Managing Difficult Patients

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					Managing Difficult Patients

      William Robiner, Ph.D.

Disclosure Information
Managing Difficult Patients
William N. Robiner, Ph.D.

Employee of University of Minnesota.

I have no financial relationships to disclose.
Raise Your Hand If
 You have ever encountered a
 noncompliant patient
 You have ever encountered a difficult
 You see anybody else in the room who
 might be a difficult patient
 You have ever been a noncompliant
 You have ever been a difficult patient
Impossible People Exist!

 You will encounter them!
 You can’t avoid them!
 You can’t fix them!
 You can’t make them like
 You can’t beat them!
 They may not want your
Deal With It!
   What is a difficult patient?
Raise your hand if you think it is somebody who
  Takes poor care of himself/herself
  Doesn’t follow your direction
  Communicates poorly
  Is mean/belligerent
  Has chronic pain or doesn’t get better
  Is unintelligent
  Wastes healthcare resources
  Wants to sue you
Definition of the Difficult Patient

… “patients who are medically challenging,
  interpersonally difficult, psychiatrically ill,
  chronically medically ill, or lacking in social
  Adams J, Murray R: The general approach to the difficult patient. Emerg Med
  Clin North Am 1998;16:689-700.

  A patient “whom most physicians would
  dread to treat.”
  Groves JE: Taking care of the hateful patient. N Engl J Med 1978; 296:883-887.
Labels for Difficult Patients
  “Crocks”                “Train wreck”
  “Gomers”                “Hateful”
  “Frequent flyer”        “Turkey”
  “Shpos”                 “Nudnik”
  “Thick chart” patient   “Borderline”
  Personality disorder
  “Heart sink” patients
In Mental Health
 Somatoform Disorders
 Impulse Control Disorders
 Personality Disorders
  » Borderline
  » Antisocial
  » Narcissistic
  » Histrionic
  » Dependent
  » Obsessive Compulsive
Descriptions of Difficult Patients
 Multiple symptoms involving multiple body
 Poor response to usual treatments
 Certain medical conditions
  » Obesity/chronic pain/fibromyalgia
 Terminal illness

 Klein D, Najman J, Kohrman AF, et al: Patient characteristics that elicit negative
 responses from family physicians. J Fam Pract 1982;14:881-888.
 Gillette RD. ‘Problem Patients’: A fresh look at an old vexation. Family Practice
 Management 2000 (July August). 7:57-
Descriptions of Difficult Patients
 Rambling, unfocused
  » “Everything hurts”
 Raises new problems as visit ends
  » “Oh, by the way…”
 Poor hygiene
 Over demanding
 Manipulative, hostile, exploitative, rude,
 demanding, dissatisfied, controlling, lying,
Descriptions of Difficult Patients
  » Seductive (sexually or otherwise)
  » Dependent, clinging
 Resistant to health professionals’
  » Under appreciative
 Poor adherence with treatment
  » Inconsistent drug use
  » Miss appointments
 High utilization of healthcare
Descriptions of Difficult Patients
 Unrealistic expectations of cure
 Difficult to communicate with
 Vague and shifting complaints
 Undue concern
  » e.g., about minor symptoms
 Excessive preoccupation with
 physical disease
Impossible People
 Play the “blame game”
 Confrontation may be fruitless
 » ...and provoke denial and blame
 Are not swayed by reason
 May need to be treated like children
 Provide valuable life lessons
Why Patients Miss Appointments
 »   Fear bad news or uncomfortable procedure
 »   Scheduling delay implies unimportant
 Perceived Disrespect by System/Provider
 »   Time in waiting room
 »   Symptom resolution by appointment- no sx
 Misunderstanding of Scheduling
 »   Doing provider a favor
 »   Perception of schedules as fluid, negotiable
     Lacy NL, Paulman A, Reuter MD, Lovejoy B. Why we don’t come: Patient
     perceptions on no-shows. Ann Fam Med 2004; 2: 541-545.
Who are Difficult Patients?

            “Patients we don’t
             like or who don’t
                  like us!”

                -Ed Shahady, M.D.
Who Might Patients Want You to Be?

Somebody caring, like
Marcus Welby, M.D.

Competent, like the
Surgeon General

                      Regina Benjamin, M.D., M.B.A.

A good looking, smart,
well-trained, capable,
helpful, patient,
cheerful, professional,
ethical, successful,
wise, talented
Who Might Patients Think You Are?

