Every physician will encounter patients who may be challenging, frustrating, and difficult and could sometimes get you upset. When you know this patient is on your schedule, you may feel anxiety, dread, or even anger and guilt.

In the past, physicians often blamed the individual patient for having an antagonistic attitude or a combative personality. And although there are patients who behave in this manner, we also now take more into account the environmental factors that may be affecting the patient, their fears about their condition, their lack of social skills in expressing themselves, their confusion or lack of knowledge about medical issues, and pressures from other family members.

Of course, there are patients who are aggressive or impatient, have scattered thinking, or are in general simply more difficult to deal with than others. Whatever the cause, when such a patient shows up in your examination room, it's your challenge to understand the issues and defuse or tone down the encounter, to make it more productive.

Attending physicians perceive up to an estimated 15% of patient encounters as challenging or difficult. Although it may be tempting to shift blame to the patient, various factors contribute to such encounters. At times, the patient is depressed or anxious, or complaining of a myriad of severe symptoms, which makes the encounter difficult.

Sometimes, physicians infuse the interaction with their own perspectives on care, with their stress, fatigue, and burnout possibly playing a role. Other extenuating factors, such as language barriers, cross-cultural issues, and the sharing of bad news, can make the visit demanding.

To better understand the dynamic of challenging patient encounters, let's take a look at some of the factors that can play a role. We'll also examine situational cues that can undermine a patient visit, and what can be done to put patient encounters back on track.

Any seasoned clinician will probably recognize patients who display many of the following behaviors. These often lead to a subpar patient encounter, with both the patient and the physician feeling unsatisfied, or perhaps misunderstood.

Resistance, anger, fear, lack of gratitude, or defensive behaviors. With patients who express these emotions and behaviors, staff should be on the lookout for body language and signs, possibly including furrowed brows, clenched fists, and heavier breathing. Have staff alert you to the presence of these signs before the patient enters the exam room.

Rather than argue with the patient, define boundaries and recognize your own triggers. Also, pay attention to how the patient's emotions imbue the encounter and reflect his or her medical concerns and chief complaints. Use empathetic statements, such as "I understand how you may feel," and follow the patient's concerns in an attempt to resolve them.

Another strategy that works well with certain patients is to be tentative rather than directive in your suggestions and advice. For instance, a patient may be angry if left waiting too long. You may have been delayed because of an emergency, but the patient probably doesn't realize this. When you do finally get to see the patient, you may hear, "My time is as valuable as yours! Where were you? Why did I have to wait so long?!"

In these situations, take a deep breath, collect your thoughts, and apologize instead of expressing anger. Perhaps say, "I understand why you're upset. I apologize, and I appreciate your patience." You can also assure the patient that next time you'll try to handle the situation differently. For instance, if in the future you're running late, have your staff tell the patient that you'll be delayed and offer to reschedule at the patient's convenience. These steps could help defuse a potentially explosive encounter.

Keep in mind that sometimes patients may project their strong emotions from other situations onto you. Emotions that may be the result of interactions with other physicians, friends, or colleagues may be triggered and the patient projects their feelings onto you, a phenomenon known as transference.

If the patient is fearful or concerned about a diagnosis or treatment, ask him or her to discuss this fear and help provide insight, so that you can determine whether their fear appropriately reflects the situation. Such insight may help the patient manage their fear more effectively.

Of course, if a patient is angry, can't be calmed, and appears to be heading toward physical violence, it's best to remove yourself from the situation and contact law enforcement or security immediately to come and protect you and your staff from harm.

Dependency. Certain patients can appear needy or overly dependent. That may be part of their overall personality, or they may be fearful and worried about their physical condition. Illnesses that are incurable or untreatable are often, for any number of reasons, more difficult to manage.

It's also important for a physician to look inward. Some physicians are less skilled at dealing with patients who have illnesses that are not improving. In these cases, it's important for these doctors to identify the source of their frustration and recognize the critical role that they play in the lives of their patients. Moreover, it's important to recognize that although more patients are engaged in shared decision-making, some still prefer that the physician make the decisions for them.

Grief. If patients are having a tough time, such as grieving the loss of a loved one, going through a divorce, or in the process of losing a job, assess normal stages of grief and its cultural context. These patients could be facing immense pain and are in need of some emotional support.

In addition, it's wise to be on the lookout for indications of depression and maladaptive behaviors (such as increasing dependence on alcohol or drugs) that hinder the grieving process. Validate the patient's grief and advise them that it's a normal process that differs by individual. Communicate in an open way; don't try to medicate emotions, and caution against any impulsive, life-altering decisions that the patient may be considering.

