A Method for Working with Displeased Patients—BLAST

Howard K. Steinman, MD
Scott & White Healthcare/Texas A&M Health Science College of Medicine, Temple, Texas

Disclosure: The author reports no relevant conflicts of interest.

Abstract
Clinicians inevitably encounter patients with complaints and concerns about the quality of their care. This causes some to experience anxiety, fear, anger, resentment, guilt, and depression, especially when they believe they may have erred or caused harm. Lack of customer-service training and experience may contribute to these emotions. The “BLAST” technique is a complaint-resolution method that is useful in patient care and as a clinical teaching tool. The mnemonic stands for: Believe (what the patient is saying), Listen (actively, to assess and restate the patient’s unmet expectations), Apologize (for the patient’s unmet expectations), Satisfy (the patient), and Thank (the patient for expressing his/her concerns and providing a second chance to satisfy the patient). The technique appears to help clinicians become more at ease and confident when handling patient complaints. This may be especially helpful for clinicians who must routinely interact with post-treatment and post-procedure patients who commonly express surprise, concern, or complaints about their results and healing. BLAST may be an effective teaching tool enabling students, residents, and clinicians to become more comfortable and adept at working with displeased and concerned patients.  (J Clin Aesthet Dermatol. 2013;6(3):25–28.)

Clinicians inevitably encounter patients with complaints and concerns about the quality of their care. Some experience anxiety, fear, anger, resentment, guilt, and depression when their care is criticized,[1,2] especially when they believe they may have erred[3] or caused harm.[4] These reactions may, in part, be due to a lack of customer-service training5 and interfere with clinician effectiveness.[1]

The BLAST technique is a complaint-resolution method developed by Albert Barneto. The mnemonic stands for Believe, Listen, Apologize, Satisfy, and Thank (Table 1).[6] This article describes its usefulness in patient care and as a clinical teaching tool. Anecdotal experience suggests its use helps clinicians remain more calm and effective when working with displeased patients.

Believe
From the outset of the patient encounter, clinicians should convey that they believe in the veracity of the patient’s concerns and validity of their emotions, even when they do not consider them to be legitimate, reasonable, or appropriate. Patients expect to be believed, and belief conveys understanding, support,[7] and empathy. Empathy, the ability to comprehend and communicate understanding of another’s emotions and their attached meanings,[8] is highly beneficial in complaint resolution and is fundamental to good doctor-patient relationships.[9,10]

When patients perceive genuine engagement, they gain trust that the physician is working in their best interests,[11] which is vital to establishing rapport and achieving successful outcomes.[12] It eliminates adversarial feelings and the need to argue11 because the clinician and patient are on the same team. Thus, showing any form of disbelief when attending to patient complaints diminishes the likelihood of successful outcomes.

Listen
BLAST’s second key element is active listening. Complaints often arise from unmet expectations. No matter the outcome, the patient expected something else. Focused, active listening is often necessary to elucidate unmet expectations13 and further strengthens rapport and trust.[12] As with disbelief, it is counterproductive for the clinician to defend, justify, or argue. This may further upset the patient[14] who wants solutions, not excuses. BLAST later provides an effective avenue for offering explanations.

Active listening requires that the clinician silence his/her inner voice and calmly and patiently attend to the patient without reacting or preparing a rebuttal. Within limits, tolerate anger, rudeness, obscenities, fabrications, exaggerations, personal criticism, histrionics, and repetition. Calmly give the patient his/her uninterrupted “magic minute” to describe, explain, criticize, and vent while conveying a sincere interest in hearing the patient.[13] This is facilitated by sitting and facing the patient with an open, relaxed posture; making eye contact, and offering expressions of understanding. Maintaining a quiet mind, emotional control, and attentive posture demonstrates that the clinician is unrushed and empathetic.[15]

When the patient has finished speaking, which may take an average of three minutes,16 the physician carefully restates the concerns in simple, non-medical terms. This shows the patient he/she was heard and understood. For example, “I understand you are very frustrated because you waited a long time for your last appointment, only to have it cancelled on short notice.” Whenever possible, it is beneficial to recapitulate in terms of unmet expectations, especially when they may be unreasonable. The physician may say, “What I hear you saying is that you are frustrated that your condition came back after the medication ran out.”

It may take several cycles of listening and restating until the patient acknowledges that their issues are understood. This is validating and calming14 and facilitates cooperation and resolution.

Apologize
The doctor then offers an apology for what the patient is experiencing and for his/her unmet expectations. This apology need not be an expression or acceptance of responsibility. Patients with legitimate complaints deserve an apology,[3] those without legitimate complaints still expect one, and a well-worded apology further defuses the situation.

This is why restating patients’ complaints in terms of unmet expectations is useful. The apology is an avenue for providing explanations without appearing defensive or accusatory. For example, “I am sorry that you are upset that your incision became infected and painful. All surgery sites can become infected if they are not cleaned and re-bandaged every day.”

