The Difficult Patient

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Chapter 189

The Difficult Patient

Perspective

Certain patients consistently arouse negative reactions in health care providers. These negative reactions may be initiated by a patient’s appearance, apparent attitude, interactive style, or presenting complaint. Difficult patients can rapidly disrupt the harmony and efficiency of an emergency department (ED). Such patients are referred to with a number of pejorative terms, such as gomer, crock, and other even less complimentary slang terms of disdain. They may receive suboptimal medical care, impede patient flow, and adversely influence the quality of care given to other patients, thus posing a medicolegal risk. Moreover, recurrent exposure to such patients, in the absence of a well-thought-out approach to dealing with them, may lead to escalating frustration for staff, promote unprofessional behaviors, and contribute to eventual burnout.

Historically, the medical literature has largely ignored the possibility of a physician’s harboring negative feelings toward any type of patient. Anger, hatred, and frustration are traditionally considered feelings that physicians should disown in favor of humor, compassion, and integrity. Although these are admirable attributes, to deny the presence of negative reactions is unrealistic. Physicians are as human as the patients they serve. Not until Freud coined the term countertransference were the negative reactions that patients can arouse in physicians actually recognized for their potential effect on care and used as diagnostic tools.

Good interpersonal skills are essential to the maintenance of the patient-physician relationship.1 Although some clinicians have more natural abilities in this area than others do, the myth that these skills are intuitive and cannot be taught is erroneous.2 Teaching of communication and relationship-building skills is now a priority of most medical schools and many primary care specialties.3 Guidelines for teaching and evaluating interpersonal skills within emergency medicine residency programs have been developed.2,4,5 The Accreditation Council for Graduate Medical Education identifies professionalism and interpersonal communication skills as two of the six core competencies required in the curriculum of all U.S. residency programs, including emergency medicine, prompting greater interest in research and education in these areas. Although it remains a challenge to measure the effectiveness of these initiatives, innovative curricula on professionalism and communication are being implemented in emergency medicine residencies.69

Distinguishing Principles

Difficult patients are often referred to as problem patients, disruptive medical patients, unwanted patients, and, less diplomatically, hateful patients.10 Patients with personality disorders are commonly included in this group because of their rigid, maladaptive personality traits. Difficult patients, however, do not necessarily have personality disorders and may fall into one of several other familiar patient categories (e.g., drug seekers, hostile patients, malingerers, and ED repeaters).

There is no universally agreed on definition of the difficult patient. The difficult patient is one who interferes with the physician’s ability to establish a normal patient-physician relationship. This impaired patient-physician relationship is often but not necessarily associated with negative feelings toward the patient.

Pathology of the Patient-Physician Relationship

An understanding of the difficult patient-physician relationship is hampered by a tendency to view it as a consequence of some inherent problem with the patient. Physician characteristics and the ED environment also play a role.11–13

Physician Factors

Impaired communication is a common problem in all forms of interpersonal relations and is often exaggerated in the medical setting. Patient satisfaction is highly correlated with patients’ beliefs that clinicians listen to them and understand their requests, coupled with the perceived professionalism of the physician.14,15 Despite this, physicians continue to focus on their own medical agenda, which may differ from patients’ concerns. When confronted with patients who have difficult social situations, physicians exacerbate the problem when they refuse to deviate from their own rigid medical model.

Physicians often have preconceived notions of how patients should behave when they are ill and tend to rapidly categorize them as either the acceptable “truly sick” patient type or the “burdensome, difficult” patient type. Patients placed within the former category are excused for their symptoms, but patients in the latter category are not. Patients may also be judged as difficult when cultural differences or language barriers interfere with the development of a mutual understanding between patient and physician.13

Physician failure to provide sufficient and interpretable information to patients about their diagnosis, treatment, and follow-up evaluation is another area of common communication breakdown. Studies show that in 20 minutes of patient-physician interaction, only 1 minute is reserved for educating patients about the illness.16 Personal biases and prejudices also affect patient treatment.11,12,17 The rapid formulation of an opinion based solely on appearance is a skill that physicians rely on to quickly form a “gestalt” about a patient. This is an essential skill for an emergency physician. To assume that such preconceived notions are influential only in a positive way, however, is unrealistic.18

Emergency Department Factors

The ED is an environment plagued with distractions and frequent interruptions, rarely approaching the comforting atmosphere that many patients expect and deserve.19,20 A sense of urgency and strict time constraints are often present. Patient assessments are sometimes conducted in suboptimal environments, such as hallways. The physician interaction is often perceived to be brief and punctuated by interruptions, which may imply to the patient that the physician does not care or that the evaluation is incomplete.1922 Patients may enter the encounter frustrated because of a lack of choice about their physicians or facilities and upset because of long waiting times, and physicians may enter the encounter biased by nursing comments or stressed by the prospect of losing control of the department while trying to deal with these particularly challenging patients.13

The Cycle of Impaired Patient-Physician Relationships

Difficult patients are often perceived by the physician to be making unreasonable demands (Fig. 189-1). Physicians react with negative feelings and may direct negative actions toward the patient. Patients are sensitive to these negative reactions, feel threatened with abandonment, and attempt to sustain the relationship by escalating symptoms. Physicians experience greater frustration at the maladaptive behavior of the patients, and so the cycle is perpetuated.

