How Should I Deal With Difficult Patients?

Sarah Averill, MD


November 18, 2010


What should I do when examing a "difficult" patient who appears to have behavioral issues?

Response from Sarah Averill, MD
Resident, St. Joseph's Hospital, Syracuse, New York

This reminds me of an experience I once had. I walked into the exam room, and a female patient began talking energetically, and moving her body about as fast as her lips. She said that she'd gone dancing last Saturday night, been bumped into the wall on the dance floor, and had sudden onset of 10/10 lower back pain, which had been constant ever since. She was smiling and she had better range of motion than a well-cooked spaghetti noodle. When asked about aggravating factors, she bent over like a folding ruler to nearly 90 degrees, "Doc, when I do this, and then this," bending a little further than should be physically possible, "it really hurts. Are you the master?" she asked, with a hint of hope in her voice.

Then plaintively, she asked, "What's wrong with my back?" When asked what therapeutic modalities she'd tried to help reduce her pain, she said that she had taken ibuprofen around the clock, but even the 800-mg tablets were doing nothing for her. She went on to demand x-rays and hydrocodone. She was way too peppy, and her story didn't match up with what I was observing her do with her body.

I could tell this was going to be a challenging encounter. For one, I liked her. She was funny. Second, I didn't really believe her story. Third, I had to set some limits on what I could provide for her from the emergency room. As an intern, I have an attending to guide me, but I still have to face the brunt of patients' reactions when I respond to their requests. Things can get ugly when you say "no" to narcotics.

Patients get labeled "difficult" for many reasons. They can draw you in with their stories and eat up your time; they can lie to you; they can behave in offensive ways; they can frustrate you by not taking steps you think they should to get their chronic conditions under control. Everyone has experience with difficult people, but how do you deal with the challenge when you can't just walk away?

Here are some tips for dealing with "difficult patients":

* Pull up a chair, sit down, and listen. If a physician sits down, patients perceive that greater time and attention is being paid to them than if the physician stands during the encounter. As a third-year medical student, I worked with an attending in the emergency room who sat down for every encounter, no matter how brief and I saw first-hand the impression it made on patients.

Give patients time to vent their feelings. Try to identify those feelings and give them a name. Don't ignore the elephant in the room. Acknowledging those feelings can help to diffuse them, and demonstrates empathy for their situation.

* Address basic human needs . Is the patient warm enough? Is the patient hungry? When patients are unnecessarily uncomfortable, it adds to the frustration that brings them in, and can alter the encounter. Common courtesy goes a long way. As an intern and resident, you will have less time and won't often be able to get those items for patients, but as a student, you will often have the time, and may get more out of your training by doing so.

*Safety first. If a patient starts to get aggressive, or physically combative, walk away, and call for help. I once worked with a resident who bragged about physically restraining patients on his own. He eventually got thrown over the side-rail of a paranoid schizophrenic's bed, with 3 rib fractures, and a 2-week suspension with mandatory anger management training.

During my difficult patient encounter, I made eye contact for several minutes, occasionally taking notes on nonmedical details. She asked. "What are you doing? Why are you writing that down?"

"I think it's interesting," I replied. "You are teaching me something about life."

I paid particular attention to her home life, work like, recreational activities, educational ambitions, obstacles she felt she faced. She then said, "You are the master." I wasn't sure what she meant by this. Was she hoping I'd take pity and write the narcotics scripts she wanted? Was she sincerely appreciative of my time and attention?

Maybe she called me the master, not because I fixed her, but because I'd listened to her, written down things she said, asked her about her life in prison, her kids, her struggle finishing high school, and her relationship to marijuana.

She left with a nonnarcotic prescription, x-rays, and 1 hydrocodone. Because there was no confrontation, I considered it a victory.