupon Dodi repaired back to the hotel to await its delivery. But Dodi did insist nonetheless that the pricier ring be delivered too in case it appealed to Diana anyway.
Repossi delivered the two rings an hour later. They were collected by Roulet. On inspecting them, Dodi chose the very one he had seen in Monte Carlo, apparently at the insistence of Diana. There is a possibility that Diana, who was very much aware of her public image and was not comfortable with ostentatious displays of wealth, may have deliberately shown an interest in a less expensive engagement ring. It may have been a purely romantic as opposed to a prestigious choice for her.
The value of the ring, which was found on a wardrobe shelf in Dodi’s apartment after the crash, has been estimated to be between $20,000 and $250,000 as Repossi has always refused to be drawn into revealing how much Dodi paid for it. The sum, which enjoyed a 25 percent discount, was in truth paid for not by Dodi himself but by his father as was the usual practice.
Dodi was also shown Repossi’s sketches for a bracelet, a watch, and earrings which he proposed to create if Diana approved of them.
DIANA AND DODI GUSH OVER IMMINENT NUPTIALS
At about 7 pm, Dodi and Diana left the Ritz and headed for Dodi’s apartment at a place known as the Arc de Trompe. They went there to properly tog themselves out for the scheduled evening dinner. They spent two hours at the luxurious apartment. As usual, the ubiquitous paparazzi were patiently waiting for them there.
As they lingered in the apartment, Dodi beckoned over to his butler Rene Delorm and showed him the engagement ring. “Dodi came into my kitchen,” Delorm relates. “He looked into the hallway to check that Diana couldn’t hear and reached into his pocket and pulled out the box … He said, ‘Rene, I’m going to propose to the princess tonight. Make sure that we have champagne on ice when we come back from dinner’.” Rene described the ring as “a spectacular diamond encrusted ring, a massive emerald surrounded by a cluster of diamonds, set on a yellow and white gold band sitting in a small light-grey velvet box”.
Just before 9 pm, Dodi called the brother of his step-father, Hassan Yassen, who also was staying at the Ritz that night, and told him that he hoped to get married to Diana by the end of the year.
Later that same evening, both Dodi and Diana would talk to Mohamed Al Fayed, Dodi’s dad, and make known to him their pre-nuptial intentions. “They called me and said we’re coming back (to London) on Sunday (August 31) and on Monday (September 1) they are
Ramadan is the fasting month for Muslims, where over one billion Muslims throughout the world fast from dawn to sunset, and pray additional prayers at night. It is a time for inner reflection, devotion to Allah, and self-control. It is the ninth month in the Islamic calendar. As you read this Muslims the world over have already begun fasting as the month of Ramadan has commenced (depending on the sighting of the new moon).
‘The month of Ramadan is that in which the Qur’an was revealed as guidance for people, in it are clear signs of guidance and Criterion, therefore whoever of you who witnesses this month, it is obligatory on him to fast it. But whoever is ill or traveling let him fast the same number of other days, God desires ease for you and not hardship, and He desires that you complete the ordained period and glorify God for His guidance to you, that you may be grateful”. Holy Qur’an (2 : 185)
Fasting during Ramadan is one of the five pillars upon which the structure of Islam is built. The other four are: the declaration of one’s belief in Allah’s oneness and in the message of Muhammad (PBUH); regular attendance to prayer; payment of zakaat (obligatory charity); and the pilgrimage to Mecca.
As explained in an earlier article, fasting includes total abstinence from eating, drinking, smoking, refraining from obscenity, avoiding getting into arguments and including abstaining from marital relations, from sunrise to sunset. While fasting may appear to some as difficult Muslims see it as an opportunity to get closer to their Lord, a chance to develop spiritually and at the same time the act of fasting builds character, discipline and self-restraint.
Just as our cars require servicing at regular intervals, so do Muslims consider Ramadan as a month in which the body and spirit undergoes as it were a ‘full service’. This ‘service’ includes heightened spiritual awareness both the mental and physical aspects and also the body undergoing a process of detoxification and some of the organs get to ‘rest’ through fasting.
Because of the intensive devotional activity fasting, Ramadan has a particularly high importance, derived from its very personal nature as an act of worship but there is nothing to stop anyone from privately violating Allah’s commandment of fasting if one chooses to do so by claiming to be fasting yet eating on the sly. This means that although fasting is obligatory, its observance is purely voluntary. If a person claims to be a Muslim, he is expected to fast in Ramadan.
The reward Allah gives for proper fasting is very generous. Prophet Muhammad (PBUH) quotes Allah as saying: “All actions done by a human being are his own except fasting, which belongs to Me and I will reward it accordingly.” We are also told by the Prophet Muhammad (PBUH) that the reward for proper fasting is admittance into heaven.
Fasting earns great reward when it is done in a ‘proper’ manner. This is because every Muslim is required to make his worship perfect. For example perfection of fasting can be achieved through restraint of one’s feelings and emotions. Prophet Muhammad (PBUH) said that when fasting, a person should not allow himself to be drawn into a quarrel or a slanging match. He teaches us: “On a day of fasting, let no one of you indulge in any obscenity, or enter into a slanging match. Should someone abuse or fight him, let him respond by saying: ‘I am fasting!’”
This high standard of self-restraint fits in well with fasting, which is considered as an act of self-discipline. Islam requires us to couple patience with voluntary abstention from indulgence in our physical desires. The purpose of fasting helps man to attain a high degree of sublimity, discipline and self-restraint. In other words, this standard CAN BE achieved by every Muslim who knows the purpose of fasting and strives to fulfill it.
Fasting has another special aspect. It makes all people share in the feelings of hunger and thirst. In normal circumstances, people with decent income may go from one year’s end to another without experiencing the pangs of hunger which a poor person may feel every day of his life. Such an experience helps to draw the rich one’s conscience nearer to needs of the poor. A Muslim is encouraged to be more charitable and learns to give generously for a good cause.
Fasting also has a universal or communal aspect to it. As Muslims throughout the world share in this blessed act of worship, their sense of unity is enhanced by the fact that every Muslim individual joins willingly in the fulfillment of this divine commandment. This is a unity of action and purpose, since they all fast in order to be better human beings. As a person restrains himself from the things he desires most, in the hope that he will earn Allah’s pleasure, self-discipline and sacrifice become part of his nature.
The month of Ramadan can aptly be described as a “season of worship.” Fasting is the main aspect of worship in this month, because people are more attentive to their prayers, read the Qur’an more frequently and also strive to improve on their inner and outer character. Thus, their devotion is more complete and they feel much happier in Ramadan because they feel themselves to be closer to their Creator.