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ETHICS IN MEDICINE   University of Washington School of Medicine
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Difficult Patient Encounters

Denise M. Dudzinski, PhD MTS & Diane Timberlake, MD MA

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Case 1

Case 2

Case 3


Introduction:

It is common for clinicians to care for a handful of patients who evoke feelings of dread, frustration, and even anger. The therapeutic relationship seems to break down, leaving the clinician feeling like the patient cannot be helped, does not want to be helped, or is sabotaging his care. “Difficult patients” can be seen as a problem to be tolerated or terminated from practice, however the difficulty is in the relationship, not simply the patient and there are techniques and strategies to help clinicians improve that relationship and retain its therapeutic nature.

What is a difficult patient-clinician relationship?

A difficult patient-clinician relationship, occurring in approximately 15% of adult patient encounters (Krebs et al., 2006) arises when physicians encounter patients with complex, often chronic medical issues (such as chronic pain, and/or mental illness) that are influenced or exacerbated by social factors (such as poverty, abusive relationships, addiction). Previous experience with similar patients along with the social and economic disparities between the physician and patient may make the physician uncomfortable. This may lead the physician to be guarded or distant which the patient may interpret as distrust. Likewise, the therapies the doctor recommends often entail behavioral changes that the patient is unwilling or unable to make, yet the patient continues to seek the clinician’s advice and treatment. The physician may become frustrated or angry because his advice is not heeded, because the diagnosis or treatment is unclear or ineffective, or because the patient is rude, seemingly ungrateful, or transgresses boundaries in the clinician-patient relationship (e.g. comes to the clinic when she does not have an appointment). The physician in turn may feel that treating the patient is futile, burdensome, and disruptive to other patients and staff. Clinicians may become angry, and avoid or sometimes ‘punish’ the patient.

What obligations do clinicians have in these relationships?

Health care providers have professional and ethical obligations to care for these patients because of the fiduciary nature of the clinician-patient relationship. The provider has knowledge, influence, and power in the relationship, which entail special responsibilities. It may be difficult to see some of these patients as vulnerable, but without a clinician’s help their vulnerability would only be compounded. While their medical, social, and psychiatric conditions may be complex, patients benefit both from a therapeutic relationship and from medical treatments and advice. Because clinicians often find these relationships exhausting and frustrating, they should identify trusted colleagues with whom they can share their frustrations, employ strategies that allow the best in the relationship to prevail, and use a team approach. Clinicians should also try to address or manage their own attitudes and behaviors that contribute to the problem, recognizing that the patient’s behaviors and attitudes may not change. The clinicians should do everything they can to maintain a therapeutic relationship (even one that is not ideal), however in some circumstances they may need to transfer care to another provider. This transfer can be done without threatening the patient. The treating provider can help to maintain the patient’s trust in the health system, while also setting clear boundaries.

What patient characteristics and behaviors make a clinician-patient relationship difficult?

Patients are labeled ‘difficult’ based on the feelings they invoke in clinicians, such as anger, frustration, anxiety, dread, and guilt. (Wasan et al., 2005)Patients who, for medical or non-medical reasons, appear ungrateful or frivolously utilize medical care are most likely to be described as ‘difficult’. They may continue to seek medical attention but not heed the advice they are given. Patients may have multiple medical complaints, psychiatric conditions (helplessness, depression, anxiety, self-loathing), abrasive personality traits (expressing rage, inflexibility), personality disorders, addictions, and multiple physical symptoms of unknown or ambiguous etiology. They often make requests that clinicians think are inappropriate, such as requests for additional pain medicine, increased phone contact or clinic appointments, etc. 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)

What physician characteristics and behaviors make the clinician-patient relationship difficult?