Satisfy
The clinician then strives to satisfy the patient. First, address any complaints, demands, and concerns that cannot be fully resolved. Examples might include a demand to fire an employee, have a scar completely disappear, correct a distorted eyelid or lip without surgery, or have all fees refunded. These are best addressed at the onset, otherwise unmet expectations may remain. Then, when appropriate, ask the patient what they desire. The patient’s answer helps confirm whether the physician has made any false assumptions about the patient’s unmet expectations.[13]

If the patient’s suggestions are reasonable, the clinician can simply accede to them. Otherwise, calmly explain why they may not be the best choice,[13] propose two or three options (any more is potentially confusing), and let the patient choose.[11] This gives the patient a sense of involvement and control. When the patient has chosen and the details explained, be certain to verify that the patient is satisfied with the solution.

Should the patient not accept any suggestions, additional active listening may elucidate why. If the patient remains dissatisfied, the clinician should suggest that they agree to disagree,[13] and should try to partially satisfy the patient.

Thank
Finally, thank the patient for expressing his/her complaints and concerns and providing a second chance to satisfy him/her. Then follow up either by telephone or at the next visit to further demonstrate concern for what upset the patient and ensure satisfaction with the outcome.11

Discussion
There are few medical references discussing complaint-resolution techniques to help clinicians effectively work with displeased patients. There are many references concerning “difficult patients” in their many forms.[17] Research on difficult patients often focuses on their clinical characteristics and etiologies, not on techniques clinicians can use to cope with and manage them.[10] Other work focuses on doctor-patient interactions after medical errors have occurred.[3,4,18]

The “BATHE” technique has been shown to permit primary care physicians to rapidly assess psychological factors potentially contributing to patients’ medical complaints within the constraints of a standard, 15-minute appointment.[7,12] The pneumonic directs investigation of “B”ackground information; patient “A”ffect; what is most “T”roubling the patient; “H”andling (patient coping), and expressing “E”mpathy.[7,12,19] The technique has been shown to increase patient satisfaction with his/her care.[19] Anecdotal experience suggests using BLAST can also effectively and rapidly satisfy displeased patients within the confines of brief, outpatient office visits.

Another apparent benefit of BLAST is its ability to help clinicians control their emotions, and it is time efficient and suitable for simple and complex issues. Many physicians are not comfortable, confident, or adept at working with unhappy patients and may experience anxiety, avoidance, fear, anger, and frustration when required to do so.[1–4] This may be due to their psychosocial makeup, emotional state,[20,21] and lack of training.[5] When physicians nominated by their peers for excellent patient-care skills were surveyed, they stressed the importance of acknowledging their own emotions during patient interactions.[10] Those accepting of their emotions were more likely to improve their patient-care skills.[10,21]

Once learned, BLAST appears to provide clinicians with a framework that helps impart confidence, emotional control, and greater empathy, and results in a better outcome. In this way, it may be similar to the beneficial effects other mnemonics have shown in training physicians to better complete emotionally charged interactions, such as “GRIEV_ING”, used when informing relatives of the death of an emergency room patient (Table 2).[22]

Physicians often quickly interrupt patients, hoping to clarify issues and move on to solutions. One study showed physicians permitted patients uninterrupted expression of their concerns 28 percent of the time and otherwise interrupted after a mean of 23 seconds.[23] Patients permitted to explain uninterrupted required an average of six additional seconds.[23,24] Precluding patients from explaining fully can result in an incomplete understanding of their expectations.[13] For those already displeased with their care, this risks further disappointing an already upset patient.

When BLAST has been presented to clinicians, some have stated that personally facing displeased patients is stressful, time-consuming, and inefficient. Yet, not doing so can be a serious, potentially perilous miscalculation.[15] It is often less stressful, less time consuming, and more efficient to satisfy patients at the first encounter than to have them return, call, or write to obtain satisfaction. Unsatisfied patients may also cease contact and disparage the clinician, file formal complaints, or initiate litigation. Many malpractice suits result from patient anger about their doctor-patient relationship, not from the quality of their care.[4,25] Properly and promptly addressing patient anger can decrease this tendency.[26]

Apologizing may also seem counterintuitive and imprudent, especially for complaints about medical errors and omissions or those that are unjustified, untrue, or caused by patients. Apologies, however, can decrease blame, anger, and antagonistic responses; restore trust; strengthen relationships;[3] and decrease the likelihood of litigation.[3,4] It is important to emphasize that the apology offered in BLAST need not be an acknowledgment or acceptance of responsibility. It is offered for the patient’s unmet expectations and the emotions they are experiencing.

There is a concern that using BLAST may result in clinicians appearing stilted, disingenuous, or manipulative. BLAST simply reminds clinicians to utilize essential, proven customer relations[27,28] and psychological counseling methods[7,12,29] when communicating with displeased patients. The separate elements of BLAST are well described[1,11,14,15] and are second-nature to clinicians adept at working with difficult10 and complaining patients.

Anecdotal experience suggests that once clinicians gain confidence in its effectiveness, BLAST appears to help anxious clinicians remain calmer during the initial, sometimes emotionally charged portions of the interaction by providing an effective structure and plan of action. It also may raise the threshold of what clinicians perceive to be “difficult” behavior by helping them feel more at ease and confident when facing patient complaints. This may be especially helpful for clinicians who must routinely interact with post-treatment and post-procedure patients who commonly express surprise, concern, and complaints about their results and healing.