The consequences of this impaired relationship for the patient include failure to identify the real problems, missing of medical diagnoses, “another poor experience” with the medical establishment, and premature or inappropriate discharge.23 The negative effect on the staff is manifested by frustration, a sense of failure and defeat, fear of litigation, and the development of unconstructive stereotypes and unrecognized prejudices, all of which may contribute to eventual professional burnout.

Strategies for Treatment of the Difficult Patient

This section discusses the treatment of difficult patients from three approaches: general strategies, dealing with negative reactions, and crisis intervention.

General Strategies

Box 189-1 lists several general strategies that are helpful in dealing with difficult patients.

Be Supportive

Being supportive is not always the natural response to difficult patients because of the negative feelings they arouse in the physician. Nevertheless, initiating the interaction with a clear and explicit demonstration of concern and empathy may be the single most powerful tool at one’s disposal. Some physicians are concerned that seeming to be “soft” with a demanding or entitled patient may exacerbate the situation. To the contrary, expressing a respectful and empathetic concern for their problem effectively disarms many patients who are preparing for a long and arduous battle to be taken seriously. The possible news that there is no immediate solution available is more willingly received by patients who are convinced that they have been heard and believe the physician’s desire to help is sincere.24

Connecting emotionally with the patient can take time. Initially addressing a smaller concern in a caring and respectful manner can build trust and create greater rapport and compliance. For example, a patient who seeks treatment for self-inflicted lacerations but who will not cooperate with a history aimed at assessment of suicidal risk is often more candid after the physician has rendered appropriate wound care in a nonjudgmental way.

Understand the Patient’s Agenda

Sometimes physicians ask themselves, Why is this patient here?1 It is often productive to ask the patient the same question in a nonjudgmental fashion. The patient may have an easily satisfied although unanticipated agenda. This may be as simple as needing a bus ticket to get home or reassurance that there is no immediate danger of dying of some minor disorder. When the patient’s needs are not as easily met, a clear understanding of the purpose of the visit may allow the opportunity to set more realistic goals.25

Dealing with Negative Reactions

Although negative reactions make dealing with difficult patients an unpleasant experience, they can also provide valuable diagnostic information. Physicians should accept these reactions as understandable responses to a patient’s unpleasant behavior and use them to their advantage.

Physicians typically have similar reactions to certain patient behaviors. The variations in these reactions depend on the individual physician’s personality style, previous experiences, and unrecognized prejudices. Physicians should know their own reactions to specific behavioral patterns to use them as diagnostic aids.

Early recognition of these reactions may, in addition to their diagnostic value, allow the physician to analyze them as the first step in preventing failure in the therapeutic relationship.11–13

Negative Thoughts about the Patient

Negative thoughts about patients have the greatest potential to adversely affect patient care. Patients are often placed into such stereotyped categories as drug addict, malingerer, or crock. These labels may describe individual patients more or less accurately, but the potential exists for physicians to make inaccurate and potentially dangerous assumptions on the basis of the biases linked to these labels.

The process of assigning patients to epidemiologic categories is a normal part of clinical judgment. Certain categories are used to help define the likelihood of encountering diseases in particular populations of patients, thereby influencing decisions about investigation, treatment, and disposition. The danger in dealing with difficult patients is that this process can result in inaccurate assumptions about patients and compromise patient care.

Inaccurate assumptions about patients based on prejudicial, stereotyped labels are called cognitive distortions.12,26 The following case exemplifies the effect that cognitive distortions can have on clinical decision-making.

An injection drug user requests analgesia for severe neck pain after minor trauma. The physician labels the patient a drug seeker and assumes the complaints to be fictitious. After becoming aware of the physician’s assumption, the patient becomes belligerent and aggressive. He is escorted from the ED by security. A few days later, he returns with quadriplegia resulting from a cervical epidural abscess.

The physician assumed that the patient was malingering because of past experience with injection drug users and did not consider other legitimate explanations for the patient’s behavior. This phenomenon, known as all-or-none thinking, leads to the real disease being overlooked.

Negative Behaviors

Physician behaviors can be the most obvious manifestations of negative feelings and thoughts. Examples include rudeness, sarcasm, and indifference toward patients. A patient may receive an incomplete clinical evaluation, and unnecessary ancillary tests may be performed as an attempt to compensate. Physical or chemical restraint use, administration of naloxone, or the performance of other procedures may be used inappropriately or punitively. Analgesics may be withheld or used sparingly. Faulty communication may result in misunderstood discharge instructions and poor compliance. Impaired patient-physician relationships may lead to a refusal of care, forcing treatment against patients’ wishes or resulting in their leaving against medical advice.27

Although patients can suffer at the hands of physicians, the potential exists for the reverse to occur. Dissatisfied patients with incorrect diagnoses and poor follow-up instructions are prone to initiate successful malpractice suits against physicians. The physician may become the victim of patient violence.28 Negative physician behaviors can also have an effect on the rest of the ED staff. Actions viewed by colleagues as inappropriate can compromise team morale and functioning. Physicians who are feeling angry, demoralized, and stressed may vent their frustrations on team members or consulting services, resulting in a further deterioration of the immediate situation and potential damage to long-term working relationships.