How to Treat Difficult Patients: A Step-By-Step Guide

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The broad term “difficult patient” can mean patients who are hard to deal with or patients who are potentially dangerous.
The broad term “difficult patient” can mean patients who are hard to deal with or patients who are potentially dangerous.

Some research suggests that as many as 15% of adult patient encounters can be described as “difficult.”1,2 Handling these situations requires skill and empathy. To shed further light on navigating this challenging terrain, MPR interviewed Karen Broquet, MD, MHPE, associate dean for graduate medical education and professor, Departments of Internal Medicine and Psychiatry, Southern Illinois University School of Medicine, Springfield.

What motivated you to focus on this issue?

I have colleagues who have been so distressed when they encountered negative feelings toward patients in themselves that they have sought advice from me. It is clear that there is a need for education in this area. In 2007, I coauthored an article with Sharon Hull, MD,3 about difficult patient encounters and my coauthor and I continue to get calls from caregivers about these issues.

What do you mean when you talk about “difficult patients?”

The broad term “difficult patient” actually encompasses 2 major categories: patients who are hard to deal with and “push our buttons,” but do not threaten our physical safety, and patients who are potentially violent.

Speaking to the first category, what types of patients can generate negative feelings in healthcare professionals?

An important starting point is to recognize that we cannot meet patients' needs all of the time. While this may be self evident to us, it is less so to patients. So one common scenario is the patient who has expectations that we cannot meet and becomes angry, demanding that we be available after hours or taking up unnecessary time during appointments.  In situations like these, it is the job of the physician to set clear and consistent limits and recognize that these limits are not only to protect ourselves but also to serve the patient. Our confidence that we are acting with the patient's best interests at heart will be helpful in providing this framework.

Are there other reasons for anger in patients?

A patient might be angry about factors that have nothing to do with the physician but the anger ends up being directed at the physician—perhaps some hospital policy or circumstance in the patient's life. It is natural to become defensive or overly solicitous and try to placate the patient. Neither approach works well.

Instead, begin with finding out why the patient is angry. Listen with empathy and respect as the patient is expressing reason for the anger and acknowledge the patient's feelings. “I understand why you feel this way, it is difficult dealing with these policies.” And apologize if the patient has been inconvenienced, even if you were not actually at fault. “I'm sorry you were kept waiting for so long and I appreciate that you waited for me.” This can help to ease the patient's frustration.

Some patients become angry if they receive a grim diagnosis or if a family member has had unexpected complications or died. In their grief, they may look to blame the physician. Recognizing the origin of the anger will go a long way to providing empathy and support. 

Sometimes patients' anger comes from a sense of entitlement. These patients can be manipulative and play on our guilt. We often respond by getting angry ourselves or wanting to “put them in their place", which sets up a negative cycle.  It is best if we do not bring our own guilt to the table. We can also channel the sense of entitlement in positive ways. Every patient is entitled to the best possible care. The key is to remain aware of our emotions, try to understand the patient's expectations, and react calmly.

If you ever become frightened that a patient's anger or aggression might escalate into physical violence toward you or your staff, do not discount your concerns. Take whatever steps you need to protect yourself, such as alerting security or appropriate hospital personnel.

Whatever the reason for the anger, utilizing the Universal Upset Person Protocol can be very helpful in diffusing it and moving the patient encounter in a positive direction. (Table 1)

Are there patients whose demands take a different form?

There are patients who have extensive emotional needs that we simply cannot fill. At the beginning, they can seem endearing and their requests can seem reasonable. We think, “I can help you and I'm surprised no one has been able to in the past.” These patients perceive the physician's ability to meet those needs as inexhaustible and their behaviors escalate from appropriate request for reassurance to repeated cries for nurture, affection, medications, or attention.

Recognize your own feelings of resentment, guilt, or shame that you may not be meeting their needs. Then have an open discussion with the patient about your limitations of time and stamina. Set limits about when the patient can call you about or how long appointments will last. If you feel the patient might have a condition such as borderline personality disorder, consider a psychiatric referral.

Are there patients who are not angry or manipulative but nevertheless make excessive demands?

Some patients have somatic complaints but no findings to back them up. They tend to be high utilizers of care but may also reject help. Some may actually be diagnosable as having somatization disorder but others are simply not fluent in recognizing their stresses and feelings on an emotional level. Some have depression or personality disorders.

It is natural for physicians to be anxious that they might have “missed something” or to think that the patient is “faking it,” so be aware of your own reactions. Validate their concerns and do not let them think that you regard their ailments as “all in their head.” It may sound counterintuitive, but it can be helpful to see them more frequently, but with regularity, even once a month. Address symptoms as they arise and do a good physical exam. We tend to underestimate the value of hands on the patient. This approach will be reassuring to the patient, reduce phone calls and also the risk of expensive unnecessary tests.

