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Difficult Patient Encounters

NOTE: The UW Dept. of Bioethics & Humanities is in the process of updating all Ethics in Medicine articles for attentiveness to the issues of equity, diversity, and inclusion.  Please check back soon for updates!

Authors:

Denise M. Dudzinski, PhD, MTS, Professor & Chair, UW Dept. of Bioethics & Humanities

Diane Timberlake, MD, MA
 

Related Topics:  Confidentiality I Futility 

Topics addressed:

  • What is a difficult patient-clinician relationship?
  • What obligations do clinicians have in these relationships?
  • What patient characteristics and behaviors make a clinician-patient relationship difficult?
  • What physician characteristics and behaviors make the clinician-patient relationship difficult?
  • How do I recognize this type of relationship?
  • Strategies for maintaining a therapeutic relationship
  • Examples of helpful communication strategies

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:

  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.

(Krebs et al., 2006; Wasan et al., 2005; Elder et al., 2006; Hass et al., 2005)

Examples of helpful communication strategies:

  • “What I hear from you is that . . . Did I get that right?”
  • “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.”
  • “It’s difficult for me to listen to you when you use that kind of language.”
  • “You seem quite upset. Could you help me understand what you are going through right now?”
  • “What’s your understanding of what I am recommending, and how does this fit with your ideas about how to solve your problems?”
  • “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.
  • Friedman EA. Must we treat noncompliant ESRD patients? Seminars in Dialysis.  2001 Jan-Feb;14(1):23-7.
  • Shapiro J, Lie D. Using literature to help physician-learners understand and manage "difficult" patients. Academic Medicine.  2000 Jul;75(7):765-8. 
  • Rianthavorn P, Ettenger RB, Malekzadeh M, Marik JL, Struber M. Noncompliance with immunosuppressive medications in pediatric and adolescent patients receiving solid-organ transplants.  Transplantation. 2004 Mar 15;77(5):778-82
  • Brennan TA, Lee TH. Allergic to generics. Annals of Internal Medicine.  2004 Jul 20;141(2):126-30. 
 
 
 
 

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.