How To Handle The Difficult Patient

While it may be tempting to write off certain patients as “difficult,” the truth is more complicated as such patients may have psychosocial reasons for their behavior. This author details the physician’s role with challenging patients, how to make patient encounters positive and how to de-escalate the situation when patients get hostile.  

It is 4 p.m. and the podiatrist’s day is winding down. Clinic is almost over and he is ready to leave. Taking a last look at his schedule, he notices Mr. Jones is his second to last patient.

Seeing this patient’s name causes the doctor’s pulse to elevate slightly and he feels a sinking sensation in the pit of his stomach. Researchers have referred to this feeling as “heartsink.”¹ Mr. Jones has been a difficult patient since the first appointment. Never seeming to be happy, he draws the doctor’s energy and takes up significant amounts of time, constantly causing his office to run late. The doctor typically leaves the encounter feeling drained after working hard to maintain his professional demeanor.

For most healthcare professionals, the podiatrist’s situation is not an isolated situation but one that occurs reasonably often. In fact, physicians have characterized an estimated 15 percent of their patients as difficult.²

Unfortunately, most providers do not receive formal training to handle difficult patients. This results in lost time and productivity, increased provider burnout and, potentially, poor patient care. Difficult patient interactions may also increase the physician’s risk of malpractice claims.³

Although each provider would very much like to eliminate these kinds of patients from their practices, that is an impossible and perhaps an inappropriate goal. Instead, a more proactive method is to gain an understanding about these patients and our relationships with them. It is imperative to be able to recognize, understand and constructively work with difficult patients for improved outcomes.

What Are The Characteristics Of Difficult Patients?
Understanding the type of patient that one may perceive as “difficult” is itself a challenging process. We may term many patients difficult but this broad, nonspecific term is based on many factors. In 1978, Groves discussed this situation in a New England Journal of Medicine article titled “Taking Care of the Hateful Patient.”⁴ He characterized patients as “dependent clingers,” “entitled demanders,” “manipulative help rejecters” and “self-destructive deniers.” This simplistic characterization pigeonholed patients into categories that were insulting. Although this article easily spoke to physician biases with pithy descriptions, this description did not provide a constructive standpoint with which to work.

However, emerging research has facilitated more of an understanding of the environment and psychosocial issues surrounding these patients, and a more comprehensive interpretation is possible. Gross and colleagues, for example, found a significantly high association of borderline personality disorder in primary care clinics.⁵ They found a 6.4 percent lifetime prevalence of borderline personality disorder but only half of these patients reported receiving mental healthcare. Additionally, primary care providers reportedly recognized psychiatric disorders in only half of this same group.

Similarly, Jackson and Kroenke performed a prospective survey of 500 adults who presented to a primary care clinic.⁶ They also performed several validated patient assessments including assessing for mental disorders and functional status. Researchers rated 15 percent of these patient encounters as difficult and patients in these situations were more likely to have a mental disorder, multiple medical issues or more severe symptoms. Given this large prevalence of unrecognized disease, it is incumbent on medical providers to consider the role of psychosocial issues and disorders in patients they previously deemed as “difficult.”

A Closer Look At The Physician’s Role With Difficult Patients
It is too easy simply to blame patients and one must recall that the patient-physician relationship is two-sided. It becomes important then to understand the role of the provider. Mathers and colleagues found after a survey of 60 British general health providers that 60 percent of their perception of difficult patients could be accounted for by physician characteristics (perceived workload, job satisfaction, lack of counseling training and lack of qualifications).¹

Krebs and colleagues found matching results.⁷ They conducted an analysis of the Physicians Worklife Survey, a random sample of 1,391 family, general and subspecialty medical physicians looking at various work-life characteristics. The surveyed physicians estimated the percentage of their patients who they perceived as difficult. The researchers found a significant positive correlation between the percentage of perceived difficult patients and physician age (over 40 years), work hours (over 55 per week) and higher stress.

Similarly, during a prospective survey of ambulatory care physicians’ views of difficult patients, Jackson and Kroenke found physicians with lower psychosocial attitudes were more likely to view their patient encounters as difficult.⁶ Clearly, physician characteristics have the potential to affect physician perceptions of the number and nature of difficult patients in their practices. Physicians must keep in mind that their own personal life situations have a potentially large effect on their perception of their patients as difficult.