Physician attitudes, biases, fatigue, stress, burn-out, as well as language and cultural barriers may negatively impact the relationship (Hull & Broquet, 2007). Angry, defensive, fatigued, harried, dogmatic, or arrogant physicians are more likely to see patient encounters as difficult (ibid). Data suggests that some physicians are more likely to describe difficult patient encounters when they have “lower job satisfaction, less experience, [and] poorer psychosocial attitudes” (Elder et al., 2006). Also, physicians who have low tolerance for illnesses that are incurable or untreatable can find patients with these illnesses difficult to manage. Also susceptible are physicians who have a hard time adjusting their practice to accommodate patients who seem overly dependent or physicians who feel helpless or annoyed when the patient’s ailments are exacerbated by social factors (family conflict, poverty, addiction, etc.). It can be particularly frustrating or infuriating when patients appear ungrateful or even resentful for the care they receive. Recognize this source of frustration and remember that you are likely a vital part of the patient’s support system even if the patient appears ungrateful or aggressive. Physicians who tend to emphasize the patient’s autonomy in medical decision-making may have a harder time with patients who abdicate responsibility for their health or are comfortable in a more vulnerable role. Highly frustrated physicians tended to be younger, more likely to practice subspecialty internal medicine, and to experience higher stress (Krebs et al., 2006).

How do I recognize this type of relationship?

Your feelings are the first clue. Be alert when you feel anger, resentment, fear, dread, or excessive anxiety about seeing a patient, when you worry that the patient will transgress a professional or personal boundary, when you want to avoid the patient, and/or are unable to feel empathy for him/her.

Strategies for maintaining a therapeutic relationship (Krebs et al., 2006; Wasan et al., 2005; Elder et al., 2006; Hass et al., 2005)

1) Be compassionate and empathic. Keep in mind that most patients whom you find frustrating to deal with have experienced significant adversity in their lives.

2) Acknowledge and address underlying mental health issues early in the relationship.

3) Prioritize the patient’s immediate concerns and elicit the patient’s expectations of the visit and their relationship with you.

4) Set clear expectations, ground rules, and boundaries and stick to them. Have regular visits, which helps convey confidence that the patient can deal with transient flare-ups without an emergency visit.

5) Be aware that strong negative emotions directed at you are often misplaced. The patient may be imposing feelings and attitudes onto you that they have had toward other doctors, friends, family members in the past. This is known as transference. Acknowledge the patient’s feelings and set behavioral expectations.

6) Be aware of your own emotional reactions and attempt to remove yourself so you can objectively reflect on the situation. Involve colleagues. Vent your feelings or debrief confidentially with a trusted colleague so that your negative emotions are kept at bay during patient encounters.

7) Recognize your own biases. For example, patients with addictions genuinely need medical care, but the behaviors associated with addiction are vexing for health care providers. These patients are often both vulnerable and manipulative. Be sure that you are attentive to their vulnerability, rather than focusing exclusively on their manipulative behaviors.

8) Avoid being very directive with these patients. A tentative style tends to work better. Remember that you provide something many of these patients do not have-a steady relationship with someone who genuinely wants to help them. This in itself can improve the patient’s health, even in the absence of medical treatment.

9) Prepare for these visits. Keep in mind your goals of care and make a strategy for the encounter before it occurs.

Examples of helpful communication strategies:

  1. “What I hear from you is that . . . Did I get that right?”
  2. “How do you feel about the care you are receiving from me? It seems to me that we sometimes don’t work together very well.”
  3. “It’s difficult for me to listen to you when you use that kind of language.”
  4. “You seem quite upset. Could you help me understand what you are going through right now?”
  5. “What’s your understanding of what I am recommending, and how does this fit with your ideas about how to solve your problems?”
  6. “I wish I (or a medical miracle) could solve this problem for you, but the power to make the important changes is really yours.”
    (Hass et al., 2005, p. 2066)

 References

Elder, N, Ricer R, Tobias B. How respected family physicians manage difficult patient encounters. Journal of the American Board of Family Medicine. 2006;19:553-41.

Krebs, EE, JM Garrett, TR Konrad. The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data. BMC Health Services Research. 2006; 6:128. http://www.biomedcentral.com/1472-6963/128

Hass LJ, Leiser JP, Magill MK, Sanyer ON. Management of the Difficult Patient. American Family Physician. 2005 15; 72(10): 2063-2068.

Hull SK & Broquet K. How to manage difficult patient encounters. Family Practice Management. June 2007. www.aafp.org/fpm

Wasan, AD, Wootton J, Jamison RN. Dealing with difficult patients in your pain practice. Regional Anesthesia and Pain Medicine. 2005; 30: 184-192.



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Case studies: Case 1 | Case 2| Case 3

Related Discussion Topics/Links: Confidentiality, Medical Futility

Core clerkship material: none


Denise M. Dudzinski, PhD MTS & Diane Timberlake, MD MA


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Last date modified: March 12, 2014