Treating a difficult patient

Excerpted from "Treating the difficult patient," Medscape News, by Batya Swit Yasgur, MA LMSW. September 20, 2012--Some patients warm your heart. They help you remember why you went into medicine. Other patients make you wish you had become anything but a physician. They yell or whine, manipulate or threaten. Some ignore their treatment plan and blame you when they don't improve; others insist they know more than you do. Some don't pay their bills, and others fail to show up for appointments. Hard as it is to admit, you wish they'd go away. "Many physicians feel they 'should' be loving and tolerant toward all patients, but that's not realistic," said Auguste Fortin, MD, Associate Professor of Medicine, Yale University School of Medicine, New Haven, Connecticut. "In every setting in life, we all get along better with some people than with others, and medicine is no exception." Although everyone has their own positive and negative traits, there are several categories of unpleasant behavior that may cast a very dark cloud over the patient visit.

Anger Outbursts - Some patients may periodically erupt. "Anger in a patient is one of the most difficult emotions for a physician to deal with," observed Neil Baum, MD, a New Orleans-based urologist. There are several reasons why a patient may snap at the physician. However, not every patient who displays anger has an identifiable "reason." Some people are easily irritable and don't restrain their anger in any aspect of their life. Still, it's up to the physician to diffuse or deal with that anger.

The "Dependent Clinger" - James E. Groves, MD, Associate Clinical Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts coined the term "dependent clingers" to describe excessively needy patients who require endless attention and reassurance. They seem to regard themselves as having "bottomless needs" and the physician as being able to provide an inexhaustible stream of services.

An Impatient, Demanding Patient - "Physicians complain about patients who want their medications to bring an instantaneous cure. These patients call the office, screaming that their treatment isn't working," said Dennis Hursh, Esq, Founder and Managing Partner of Hursh and Hursh, PC, a Pennsylvania-based law firm specializing in physician-related legal issues. Some patients make unethical demands, such as asking for documentation supporting a disability claim when there is no disability, or opioid drugs when they are not truly experiencing pain, cautioned Hursh. In these situations too, explain to the patient that you are unable to fulfill their request. And be sure to document all of these discussions in the patient's chart.

"I'll Never Get Better! - Some patients remain perpetually ill, despite your best efforts -- not because their illness resists treatment, but because they reject medical interventions, believing that no treatment will help them, says Dr. Groves. They seem smug when they return to your office, time after time, complaining that your latest treatment has been useless. According to Dr. Groves, these patients are not seeking relief from illness but rather an "admission ticket" to a relationship with the physician that can exist only when the symptoms remain. Many of these patients are depressed, but typically they refuse to see a psychiatrist.

The Stubbornly Non-adherent Patient - When a patient disregards the necessary treatment regimen, a physician may begin to feel like a parent dealing with a rebellious teenager. Dr. Groves added, "I think there are 2 prongs to dealing with noncompliant patients. The doctor should decrease the expectation that all patients can be helped, and should look for ways to make small changes -- and keep looking. "The second is to realize that sometimes the best you can do is to keep the relationship going and trust that this alone is doing some good for the patient, at least in providing a humane environment," says Dr. Groves.

Latecomers, No-Shows, and Bill-Dodgers - "Patients who are always late, don't show up for appointments, or don't pay their bills are devastating to a practice," said Dennis Hursh. "If it happens repeatedly, you need to make it clear that your practice cannot tolerate it."

"When dealing with difficult patients, bear in mind that in the profession of medicine, we tend to see people at their worst, not at their best," Dr. Fortin commented. "We don't have to deny our own human needs, but we need to build skills that will help us treat even the most difficult people." Click here to read full story.



CMDA Past President Al Weir, MD: "Certainly, we have patients who cause us to groan a bit when we see them coming and we have those who surprise us with their anger or inappropriate behavior. We also care for patients who may behave appropriately but whose personalities grate against our own, simply because we view life differently.

“Some patients are more difficult to care for than others but none are less important. Just as we have cool drugs that put some malignancies into remission with a simple prescription, while other tumors require complex, multidisciplinary management, some patients are a cinch to deal with, while others require hard work. Whole person health is our business with the entire person package of disease, personality, education, income, spirit, relations and emotions. Just as there are skills to gain in order to manage disease, there are skills to gain that will help us manage these other aspects of patient care. We should seek to improve our performance in these areas through courses, literature and counsel with our mentors. We should develop support systems within our offices, using ancillary personnel to provide the additional time necessary to assist our difficult patients.

"And, as Christian doctors, we need to remind ourselves that Jesus did not die only for nice people. The foundation of our care for difficult patients should be the blood that flowed on Golgotha for difficult people like you and me."

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