Difficult Patient Encounters

Difficult Patient Encounters: Case 3

Mr. B is a 46-year-old man who comes into clinic to follow-up on multiple uncontrolled medical problems including diabetes, hypertension, obesity, depression and sleep apnea. He is unemployed and is currently homeless, though had been sleeping regularly on a friend’s couch. He and the friend have been getting into some arguments and he does not feel comfortable staying there anymore, so is sleeping in his car. On further discussion the patient shares that he lost his last job due to recurrent conflict with a co-worker.

Difficult Patient Encounters: Case 2

Mr. S is a 48-year-old man with a long history of drug and alcohol use. He has continues to drink alcohol regularly though is regularly seeing a substance abuse counselor. He also uses cocaine with some regularity and buys pain pills on the street. Mr. S has chronic pain due to back, shoulder and neck injuries from the past. When he takes a narcotic he feels better, so would like to be on a regular dose of pain medicine. He is seen frequently in clinic, often as a walk-in seeing a variety of providers, and he invariably asks for pain medicine. Mr.

Difficult Patient Encounters: Case 1

Mr. D is a 64-year-old man with multiple complex medical problems including uncontrolled diabetes, untreated depression, coronary artery disease (status post myocardial infarction with multiple stents), painful peripheral vascular disease, hypertension, hyperlipidemia, chronic hepatitis C, spinal stenosis and ongoing 2 pack per day tobacco use. He is on a long list of 16 medications and insulin, though does not take any of his medications with regularity. Mr. D returns to clinic and all of the above medical problems are not well controlled.

CASE STUDIES

Mr. D is a 64-year-old man with multiple complex medical problems including uncontrolled diabetes, untreated depression, coronary artery disease (status post myocardial infarction with multiple stents), painful peripheral vascular disease, hypertension, hyperlipidemia, chronic hepatitis C, spinal stenosis and ongoing 2 pack per day tobacco use. He is on a long list of 16 medications and insulin, though does not take any of his medications with regularity. Mr. D returns to clinic and all of the above medical problems are not well controlled. He has not been taking medication or following up with specialty care as advised. He continues to smoke and has not improved his extremely sedentary activity level. He requests that something more be done.

Case Discussion

Be aware of your own feelings. It is frustrating to devote time and compassion to patients when they do not take your advice. Still, you provide essential service to the patient by listening to his concerns and providing an opportunity for care. Prepare for the visit by acknowledging your frustrations before seeing the patient and strategize about how you will make the most of his visit. Set your own goal for the visit. Also ask him why he is coming to see you. If it is unrealistic to expect Mr. D to comply with all his medical therapies, if he feels respected and heard, he will be more likely to heed your advice. Consider asking which of his medical problems is bothering him most and negotiate with him on ways that he can work toward mutually agreed upon goals. Explore causes of his non-compliance and problem solve together toward a more coherent medical plan. Emphasize that the two of you work together to improve his health and establish one or two goals for his next visit (e.g. better diabetes control). Plan to maintain a patient and respectful demeanor even though you might actually be feeling frustrated. Enlist other providers (pharmacist, nurse, counselor or social worker) to help.  

Mr. S is a 48-year-old man with a long history of drug and alcohol use. He has continues to drink alcohol regularly though is regularly seeing a substance abuse counselor. He also uses cocaine with some regularity and buys pain pills on the street. Mr. S has chronic pain due to back, shoulder and neck injuries from the past. When he takes a narcotic he feels better, so would like to be on a regular dose of pain medicine. He is seen frequently in clinic, often as a walk-in seeing a variety of providers, and he invariably asks for pain medicine. Mr. S is often so focused on getting a narcotic prescription that the majority of the visit is consumed and little other health care is provided.

Case Discussion

Prepare for your visit with Mr. S by thinking through your goals of care, and determining how you will meet his pain management needs. In patients with active addictions, prescribing or increasing the dosages raises patient safety concerns and tends not to lead to positive outcomes for the patient. Consider talking with colleagues about how they might manage his requests and seek advice from or referral to pain management and/or addiction specialists. If you’ve noticed that Mr. S has not always been truthful in the past (a common component of addiction), expect that to be the case again. Establish boundaries at the beginning of the visit. Acknowledge his request and share with him what you would like to accomplish before you will discuss pain prescriptions. Consider putting your expectations and agreements about pain management in writing. Make sure he knows that you believe he has legitimate pain issues, but that the therapies you prescribe may not be exactly what he wants. Be firm with the boundaries you set with him. For example, you might tell him “We can schedule monthly visits, but I will not refill prescriptions in between appointments.” Create a plan for pain crises.  

Mr. B is a 46-year-old man who comes into clinic to follow-up on multiple uncontrolled medical problems including diabetes, hypertension, obesity, depression and sleep apnea. He is unemployed and is currently homeless, though had been sleeping regularly on a friend’s couch. He and the friend have been getting into some arguments and he does not feel comfortable staying there anymore, so is sleeping in his car. On further discussion the patient shares that he lost his last job due to recurrent conflict with a co-worker. He shares his frustration that “everyone is out for me because they’re racist.” On several occasions he has yelled at the personnel at the front desk when he was unable to get the assistance or appointment he needed. He was seen by a counselor in clinic for his depression, but this also ended in an episode of Mr. B becoming angry and security being called. He has been banned from one of the specialty clinics where he had been referred after a confrontation with staff there. He wonders why he is always getting kicked out of places and feels he has cause and a “right” to be angry. Though he seeks ongoing care, he does not have insight into how his anger is perceived by others.

Case Discussion

Prepare for your visit with Mr. B by ‘venting’ and strategizing with trusted colleagues. Establish and review ground rules for interactions with you and staff. “I understand that you are angry and I would like to spend some time talking with you about that, but I will immediately end our appointment if there is any threatening speech or behavior.” Validate some of his feelings by agreeing that racism and other forms of discrimination are wrong and he has every reason to be angry, but that learning different ways to express his anger may help minimize the kinds of social interactions that he dislikes. Discuss treatment modalities that may be beneficial to him in this regard. If possible, schedule his visit before your lunch or a break so you attend to yourself after the visit.