Dr. Evil

Dr. Demento

Some Clown
Or somebody…

Who just doesn’t
help much

Someone very smart,
but unfeeling

An unconventional,
diagnostic genius

Neurotic, surreal,
zany, ridiculous,

A Kid
Or even

An authority figure
telling them what to
Who is not listening…

   Or with whom they might disagree
It Takes 2 to Tango
 A difficult patient for one
 doctor may not necessarily
 be difficult for another
 Mathers NJ, Jones N, Hannay D. Heartsink
 patients: a study of their general
 practitoners. British Journal of General
 Practice 1995;45: 293-296.

 Doctors with poorer social
 skills perceive more of their
 medical encounters as
 Jackson JL, Kroenke K. Difficult patient
 encounters in the ambulatory clinic: Clinical
 predictors and outcomes. Archives of
 Internal Medicine 1999;159:1069-1075,
Scope of the Problem
 Older, more often divorced or widowed,
 more acute problems, chronic problems,
 chronic & medications
    Chandry J, Schwenk TL, Roi LD, et al: Medical care and demographic
    characteristics of difficult patients. J Fam Pract 24:607-610, 1987.

 Of patient encounters in PC (n = 722):
 » ≈ 30% were troubling to physicians
 » Psychosocial problems & lower social class
   patients ⇒ greater frequency of difficulty

   Havens LL. Taking a history from the difficult patient. Lancet 1978;1:138-40.
Prevalence and Impairment
 Of patients in 4 PC settings (n = 627) 15 % were
 judged to be “difficult”
 “Difficult” vs. non-difficult patients had:
  ↑ More functional impairment
  ↑ Higher health care utilization
  ↓ Lower satisfaction with care
 Difficult patients did NOT differ from non-
 difficult patients in:
  » Demographic characteristics
  » Physical illnesses
 Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: Prevalence,
 psychopathology, and functional Impairment. Journal of General Internal Medicine
Underlying Reasons for Patients to be
 Feelings of fear, guilt, worthlessness,
 incompetence, shame
 Loneliness, social isolation
 Fear of abandonment
 Life stress
 Concern about personal safety:
      at home, on the street, in clinic/hospital, etc.
 Past abuse, sexual or other
 Disorganized, chaotic life
 Adverse earlier medical experiences
 Gillette RD. ‘Problem Patients’: A fresh look at an old vexation. Family Practice
 Management 2000;7:57-
Underlying Reasons
 Rational need for medical info/treatment
 Mental Disorders
 » Somatoform disorders
 » Personality disorders
     borderline, dependent, ASPD, OC, etc.
 » Mood disorders
 » Substance use disorders
 Involvement with tort law or Worker’s
 Compensation system
                                         (Gillette, 2000)
Role of Mental Disorders
  Difficult patients (67%) were much more likely
  than non-difficult patients (35%) to have a mental
  disorder (p < .0001)
  Mental disorders accounted for a substantial
  proportion of the excess functional impairment
  and dissatisfaction in difficult patients

  Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: Prevalence,
  psychopathology, and functional Impairment. Journal of General Internal
  Medicine 1996;11:1-8.
Depression and Medical Illnesses

                        Prevalence of Depression
Cancer                  5–50 (most studies: 20–25)
Diabetes                         14–22
Fibromyalgia                    20–71
Myocardial infarction       18–25 (40–65 sx)
Alzheimer’s dementia              15–57
Epilepsy                          25–75
Stroke                            10–40
Multiple sclerosis                34–40
Parkinson’s Disease                40
Psychiatric Disorders In “Difficult”
   Disorder        Odds       95%
                   ratio [OR] confiden ce
                              interval [CI]
   Somatofor m     12.3       5.9 - 26.8
   Pan ic           6.9       2.6 - 18.1
   Dysthymia        4.2       2.0 - 8.7
   GAD              3.4       1.7 - 7.1
   Major Depression 3.0       1.8 - 5.3
   ETOH U se        2.6       1.0 - 6.7
   Hahn et al., 1996
Lifetime Prevalence of Psychiatric
Disorders In Fibromyalgia Patients
 Disor d er                      Fibromyalgia              R he uma toi d
                                 n = 78                    Arthritis n = 40
 S o m a toform                  1.3
  Panic                         28.2                        7   .5
  PTSD                          23.1                        5   .0
  GAD                            5.1                        7   .5
 Any Anx      iety              60.3                       25   .0
  Depression                    61.5                       27   .5
  B ipolar                      12.8
 Any    D ep r ession           74.4                       27   .5
  ETOH       Use     D/O        21.8                       10   .0
 Any Su bstan c e Use           25.6                       12   .5
 Eati n g Disor d er            9.0                         2   .5
 Psychotic     Disor d er       1.3