Finally, anecdotal academic experience has shown that BLAST is effective in teaching medical students and residents to be more comfortable and adept at working with displeased and concerned patients. Further quantitative study is warranted to confirm these impressions.

References
1.    Bobinski D. Complaint resolution: a practiced skill. Norfolk, UK: Management-Issues Ltd; 2006. http://www.management-issues.com/2006/10/12/opinion/complaint-resolution-a-practiced-skill.asp. Accessed September 15, 2009.
2.    Breuner CC, Moreno MA. Approaches to the difficult patient/parent encounter. Pediatrics. 2011;127:163–169.
3.    Robbennolt JK. Apologies and medical error. Clin Orthop Relat Res. 2009;467:376–382.
4.    Frenkel DN, Liebman CB. Words that heal. Ann Intern Med. 2004;140:482–483.
5.    Platt FW, Gaspar DL, Coulehan JL, et al. “Tell me about yourself”: The patient-centered interview. Ann Intern Med. 2001;134: 1079–1085.
6.    Barneto A. Dealing with customer complaints—B.L.A.S.T; http://ezinearticles.com/?Dealing-With-Customer-Complaints—B.L.A.S.T&id=263054. Accessed September 15, 2009.
7.    McCulloch J, Ramesar S, Peterson H. Psychotherapy in primary care: The BATHE technique. Am Fam Physician. 1998;57: 2131–2134.
8.    Reynolds WJ, Scott B. Do nurses and other professional helpers normally display much empathy? J Adv Nurs. 2000;31:226–234.
9.    Epstein RM. The science of patient-centered care. J Fam Pract. 2000;49:805–807.
10.    Elder N, Ricer R, Tobias B. How respected family physicians manage difficult patient encounters. J Am Board Fam Med. 2006;19:533–541.
11.    Evey K. Improve patient satisfaction and patient compliance by effective complaint management. http://ezinearticles.com/ ?Improve-Patient-Satisfaction-and-Patient-Compliance-              by-Effective-Complaint-Management&id=3900155. Accessed September 15, 2010.
12.    Lieberman JA, III, Stuart MR. The BATHE method: Incorporating counseling and psychotherapy into the everyday management of patients. Prim Care Companion J Clin Psychiatry. 1999;1: 35–38.
13.    Lazoritz S. Dealing with angry patients. Physician Exec. 2004;30:28–31.
14.    Essary AC, Symington SL. How to make the “difficult” patient encounter less difficult. JAAPA. 2005;18:49–54.
15.    Huntington B, Kuhn N. Communication gaffes: a root cause of malpractice claims. Proc (Bayl Univ Med Cent). 2003;16:157–161.
16.    Beckman HB, Frankel RM, Darnly J. Soliciting the patient’s complete agenda: a relationship to the distribution of concerns. Clin Res. 1985;33:714A.
17.    Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159:1069–1075.
18.    Mazor KM, Simon SR, Yood RA, et al. Health plan members’ views about disclosure of medical errors. Ann Intern Med. 2004;140:409–418.
19.    Leiblum SR, Schnall E, Seehuus M, et al. To BATHE or not to BATHE: Patient satisfaction with visits to their family physician. Fam Med. 2008;40:407–411.
20.    Longhurst MF. Angry patient, angry doctor. Can Med Assoc J. 1980;123:597–598.
21.    Schwenk TL, Marquez JT, Lefever RD, et al. Physician and patient determinants of difficult physician-patient relationships. J Fam Pract. 1989;28:59–63.
22.    Hobgood C, Harward D, Newton K, et al. The educational intervention “GRIEV_ING” improves the death notification skills of residents. Acad Emerg Med. 2005;12:296–301.
23.    Marvel MK, Epstein RM, Flowers K, et al. Soliciting the patient’s agenda: have we improved? JAMA. 1999;281:283–287.
24.    Rabinowitz I, Luzzati R, Tamir A, et al. Length of patient’s monologue, rate of completion, and relation to other components of the clinical encounter: observational intervention study in primary care. BMJ. 2004;328:501–502.
25.    Virshup BB, Oppenberg AA, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Qual. 1999;14:153–159.
26.    McCord RS, Floyd MR, Lang F, et al. Responding effectively to patient anger directed at the physician. Fam Med. 2002;34:331–336.
27.    Golden M. The ten golden rules for complaint resolution. Myra Golden Seminars; 2004. http://myragolden.com/PDFs/ The%2010%20Golden%20Rules%20for%20Complaint%20Resolution.pdf. Accessed February 10, 2011.
28.    Golden M. Ten ways to get an angry customer to back down. Myra Golden Seminars; 2004. http://myragolden.com/ PDFs/Ten%20Ways%20to%20Get%20An%20Angry%20Customer%20To%20Back%20Down.pdf. Accessed February 10, 2011.
29.    Platt FW, Gordon GH. Field Guide to the Difficult Patient Interview. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004.