Managing ‘Difficult’ Patient Encounters

Donald W. Black, MD

Curr Psychiatr. 2021;20(7):13-19.

Introduction

“I did not like those patients… They made me angry and I found myself irritated to experience them as they seemed so distant from myself and from all that is human. This is an astonishing intolerance which brands me a poor psychiatrist.”

Sigmund Freud, Letter to István Hollós (1928)

While Freud was referring to psychotic patients,^[1] his evident frustration shows that difficult and challenging patients have vexed even the best of us. All physicians and other clinicians will experience patient encounters that lead to anger or frustration, or even challenge their sense of equanimity and professional identity. In short, difficult and challenging patient interactions are unavoidable, regardless of the physician’s discipline.^[2,3,4,5] At times, physicians might struggle with demanding, unpleasant, ungrateful, and possibly dangerous patients, while sometimes the struggle is with the patient’s family members. No physician is immune to the problem, which makes it crucial to learn to anticipate and manage difficult patient interactions, skills which are generally not taught in medical schools or residency programs.

One prospective study of clinic patients found that up to 15% of patient encounters are deemed “difficult.”^[6] Common scenarios include patients (or their relatives) who seek certain tests after researching symptoms online, threats of legal or social media action in response to feeling that the physician is not listening to them, demands for a second opinion after disagreeing with the physician’s diagnosis, and mistrust of doctors after presenting with symptoms and not receiving a diagnosis. It is also common to care for patients who focus on negative outcomes or fail to adhere to treatment recommendations. These encounters can make physicians feel stressed out, disrespected, abused, or even fearful if threatened. Some physicians may come to feel they are trapped in a hostile work environment with little support from their supervisors or administrators. Patients often have a complaint office or department to turn to, but there is no equivalent for physicians, who are expected to soldier on regardless.

This article highlights a model that describes poor physician-patient encounters, factors contributing to these issues, how to manage these difficult interactions, and what to do if the relationship cannot be remediated.

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Next Section

Abstract and Introduction
Describing the ‘Difficult’ Patient
A Model for Understanding Difficult Patient Encounters
The Consequences of Difficult Interactions
How to Manage Challenging Situations
When All Else Fails
References
Sidebar

Collaboration and empathy: How a patient’s positive perception can improve outcomes

Mr. L, a 60-year-old veteran, is admitted to an inpatient unit following a suicide attempt that was prompted by eviction from his apartment. Mr. L is physically disabled and has difficulty walking without assistance. His main concern is his homelessness, and he insists that the inpatient team find a suitable “Americans with Disabilities (ADA)-compliant apartment” that he can afford on his $800 monthly income. He implies that he will kill himself if the team fails in that task. He makes it clear that his problems are the team’s problems. He is prescribed an antidepressant, and both his mood and reported suicidal ideations gradually resolve.

The team’s social worker finds an opening at a well-run veterans home, but Mr. L rejects it because he doesn’t want to “give up his independence.” The social worker finds a small apartment in a nearby community that is ADA-compliant, but Mr. L complains that it is small. He asks the resident psychiatrist, “Where will I put all my things?” The next day, after insulting the attending psychiatrist for failing to find an adequate apartment, Mr. L says from under the bedsheet: “How come none of you ever help me?”

Mr. L presents a challenge to the entire team. At times, he is rude, demanding, and entitled. The team recognizes that although he had served in the military with distinction, he is now alone after having divorced many years earlier, and nearly friendless because of his increasing disability. The team surmises that Mr. L lashes out due to frustration and feelings of powerlessness.

Resolving this conflict involves treating Mr. L with respect and listening without judgment. No one ever confronts him or argues with him. The team psychologist meets with him to help him work through his many losses. Closer to discharge, he is enrolled in several post-hospitalization programs to keep him connected with other veterans. At discharge, the hospital arranges for his belongings that had been in storage to be delivered to his new home. He is pleasant and social with his peers, and although he is still concerned about the size of the apartment, he thanks the team members for their care.

Table 1 Groves’ ‘hateful patients’
Patient type	Description	Recommendation
“Dependent clinger”	“… [they] escalate from mild and appropriate requests for reassurance to repeated, fervid incarcerating cries for explanation, affections, analgesics, sedatives, and all forms of attention imaginable.” “Such dependency leads to a sense of weary aversion toward the patient.”	“The patient must be told … that the physician has not only human limits to knowledge and skill but also limitations on time and stamina.”
“Entitled demander”	“…[they] use intimidations, devaluation, and guilt-induction to place the doctor in the role of the inexhaustible supply depot.” “The physician becomes fearful about [his] reputation and enraged that the patient is not cooperative and grateful.”	“The most therapeutic strategy … is to support the entitlement but to rechannel it in the direction of the indicated regimen.”
“Manipulative help rejector”	“[They] … are familiar to every practicing physician. [They] have a quenchless need for emotional supplies.” “The behaviors elicit first in the physician anxiety that a treatable illness has been overlooked, next irritation with the patient, and finally depression and self-doubt in the doctor.”	“The remedy … is for the doctor to [convey] that the patient will not be allowed to become so close as to be engulfed nor so distant as to starve.”
“Selfdestructive denier”	“[They] display unconsciously selfmurderous behaviors such as the continued drinking of a patient with esophageal varices and hepatic failure.”	“What the physician can do … is quite limited. The starting point … is to recognize without shame or selfblame that [these patients] provoke in their caregiver the fervent wish that they would die and ‘get it over with.’”

Source: Adapted from reference 7

Table 2 Factors that contribute to difficult encounters: The patient, the physician, and the system
Patient characteristics
Patients who are angry or defensive note the clenched fists, furrowed brows, handwringing Patients who are manipulative play on the guilt of others; threaten rage, legal action, or suicide Patients with somatic symptoms chronic, multiple, vague symptoms or exaggerated symptoms often shop around for physicians and have many tests multiple medical problems, chronic pain, ill-defined syndromes (eg, chronic fatigue) Patients who are grieving Patients who are “frequent fliers” • tend to be very dependent and to seek the nurturance of the hospital or clinic
Physician characteristics
Physicians who are angry or defensive burned out, stressed, frustrated might snap at patient Physicians who are fatigued or harried overworked, sleep-deprived, busier than desired Physicians with personal problems (eg, marital, family problems) Personality traits rigidity, obsessionality
Systems issues
Language and literacy issues patient’s primary language may not be English patient’s culture may lead to different health or illness beliefs ,br>Multiple people in the exam room does the patient want other people in the room? Breaking bad news Environment chaotic or noisy clinic, ward lack of privacy

Source: Adapted from references 2,8,9

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Managing ‘Difficult’ Patient Encounters

Introduction

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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