Manipulative behaviors. Patients who engage in manipulative behaviors can play on the guilt of others or threaten with rage, legal action, or suicide. Their behavior may be impulsive and pushy. With these patients, gauge your own emotions, attempt to understand their expectations, and set limits — saying "no" as needed.

It's important to note that an encounter that appears manipulative may still include reasonable requests. For example, a manipulative encounter could involve a patient seeking a prescription for a benzodiazepine, opioid, or other drug with a high likelihood of misuse. In these cases, it's important for you to stand firm and follow a strict policy of not prescribing such a drug if it's not needed.

When responding to requests for these drugs, simply say, "I don't prescribe these types of drugs," or "According to health guidelines, we don't prescribe these types of medications." This answer is enough, and you don't need to further explain yourself. Shift the focus of the interaction away from the request for drugs of misuse and toward the chief concern at hand.

Frequent unnecessary visits. In recent decades, referring to patients as "frequent fliers" has been roundly denounced as pejorative. Nevertheless, certain patients do come in for many more visits than are likely needed. It's important to recognize that these patients may be lonely, afraid, or embarrassed and are sincerely looking for assistance. Sometimes they're healthy but still worried, whereas others have been influenced by misinformation.

With patients who make many visits, it's important to help them identify the reasons for their frequent visits. Explain that in other similar instances, patients come in often for reassurance, relief from chronic pain, or just to talk. Ask whether these reasons apply, and whether there may be any other contributing factors. This insight will help determine a plan for future visits and direct the patient to patient-education materials and support personnel. In cases of complex pain-management needs, it may be a good idea to consult with a specialist.

In a high-powered study published in the Journal of Hospital Medicine, researchers mined a comprehensive administrative database for characteristics of patients admitted five or more times during a 1-year period. The researchers found that although these frequent visitors accounted for 1.6% of the patient population, they accounted for 8% of admissions and 7% of direct costs.

Admissions were typically guided by multiple chronic conditions; a high number of comorbidities compared with other hospitalized patients (7.1 vs 2.5); and, to a lesser extent, psychiatric comorbidities and substance misuse. Although these patients were somewhat more likely to be on Medicaid or uninsured, almost 75% had private or Medicare coverage.

"Patients who are frequently admitted to US academic medical centers are likely to have multiple complex chronic conditions and may have behavioral comorbidities that mediate their health behaviors, resulting in acute episodes requiring hospitalization," the authors wrote.

"This information can be used to identify solutions for preventing repeat hospitalization for this small group of patients who consume a highly disproportionate share of healthcare resources," they concluded.

With patients who make frequent visits, remember that hospital administration may be a useful resource. Notify administrators of patients who make multiple visits so they can create a list of names, medical record numbers, and diagnoses. These steps will help identify specific patient characteristics and streamline interactions in case of future visits.

Somatization, or so-called "hypochondriacs." Some patients show up complaining of various vague or exaggerated symptoms, as well as comorbid psychiatric issues, including anxiety, depression, and personality disorders. These patients often "doctor shop" and receive multiple tests.

Although it may be obvious to you that many of their complaints have little basis in reality, stay compassionate and emphasize the need for regularly scheduled visits, with issues addressed as they arise. If you're aware of any previous history of doctor-shopping, talk about it with the patient and discuss the fact that previous diagnostic testing supported no serious medical condition. By addressing these behaviors, which waste healthcare resources, you can minimize them and focus the patient on seeing you for their issues. Many physicians find it effective to enter into a "contract" to meet with the patient every 2-4 weeks to discuss any new issues.

Avoid telling the patient that the problem is "all in their head." In addition, don't fall into a trap of doing extraneous diagnostic testing or scheduling unnecessary referrals. It is a good idea, however, to manage psychological comorbidities and address any diagnosed psychiatric illness that may be present.

The vast majority of physicians are compassionate, considerate, and dedicated professionals intent on doing their absolute best for the patient. Nevertheless, doctors are busy people with lots on their minds. And, being human, certain attitudes and behaviors can influence patient interactions. It's important to recognize these possible stressors.

Some of the stressors that influence physicians' attitudes toward patients include:

Frustration. Burnout, frustration, depression, and anger are affecting an increasing number of physicians. These sentiments may relate to either short- or long-term concerns. Particularly during the pandemic, many people of all professions are on edge and overreactive. When interacting with patients, it's important to recognize potential triggers that can stir up such emotion. In fact, in Medscape's National Physician Burnout & Suicide Report 2021, 36% of physicians with depression said that they were more likely to express exasperation in front of their patients, with 13% admitting to expressing frustration.

