Question

According to your own experience and information you have read, what causes some patients to be difficult? Be specific and detailed.

Answer 1

Difficult patients complain, criticize, shout, swear and may even try to hit you. Difficult patients are an unfortunate fact of life in healthcare. But knowing how to identify, understand and respond to them can make your work life safer and less stressful.

Patient factors:-It can be hard to have productive encounters when patients exhibit the following characteristics. Here's how to identify them and respond appropriately.

(1.)Angry, defensive, frightened or resistant patients.:- Clenched fists, furrowed brows, wringing of the hands, restricted breathing patterns and warnings from office staff that something is wrong can help to identify these patients. When you see these signs, try to uncover the source of difficulty for the patient and pay attention to the way his or her emotions relate to the medical issues at hand. Don't get drawn into a conflict. Instead, define your boundaries and recognize when your “triggers” are invoked, as this will help you to modulate your response to the situation and allow you to empathize with the patient. Use reflective statements such as, “I can understand why you might feel that way,” and follow with a discussion about what it might take to resolve the situation.

For example, a patient who is in pain and has been waiting for an hour because you have been tending to a hospital emergency might be quite angry when you finally get to the room. He may say, “My time is as valuable as yours. I don't understand why I had to wait.” Your own sense of being harried and running late may trigger an angry reaction from you, but simply taking a deep breath and offering a sincere apology would be a more constructive response than having your own meltdown. A statement such as, “I can understand why you are upset, and I appreciate your waiting for me,” would go a long way toward easing the patient's frustration. If you can say with confidence that you'll handle the situation differently next time, for instance, by instructing your office staff to tell your patients that you are running late and to offer alternatives to waiting, such as rescheduling, then tell the patient what you intend to do.

If you sense that a patient is fearful about a diagnosis or treatment, encourage the patient to talk about it, and assess whether the fear is appropriate in proportion to the situation. This may help to establish a context for the fear, allowing the patient to deal with it more constructively.

Of course, if at any point during an encounter with an angry patient you sense a potential for harm to you or your staff, ask for assistance from law enforcement and remove those you can from harm's way.

(2.)Manipulative patients:-. These patients often play on the guilt of others, threatening rage, legal action or suicide. They tend to exhibit impulsive behavior directed at obtaining what they want, and it is often difficult to distinguish between borderline personality disorder and manipulative behavior. The keys to managing encounters with manipulative patients are to be aware of your own emotions, attempt to understand the patient's expectations (which may actually be reasonable, even if his or her actions are not) and realize that sometimes you have to say “no.”

(3.)Somatizing patients:-. These patients present with a chronic course of multiple vague or exaggerated symptoms and often suffer from comorbid anxiety, depression and personality disorders. They often have “doctor-shopped” and likely have a history of multiple diagnostic tests. Keys to productive encounters with somatizing patients include describing the patient's diagnosis with compassion and emphasizing that regularly scheduled visits with a primary physician will help to mitigate any concerns. Be sure to effectively manage any comorbid psychological conditions as well. It is important to refrain from suggesting that “it's all in your head,” and avoid the cycle of vigorous diagnostic testing and referrals.

A strategy for communicating with a new somatizing patient who has “doctor-shopped” might be to address the issue directly at the beginning of the encounter.

For example:-   “I noticed that you have seen several physicians and have had extensive medical tests to try to uncover the cause of your symptoms. I recognize that the symptoms are a real difficulty for you, but I believe that these tests have ruled out any serious medical problems. I have another strategy to suggest that has worked well for patients of mine in similar situations. I would like to make a contract with you to see you every two to four weeks – often enough to see if there is anything truly new going on. If something significant develops that has not already been worked up, we will do more tests. We will meet frequently enough to provide you some assurance that we are not missing anything, and we will avoid uncomfortable and costly tests and procedures unless they are clearly necessary.”

(4.)Grieving patients. :-Recognizing the effect of grief on some patients' health requires familiarity with the normal stages of grief and the cultural context in which it occurs. Look for vegetative 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 that takes varying degrees of time for different people. Encourage open communication, avoid inappropriate medication to suppress emotions, and caution against major lifestyle changes too early in the process.

(5.)“Frequent fliers.” :- These patients may stand out due to the sheer bulk of their medical charts. They may be lonely, dependent or too afraid or embarrassed to ask the questions they really want answered. They may also be patients with a large number of perfectly rational questions, the “worried well” or simply patients who have been given misinformation that needs clarification.

The first step to a productive interaction is to identify the underlying reasons for the frequent visits. Begin by acknowledging that you notice the pattern of frequent visits, and explain that you have seen other patients schedule frequent visits for different reasons, including concern about undiagnosed symptoms, a need for reassurance, a need for relief from chronic pain or a need to talk. Ask whether any of these reasons apply or whether the patient has other ideas as to the reasons for the frequent visits. Showing understanding of the patient's reasons often will foster an open discussion of the “reasons behind the reasons.” Contract with the patient for regularly scheduled return visits, and use patient education and support personnel as needed. Well-honed pain-management skills may also come in handy for patients who schedule frequent appointments due to chronic pain.