Initiating Positive Patient Encounters
A large amount of medial literature is available to provide health professionals with evidence-based recommendations when handling patients in difficult situations.^8,9 The first item to recognize is that patients often come to their providers with specific needs and agendas. However, in many cases and for many reasons, these patients may not verbalize their needs to the provider.

Using a qualitative survey design, Barry and colleagues investigated patient agendas when presenting for primary care consultation.¹⁰ They found that only four of 35 patients actually voiced their concerns to the provider and in all of the consultations with problem outcomes, at least one of the problem outcomes was due to an unvoiced patient issue. This demonstrates the need for providers to create an environment in which patients feel comfortable and empowered to communicate their concerns or questions with their provider.

The first step in this process must come from the provider in establishing an open patient-centered interaction. One can best accomplish this by allowing patients to complete their first comments without interruption. Beckman and Frankel reviewed audiotapes of 74 medical interviews by primary care physicians.¹¹ They found that only 23 percent of patients were allowed to finish their opening statement of concerns at the onset of the medical interview with only one of 52 opening statements actually completed. They also found that physicians interrupted patients after only 18 seconds on average.

If one does not allow patients the opportunity to at least complete their opening statement of concern, they are unlikely to do so at all. This creates at the outset a weak patient-physician interaction in which a greater risk of future complications is established. Furthermore, Duberstein and colleagues found patients were more satisfied with physicians they rated as higher in “openness” and “conscientiousness.”¹²
It is also important to watch nonverbal communication during patient encounters. Inadvertently revealing an angry face or crossing the arms may escalate an already tense situation. A recent meta-analysis of 26 observational studies found that physicians who demonstrated warmth and listened to their patients had a greater patient satisfaction rate to a statistically significant degree.¹³ Gestures such as nodding, uncrossed arm positions and eye contact are facilitating nonverbal cues that relay openness by the physician for patients to continue expressing themselves.

Eye contact is also important to improve patient-centered communication and interactions. Gorawara-Bhat and Cook studied the effects of types of eye contact by physicians.¹⁴ They reviewed videotapes of routine clinical visits and applied two validated scoring systems to establish a level of “patient-centeredness.” The authors found that physicians scored highly in patient-centeredness when they maintained sustained eye contact rather than having brief episodes of eye contact. These results are not surprising. Maintaining eye contact creates an important bond between patient and caregiver, and clearly demonstrates the physician is fully present in the conversation and cares about the patient’s concerns.

Additionally, authors have noted that patients tend to mirror their physician’s gaze during affiliative encounters in which there is a closer, more positive relationship.¹⁵ This is converse to more dominating or authoritarian relationships in which physicians spend a greater proportion of time speaking. The sophisticated physician may use this concept to his or her benefit. Establish a slightly closer physical distance while maintaining eye contact slightly longer during a difficult patient encounter. The patient will reciprocate by mirroring the longer gaze, thus establishing an improved sense of physician openness and caring.

Certain verbal behaviors may also be beneficial when working with patients perceived as difficult. In a study involving 59 primary care physicians (PCPs) and 65 general or orthopedic surgeons, Levinson and colleagues investigated physician behaviors in doctors who either had or did not have medical malpractice claims.³ The authors then performed an audiotape analysis of these physicians’ communication styles. They found that in comparison to PCPs who had two or more malpractice claims, PCPs with no history of malpractice claims used more statements of orientation (educating patients about expectations), humor and facilitation (asking opinions and thoughts). The “no claim” PCPs also spent a greater amount of time in the room. The study also looked at the same situation with surgeons but did not find a significant difference between claims and no-claims surgeons. This may be due to the additional role the technical side of surgery plays with patient outcomes.

Formulating Strategies For Success With Difficult Patients
The aforementioned research enables the astute physician to fashion a patient-centered, caring and effective approach to working with the “difficult” patient. When a situation arises, an effective clinician must be ready to address this successfully in a manner that resolves the current patient issue and improves long-term outcomes, but doing so in a way that is not detrimental to the productivity of the practice.

First, one must eliminate the destructive idea that a patient is inherently “difficult.” As I have noted above, there are many reasons why we may perceive a patient as difficult, including the provider’s own experiences and situation. Those seeking drugs or other secondary gain are usually the minority and have their own issues. For the rest of patients whom one may initially perceive as difficult, it is more helpful to view these patients as undergoing a difficult situation in which they desire resolution of some kind. Accordingly, focusing on the difficult situation (rather than the patient’s personality) and working toward a successful outcome are the goals.