 Arnold et al. Comorbidity of Fibromyalgia and Psychiatric Disorders. J Clin
 Psychiatry 2006;67:1219-1225.
Given the Role of Mental Disorders

Consider consultation with mental health

   Health Psychology
   Consultation-Liaison Psychiatry
   Social Work
Doctors and Difficult Patients
 Evidence suggests that the “problems do
 not lie exclusively with the patient”
                        (Gillette, 2000)

 Patients are labeled “difficult” by
 physicians because of their frustration
 with the relationship or because of how
 the patient sought healthcare
                        (Chandry et al., 1987)
Provider Contributions to Difficult
Patient Interactions
 Provider Personality and Beliefs
  » Judgmental, perfectionism, stubborn
  » Depression, ⇓ self-esteem
  » Anxiety, approval-seeking
  » Need for control, defensiveness
 Other Stressors
 Work Style
"If our fast-food society becomes also a
fast-care society, the process may
ultimately squeeze out the essential
ingredients of a workable patient-doctor
relationship, leaving both frustrated
doctors and frustrated patients."

              Don Lipsitt, M.D., 1997
              Editor, General Hosp Psych
Cultural Contributions to Difficult
Patient Interactions
 The Spirit Catches You and You Fall Down: A Hmong Child,
 Her American Doctors, and the Collision of Two Cultures.
     Anne Fadiman. New York, NY: Farrar, Straus, and Giroux, 1997.

 “The history of the Hmong yields several lessons that anyone
 who deals with them might do well to remember. Among the
 most obvious of these are that the Hmong do no like to take
 orders; that they do not like to lose; that they would rather
 flee, fight, or die than surrender; that they are not intimidated
 by being outnumbered; that they are rarely persuaded that
 the customs of other culture, even those more powerful than
 their own, are superior, and that they are capable of getting
 very angry.” (p. 17)
Relationship Building Techniques
 Partnership                   Let’s work together
 Empathy                       That sounds hard...
 Apology                       I'm sorry for...
 Respect                       I appreciate your...
 Legitimization                Anyone would be.. ...
 Support                       I'll stick with you …

Dealing with Difficult Patients
   The patient “whose problems will not go an uncomfortable reminder of
   the doctor’s inadequacy and impotence…”
Corney RH, Strathdee G, Higgs R, et al: Managing the difficult patient:
   Practical suggestions from a study day. J R Coll Gen Pract. 1988;38:349-

   Providers’ internal reactions can include:
    » Anger, depression, frustration, resignation,
       repugnance, disgust
       Simon JR, Dwyer J, Goldfrank LR. Ethical issues in emergency medicine: The
       difficult patient. Emergency Medicine Clinics of North America 1999; 17: 353-
When Using Confrontation

 Choose power struggles carefully
 » Enter only those that are worth having
 » Enter only those that you can win
 » Avoid Win-Lose situations
 » Avoid Lose-Lose situations
 » Take a long view
     Seek to “win” wars, not battles
 Be diplomatic
Coping with Difficult Patients-
 Avoid being judgmental
 Be patient, tolerant
 Get good history to understand patient
 Use direct communication
 Selective personal disclosure
Coping with Difficult Patients-
Additional Strategies
 Set limits for time and content
 Referral for tests, labs, specialists, alternative
 health, mental health
 Develop treatment plan/contract
  » Set limited objectives
  » Schedule for addressing needs
 Involve others- family/friends w/consent
 Steer focus away from emotional issues
 Terminate/Transfer case
A doctor’s job is to give you what
 you need, not what you want.

    Sign in the office of Carl J. Forester, M.D.
Benefits of Regularly Scheduled
 Make patients feel cared for and
 Address small concerns before they
 overwhelm patient
 May gradually lead patient to more mature
 thought patterns
 Reduce or eliminate unnecessary
 telephone calls, tests, admissions, ER
                                    Gillette, 2000
Coping with Difficult Patients-
 Prepare for the encounter
 »   Breathe deeply/catch breath
 »   Check labs/chart in advance
 »   Spread out difficult encounters
 Accept the situation
 » “It’s life; this is part of my job”
 Approach situation gingerly
 » Choose words carefully
 » Find things to appreciate
Neutralizing Impossible People
 Maintain/protect your self-esteem
 Avoid letting your anger take hold
 Sidestep accusations/complaints
 Don’t appear defensive
 Don’t absorb their impossibleness
 Use silence, humor
 Use touch (e.g., handshake, pat on back)
Coping with Difficult Patients-
Learn and Be Proactive
 Analyze cases
 » What worked?
 » What didn’t? Why?
 Seek input from colleagues
 » M & M Conferences
 » QAI/Performance improvement
Models for Managing Difficult
 Stages of Change
    Prochaska & DiClemente, 1983, 1992

