How to Identify and Manage Difficult Patients

Angry, defensive, frightened, or difficult patients. When you see signs of clenched fists, furrowed brows, wringing of the hands, and/or restricted breathing patterns, try to uncover the source of difficulty for the patient. Don’t get drawn into a conflict. Instead, identify the cause, recognize when the triggers are invoked, and respond to the situation patiently.

For example, a patient who is in pain and has been waiting for an hour because the physician is tending to an emergency may be quite impatient and angry in the waiting room. He or she may respond with, “My time is as valuable as yours. I don’t understand why I had to wait for so long.” Responding with a sincere apology can be more constructive than having your own meltdown.

If the patient is scared about a diagnosis or treatment, encourage the patient to talk about it. This may help to establish a context for the fear, allowing the patient to deal with it more constructively.

If at any point, however, an encounter with difficult patients yields potential harm to you or your staff, ask for assistance from security and law enforcement.

Manipulative Patients

Patients who play on the guilt of others, threatening rage, legal action or suicide often exhibits impulsive behavior directed at obtaining what they want. The key to managing encounters with manipulative patients is to be aware of your own emotions, attempt to understand the patient’s expectations (which may sometimes be reasonable despite their actions), and realize that sometimes you must say “no.”

Patients and Somatization

These patients experience a chronic course of multiple vague or exaggerated symptoms and often suffer from anxiety, depression, and personality disorders. Essentially, somatization is when a patient associates a psychiatric condition with a physical condition. So if they’re suffering from anxiety but aren’t aware of it, they may believe they’re suffering from a physical issue such as bodily shakes or heart issues (such as the comparable symptoms of a heart attack vs. an anxiety attack).

The key to manage encounters with patients who mistake potential psychiatric conditions with somatic symptoms is to describe the patient’s diagnosis with compassion, and to emphasize that regularly scheduled visits with a primary physician will help reduce any concerns.

Grieving Patients

Familiarity with the normal stages of grief and the cultural context in which it occurs is key to managing communication with grieving patients. Look for signs of depression and maladaptive behaviors that prevent progression through the normal grieving process, and treat them. Help grieving patients by validating their emotional experience and making sure they understand that grief is a process. Encourage open communication, avoid inappropriate medication to suppress emotions, and advise against major lifestyle changes in the early stages.

External Factors to Consider

Physicians own attitudes and behaviors, as well as situational factors, may also contribute to difficult encounters with patients.

  • Angry or defensive physicians are more likely to react negatively to patients. Recognizing your own trigger issues and knowing what personal baggage you bring into the exam room can be valuable.
  • Fatigued physicians are often overworked, sleep deprived, and/or generally busier than needed to be at one time or another. It is important that you remain sensitive to the impact of physician fatigue on medical errors and patient safety.
  • Language and literacy issues are increasingly an issue among a more diverse population. Try to allow for extra time for these encounters. Whenever possible, work with a trained interpreter to minimize miscommunication.
  • Breaking bad news. When it is necessary to give patients information that will be difficult for them to digest, preparation is critical. Allow adequate time and privacy, and review the clinical situation. Assess what the patient already understands or believes about the situation and how much more information he or she wants. Disclose the news directly, allowing adequate response time for the patient and others in the room to process the information. After giving the news, offer additional resources, agree on next steps, and summarize the discussion and arrange for follow-up.

Further Reading

http://www.aafp.org/fpm/2007/0600/p30.html