Sexual harassment by patients. Despite nearly 1 in 4 physicians reporting being sexually harassed by a patient, this phenomenon is very much underreported. Sexual harassment by patients is much more likely than that initiated by colleagues and administrators, with female physicians more likely to experience abuse.

Examples of sexual harassment include unwanted comments of a sexual nature; sexual innuendo; sexual texts, pictures, or emails; or unwanted touching, hugging, or groping.

These interactions should always be reported because these dreaded occurrences not only undermine and make challenging the patient encounter, but one form of sexual harassment involves the patient making false claims about the provider.

What should you do if a patient makes a sexual advance or accuses you of doing so? Immediately exit the room and ask for assistance from a partner or another healthcare professional who is informed of the sexual harassment. The physician should then file a report with a superior or with the authorities and arrange to transfer care to another provider, with explicit warning about the event.

Of note, the patient's mental condition, including dementia, stress disorders, and traumatic brain injury, can contribute to the likelihood of sexual harassment. This may be something to consider before dismissing the patient from your practice or initiating legal action.

Other factors that may influence physicians' attitudes include fatigue and dogma. Fatigue has a way of spilling over into all professional aspects of a physician's life, including patient interactions. As far as dogma, doctors often bring personal conviction to their work, with foundational values and beliefs about patient care all honed by clinical acumen. Although to a certain extent, conviction is honorable, it's important not to let rigid beliefs disempower patients or dismiss their concerns.

It's not only the patient and the physician who bring attitudes and contributing factors to their encounter. In some challenging encounters, other circumstances can make the situation more difficult.

With difficult patient encounters, it's important to take some time and mentally prepare before the person enters the room. If you anticipate that the patient will trigger you in some way, visualize yourself facilitating an appropriate, compassionate, and helpful visit. If necessary, plan to later vent any frustrations you may have with a trusted colleague who understands the struggle.

Too many visitors. Sometimes there are too many people in an exam room. Although a medical chaperone may be a good idea to protect your interests, make sure that the patient truly wants others in the room. Evaluate whether there's a true need for another individual to help with decision-making or whether it's customary from a cultural perspective for the visitor to be present.

Other issues to consider are whether the visitor is influencing or manipulating the patient in some way. If possible, ask the patient alone whether the visitor should stay. Always communicate with the patient directly, and avoid taking sides in case conflict arises.

Language barriers. Physicians need to be able to understand their patients. Fortunately, technology has made access to virtual interpreters readily available. When communicating with a patient who speaks a different language, allow adequate time for the appointment and ask that the interpreter translate everything verbatim. One problem when using the patient's family or friends to interpret is "editing." It's counterproductive if the information is spun, editorialized, redacted, or otherwise changed.

Bad news. Nobody likes to break bad news, and physicians are no different. Before giving bad news to a patient, gauge what is already known and how much more information the patient desires to hear. Be direct with the news while remaining compassionate, and allow enough time for the patient — and any others in the room — to process the information. Once the bad news is relayed, summarize the information given, discuss the implications, offer additional support, plan next steps, and schedule follow-up.

As a physician, you're only in control of your own attitudes and behaviors. Knowing this can sometimes help redirect a challenging patient encounter and make it more productive. Of course, doctors would like it if some patients would change their attitude and behaviors, but in most cases, that won't happen. The onus is on you to become comfortable dealing with (and mitigating) patient interactions that may be fraught with emotion, anger, arguments, or other difficult behavior.

The following overall guidelines may help maintain a productive therapeutic relationship.

• Be kind, compassionate, and empathetic. Remember that patients may be facing challenging and scary life stressors that make them more emotional and more volatile. Patients facing difficulties often react well to kindness.

• Acknowledge any diagnosed mental health issues or doctor-shopping, and make plans to address these issues. Inform patients that if they don't agree with a diagnosis or treatment, they're more than welcome — and even encouraged — to get a second opinion.

• Address the patient's chief complaints and expectations from each visit.

• Set clear expectations, limitations, and boundaries, and make plans to continue care in a regular fashion.

• Recognize what you bring emotionally to the challenging patient encounter. Don't let frustration or anger overtake you. Confide in and vent to colleagues; it's often very helpful to let off steam and also get their ideas to help you deal with such situations.

• Recognize your own triggers. For instance, it may be easy to become exasperated by a patient with drug misuse and dependence — especially if they demand prescription opioids. Instead of becoming upset, recognize that this patient is vulnerable and needs help from a mental health professional specializing in drug misuse. Help the patient find this care in a calm and collected manner.

• Remember the common adage, "You attract more flies with honey than you do with vinegar." Be tentative and gracious in the suggestions you make during a patient encounter. Often, being assertive and stern will make it harder to find common ground and work together.