 A Practical Approach for Managing
 Problem Patients
    Gillette, 2000
Stages of Change

1   Precontemplation
    The problem exists, but person
    minimizes or denies it.
2   Contemplation
    Person thinks about problem
    and initiating change
      costs & benefits
Stages of Change

3   Preparation/Determination
    Person commits to a time & plan
    for resolving the problem
4   Action
    The person makes daily efforts
    to overcome the problem
Stages of Change

5   Maintenance
    Person has overcome the
    problem but needs to stay
    vigilant to avoid relapse
Benefits of Stages of Change

                    Bad               Good ☺

Precontemplation Contemplation Preparation   Action   Maintenance

     “Six Steps to Serenity” for
     Teachers to Help Residents
     Work with Difficult Patients
Pomm, HA, Shahady E, Pomm RM. The CALMER approach: Teaching
learners six steps to serenity when dealing with difficult patients. Fam Med
  Questions for Providers

 What stage of change is the patient exhibiting?
 What feelings do you have as you think about
 the patient?
 How might your feelings influence your
 relationship with, and treatment of, the
 What might be underlying the patient’s
CALMER (6 Step Action Phase)
C atalyst for change (vs. responsible for it)
A lter your thoughts (⇒ change your feelings)
L isten and then make a diagnosis
M ake an agreement with the patient
E ducation & follow-up
R each out & discuss your feelings with
   trusted colleagues after seeing the patient
  • Attendings; peers; team
Catalyst For Change
  Focus on how you can help the patient
  move to the next stage of change?
  The only thing health professionals can
  control is their own reaction to people,
  situations, events
  Health professional can only be a
    Not responsible for changing
    the patient’s behavior!
Alter Thoughts to Change Feelings

 What can you tell yourself to feel less
 angry, frustrated, resigned, disgusted
 with patient?
 “We feel what we think”
   The way to control reactions (feelings)
   is to change thoughts
   “I can’t stand this” ⇒

   “This is difficult, but I can get through it” ⇒   ☺
Listen & Then Make a Diagnosis
 Difficult patients are draining,
 leading health professionals to
 not “listen” clearly to what they
 are saying (biases, beliefs)
 Only after engaging in the first
 two steps can you really hear
 or see what the patient is
 describing or exhibiting
Make an Agreement
 Let go of your agenda, even though you
 may be right
 » Recognize what stage of change they are in
 » Agree on “doable” or achievable
 Confirm patient’s understanding of plan
 » Patient’s behaviors
 » Your actions/system actions
Education & Follow-Up

 Based on your CALM analysis, how
 can you best educate the patient?
 » Help patient understand rationale for tx

 Prescribe “homework” based on
 patient’s stage of change
 » Include plan for follow-up
Reach Out/Discuss Your Feelings

 How do you feel about the patient and
 their behaviors?
 How can you take care of yourself when
 patients elicit feelings?
 Reach out and talk about your feelings
 with someone you trust
  » We all experience frustration at times
    with some patients
  » You don’t have to do this alone!
The Paradoxical Commandments
 by Kent Keith
People are illogical, unreasonable, and self-centered
                                        Love them anyway
If you do good, people will accuse you of selfish ulterior
                                           Do good anyway
If you are successful, you will win false friends and true
                                           Succeed anyway
The good you do today will be forgotten tomorrow
                                           Do good anyway
Honesty and frankness make you vulnerable
                           Be honest and frank anyway
The Paradoxical Commandments
The biggest men and women with the biggest ideas can be
  shot down by the smallest men and women with the
  smallest minds
                                        Think big anyway
People favor underdogs but follow only top dogs
                   Fight for a few underdogs anyway
What you spend years building may be destroyed overnight
                                             Build anyway
People really need help but may attack you if you help them
                                     Help people anyway
Give the world the best you have and you'll get kicked in the
         Give the world the best you have anyway
Want More Tips for Dealing with
Difficult Patients?

Difficult Patient: Psychological and
  Psychiatric perspective

    Dubai to Mumbai CME cruise:
    October 24 - November 2, 2009

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