Are there patients who are difficult but not outright demanding?

Self-destructive patients are very difficult. This includes those with severe addictions, patients who are not adherent with treatment recommendations, and patients who are physically self-destructive through acts like burning or cutting themselves. Caregivers often react by becoming anxious and frustrated, feeling angry, and wishing that these patients would simply go away.

It would be optimal to refer these patients to addiction or mental health services when available. Otherwise, organize a treatment team so you are not the only one treating this patient. You and your colleagues can support each other. You may also have to adjust your treatment goals. For example, a person with a severe addiction may not be able to discontinue completely but you can help that patient to reduce the fallout.

You have mentioned setting boundaries. What challenges do physicians face in doing that?

Many are afraid that patients will become angry or that the practice will get bad reviews. Although this might happen, the good that comes from setting boundaries outweighs these concerns. Again, remember that boundaries are also in the patient's best interest.

What other strategies do you recommend?

Have good communication skills, which includes listening to patients even when they are angry or when you feel they're wrong.  If you find yourself becoming worked up, take deep breaths, slow down, and listen.

Some physicians are afraid that by being kind to angry patients they are actually condoning the patient's inappropriate behavior. But on the contrary, creating a respectful environment can prevent a situation from escalating and further a smooth clinical encounter.

You have talked about patient factors but are there also physician factors that contribute to difficult patient encounters?

There are definitely factors that physicians and other providers bring to the table, including being tired and harried, angry and resentful, or arrogant and dogmatic. Physicians should strive to create personal balance, have a more feasible schedule, have adequate staffing, have adequate EHR support, utilize resilience and wellness services, engage in self-care, and pursue mental health treatment when necessary.

What practical tips can you suggest to reduce the risk of difficult patient encounters?

Be aware of language barriers and cultural issues, which can interfere with adequate physician-patient communication. As much as possible, have a conducive physical space that is comfortable, private, and not too noisy.

Have clear, easy-to-understand policies in place. (Table 2) All staff members should be aware of these policies.

You mentioned violent patients. How can violence be addressed?

While violence can potentially occur in any environment, it is most common in emergency departments, psychiatric units, the ICU, and the IMC. Be particularly aware of the potential for violence in high-risk patients and be cognizant of warning signs that a patient might be escalating in that direction. (Table 3)

While you may ultimately need to call security, physical restraint should be a last resort.

Table 1
The Universal Upset Person Protocol

Step 1 Recognize that the person is visibly upset
Step 2 Verbally acknowledge that the person is upset. (“You sound/look really upset.”)
Step 3 Let them identify their feeling (“You bet I am” or “No I'm not…I am angry/frustrated…”)
Step 4a Say, “Tell me about it” or “Tell me what happened.”
Step 4b Really listen as they tell you and try to understand their viewpoint
Step 5 When they are done, look them in the eyes and say, “I am so sorry that happened” or “I am so sorry you feel that way.”
Step 6 Ask, “What would you like me to do to help you?”
Step 7 Tell them what you suggest be done now
Step 8 Thank the person for being open with you
Step 9 Move on (You have now “cleared the air” with the patient and you can now move on to the reason for their visit)

Dike Drummond, MD Available at: https://support.thehappymd.com/hs-fs/hub/263814/file-43144098-pdf/Documents/UniversalUpsetPersonProtocol.pdf?t=1510448516301

Table 2
Establishing Clear Policies

• Prescription refills
• Pain medications
• Behavioral expectations
• No show/same day cancellations
• Patient lateness to appointments
• Patient termination policy

Karen Broquet, MD, MHPE

Table 3
Warning Signs of Violence

• Yelling, talking loudly
• Using profane/overtly sexual language
• Demanding unncessary care
• Accusing caregivers of conspiracy
• Darting eye movements
• Clenched fists or jaw
• Throwing objects or punching walls
• Inability to comply with directions
• Agitation
    o Can range from anxiety to aggression
    o Connected to many underlying conditions (most/all with slowed cognitive processing)
    o Repetitive non-goal-directed motor activity
    o Repetitive thoughts
    o Irritability
    o Heightened sensitivity to stimuli

Karen Broquet, MD, MHPE

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References

  1. Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomesArch Intern Med. 1999;16:689-700.
  2. Krebs, EE, JM Garrett, TR Konrad. The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey dataBMC Health Services Research. 2006; 6:128
  3. Hull SK, Broquet K. How to manage difficult patient encountersFam Pract Manag. 2007 Jun;14(6):30-4.

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