General rules and protocols for patient management may also reduce physician “heartsink.” Staff should be aware of patients who typically take extra time or require more counseling. This will allow for the scheduling of increased time into the appointment and decrease the potential effect on the rest of the day’s productivity. Similarly, one should sequester difficult or disgruntled patients from other patients, both in the waiting room and in the patient care area.

Before walking into the room to see a “heartsink” patient, take a deep breath, put on a professional demeanor and recall that the purpose of the encounter is to help heal a patient’s condition. This action will center the provider during the encounter. Most importantly, one should never forget to remain polite and patient at all times, and never visibly or with body language demonstrate anger or frustration.
During conversations with an excessively talkative patient or one with multiple complaints, the physician should always aim to keep the discussion on track, gently interrupting the patient if he or she appears to be monopolizing the encounter time. Prioritizing goals for a particular encounter will also help focus the visit while making clear to the patient that having more than one complaint will require an increased number of visits.¹⁶ However, temper this with the understanding that patients need time to have their complaint heard. Redirecting the discussion diplomatically will enable you to control the patient encounter.

When Patients Get Angry
In certain situations, a patient may become angry or belligerent. Deal with this situation carefully and clearly. First, remain calm and professional regardless of the situation. Then proceed to de-escalate the situation. This may happen in several ways, including stepping out of the room and allowing everyone to calm down. Similarly, verbally and empathetically recognizing the patient’s anger at the situation without assuming blame will often demonstrate a caring attitude with resulting calm.¹⁶

Next, ascertain the specific concern and then repeat this back to the patient to confirm understanding of the situation. Ask the patient’s input. A simple “How can I help you?” or “What would you like to see happen?” will empower the patient to become a participant in determining a solution. After determining a plan, review that plan together to ensure a match between expectations and planned outcomes.

In Conclusion
Working with patients deemed difficult is more effective if one views such patients through a different lens. Understanding that there is usually an underlying reason (possibly including the physician’s own beliefs) for the patient appearing to be difficult refocuses attention on the situation rather than the person, opening the door for a more effective management strategy. In the long run, working with this type of patient is an opportunity to improve both a physician’s patient care skills and patient outcomes.

Dr. Shapiro is an Assistant Professor with the College of Podiatric Medicine at the Western University of Health Sciences in Pomona, Calif. He is the Director of the Chino Valley Medical Center PMSR/RRA Podiatric Residency in Pomona, Calif.

References

1.     Mathers N, Jones N, Hannay D. Heartsink patients: a study of their general practitioners. British J Gen Pract. 1995; 45(395):293-295.
2.     Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996;11(1):1-8.
3.     Levinson W, Roter DL, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. J Am Med Assoc. 1997; 277(7):553-559.
4.     Grove J. Taking care of the hateful patient. New England J Med. 1978; 298(16):883-887.
5.     Gross R, Olfson M, Gameroff M, et al. Borderline personality disorder in primary care. Arch Intern Med. 2002; 162(1):53-60.
6.     Jackson J, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999; 159(10):1069-1075.
7.     Krebs EE, Garrett JM, Konrad TR. The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data. BMC Health Services Research. 2006; 6:128-135.
8.     Cannarella Lorenzetti R, Jacques CH, Donovan C, et al. Managing difficult encounters: understanding physician, patient, and situational factors. American Family Physician. 2013; 87(6):419-425.
9.     Haas L, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. American Family Physician. 2005; 72(10):2063-2068.
10.     Barry CA, Bradley, CP, Britten N, Stevenson FA, Barber N. Patients’ unvoiced agendas in general practice consultations: Qualitative study. BMJ. 2000; 320(7244):1246-1250.
11.     Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Modern Med. 1984; 101(5):692-696.
12.     Duberstein P, Meldrum S, Fiscella K, et al. Influences on patients’ ratings of physicians: Physician demographics and personality. Patient Educ Couns. 2007: 65(2):270-274.
13.     Henry SG, Fuhrel-Forbis A, Rogers MA, Eggly S. Association between nonverbal communication during clinical interactions and outcomes: A systematic review and meta-analysis. Patient Educ Couns. 2012; 86(3):297-315.
14.     Gorawara-Bhat R, Cook MA. Eye contact in patient-centered communication. Patient Educ Couns. 2011: 82(3):442-447.
15.     Mast M. On the importance of nonverbal communication in the physician-patient interaction. Patient Educ Couns. 2007; 67(3):315-318.
16.     Elder N. How respected family physicians manage difficult patient encounters. J Am Board Family Med. 2006; 19(6):533-541.