Education Columns

Rachel Franklin, MD, University of Oklahoma

Despite our efforts teaching an empathic approach to our fellow human beings, students and residents alike often express frustration in clinical settings about their “difficult patients.” Physician learners sometimes express resistance to the “touchy-feely” physician-patient communication aspects of clinical practice, failing to recognize that these are the most critical skills to learn in caring for our patients.

However, I have found that students and residents are motivated to learn about those elements of practice that enhance their bottom line and avoid lawsuits and have used this as my “hook” to spur their interest in and attention to this most important aspect of patient care. Since 2008 I have given an annual hour-long lecture and role-playing workshop on the subject as part of our Practice Management curriculum for our residents. They respond well to having the same faculty who teaches them how to make money and avoid and survive lawsuits guide them through this information.

Epidemiology:
“Difficult patient” visits represent 5%–15% of all clinical encounters and can result in poor clinical outcomes, even lawsuits, if not handled effectively.1-3

Background:

• The patient: Some have unrealistic expectations. Patients’ psychiatric disorders may make it difficult to establish rapport, understand instructions, or maintain compliance. Multiple medical problems can make it difficult to easily address an acute complaint. Cultural, religious, or racial differences can create communication problems or taboos that interfere with communication.
• The physician: Overwork and inexperience can cause missteps during a visit. Language barriers may cause misunderstanding. Patients’ behavior may remind us of someone we dislike–and we can be tempted to respond accordingly. Non-compliance or other barriers to care can leave us dissatisfied with the patient. Physicians can suffer psychiatric illness or impairment as well, and this can hamper our clinical decision making.
• The system: Managed care and reduced reimbursements create the impression that we’re too busy to see our patients or to spend quality time with them. The Internet is full of misinformation. Poorly run, inefficient, or unfriendly offices create dissatisfaction before patients even see the doctor. And, the doctor has 30 minutes after a patient’s appointment time to be in that room or the patient is already angry–even if he/she doesn’t admit it.
• And all of us can simply have a bad day.

Symptoms and signs:
Behaviors:

• The patient interrupts,repeats, becomes angry, or engages in stereotypical nonverbal responses, such as stamping or shuffling feet, shifting in the chair, or refusing to make eye contact. The patient may become noncompliant or complain to others after the visit.
• The physician responds emotionally to the patient’s behavior, dreads every encounter with the patient, and may want to “fire” the patient.

The physician feels:

• Distracted from effective patient care
• Frustrated
• Surprised by patient or staff complaints about his/her care
• Fearful of an impending lawsuit or poor patient outcome

I next highlight that it is not the patient but the visit itself that is the problem. I emphasize that, as the “professional” in the room, it is the physician, not the patient, who is responsible for identifying and fixing the problems.

Diagnosis and treatment:

• Recognize the symptoms: do you feel uncomfortable? Is the patient displaying typical behaviors? Do you know you’re running behind or have another good reason for the patient’s anger?
• Initiate the “therapeutic sequence:” it’s what you learned in the first year of medical school. Identify the primary emotion, establish congruence, and legitimize your patient’s feelings. Apologize if appropriate, or praise what your noncompliant patient has done well so far.
• Set boundaries: yours and theirs. Clarify the patient’s expectations and inquire about cultural influences. Emphasize what you can agree on and encourage the patient to solve their problem within the limits you can offer.

And, give yourself permission to recognize when you can’t fix it. If a patient refuses to accept your boundaries, or if you feel you cannot create a therapeutic relationship with the patient, it may be time to withdraw from your patient’s care. Tell the patient, in writing, what about your relationship can’t be fixed, and express regret that you aren’t the doctor for him/her. Give the patient a window of time you’ll see his/her, and urge the patient to find a new physician ASAP. And remember, the physician-patient relationship was never about you. It’s always been about the patient—even the “difficult” patient.

References:
1. Haas L, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. Am Fam Physician2005;72:2063-8.
2. Essary AC, Symington SL. How to make the “difficult” patient encounter less difficult. JAAPA 2005;18(5):49-54.
3. Hull SK, Broquet K. How to manage difficult patient encounters. Fam Pract Manage 2007;June:30-4.