It was 6 a.m. when the phone rang at the home of internist Robert Centor. A patient, eager to discuss her condition, had discovered that daybreak was a surefire time to reach him. “Patients who feel entitled to you at all hours are particularly difficult,” says Centor, a past president of the Society of General Internal Medicine. “I was in the shower when this patient woke my wife up. [The patient] obviously didn’t understand social boundaries, but she did understand what my wife said to her.”
Difficult patients, who can vex even the most mild-mannered physicians, span the spectrum of challenging behavior. Some specialize in self-diagnosis, demanding unnecessary tests and medication. Others monopolize your time and energy. Still others refuse to pay their bills, or they verbally abuse your staff. Amid the many in your patient population who are gratifying to treat, these few rabble-rousers can make you wonder why you ever got into the business of healing.
Fear not. With the right communication tools, a little sensitivity, and a hefty dose of patience, you can learn to work with your challenging charges, but you may also discover how to better treat their emotional — as well as their physical — needs.
A universal pain
“These patients do take a lot of time and energy and we can end up exacerbating the whole thing by our response,” says Andrew Wolf, a general internist and associate professor at the University of Virginia School of Medicine, who holds regular seminars on dealing with tough patients. “One really does need to work on becoming an expert at treating these patients. They’re not going away.”
The first step, says Shakaib Rehman, associate professor of medicine at Ralph H. Johnson V.A. Medical Center at Medical University of South Carolina, is to recognize that it’s not necessarily the patient who is difficult; rather, the situation makes them so. A large number of patients who express anger, for example, have not been given the right information at the right time. “Most experienced physicians realize that difficult patients are not the same as say, someone with diabetes or hypertension,” says Rehman, who delivers workshops on doctor-patient communication. “You yourself can have a difficult conversation with the phone company, and suddenly, it’s you who are difficult.”
The fearful patient
The underlying cause of your patient’s irksome behavior may not in fact be what you think. Often, for example, it’s fear, which can drive an otherwise reasonable person to become overly emotional, quick-tempered, or disagreeable. “Patients don’t always feel in control in the doctor’s office,” says James Welters, a family practitioner and chief medical officer with Northwest Family Physicians, an 18-physician practice in Minneapolis. “They may be scared because of a previous interaction with a physician or something a family member experienced. Certainly, when you’re ill, you feel more vulnerable.”
When interviewing patients during exams, he says, it sometimes helps to simply ask them to describe their worst health concerns. “Sometimes their fear is something that wouldn’t even cross my mind, like a patient with a persistent cold who immediately thinks lung cancer,” says Welters. “Just telling them, ‘No, I don’t think that’s what it is,’ can put their mind at ease.”
You can also help allay fears by improving your communication skills. That means focusing on your patient’s verbal and nonverbal cues (e.g., facial expressions, uncomfortable shifting). Allow them to speak without interruption while you maintain eye contact. Ask open-ended questions that encourage patients to provide more detail. “And how is this affecting your personal life?” can throw wide the gate of communication.
Empathy is equally important, but it must be sincere. “Don’t say things like ‘I understand,’ because you really don’t know what they’re feeling,” says Welters. “It comes across as false. Instead, use phrases such as, ‘I understand from other patients who have had this condition that these are the things you might be feeling.’”
The drug seeker
Some patients are difficult to manage because they’ve become dependent on pain medication or another controlled substance. Often, these patients have a legitimate medical condition and are experiencing discomfort. Unfortunately, they become relentless in their pursuit of stronger drugs.
“Some patients will go to great lengths to get them from you and others,” says Welters. “I had one patient who went from hospital to hospital saying she wasn’t getting pain medication or anti-anxiety medication or sleeping pills from her physician. Ultimately, she started forging her own prescriptions.”
At his office, Welters asks all patients who are on controlled substances for more than two months to sign a contract saying they won’t solicit medication elsewhere and if they do, they must agree to let his office know.
The angry patient
If you’ve been in practice for any amount of time, you’ve no doubt experienced the angry patient who walks in with a chip on her shoulder and untenable expectations on her mind. She finds fault with the medical profession in general and, often, with you, personally. “It’s important to keep your cool under any circumstance, but these are the ones who really test that,” says Wolf. “They say things like, ‘You’re late. What kind of care is this? I don’t know why I’m here; you can’t fix me anyway.’”
What works? Let the person vent — briefly. Then follow up with a comment, such as, “I can see you’re very angry.” This sort of reflective response counts with these patients because it legitimizes their feelings. Often, adds Wolf, these are patients who feel impotent either in life or in the doctor-patient relationship. You can help to re-empower them. “Tell them [that] what you really want to do is work together to address their health concern,” says Wolf. “Let them know that they’re the one who ultimately makes the call on whether or not they choose to get that MRI or take the medication you prescribe. If you allow them to choose it on their own, they’ll choose it.”
