COMMENTARY

Patient Personalities 101

Gregory J. Warth, MD

Disclosures

July 22, 2011

As you progress in your medical training and career, you will encounter many different types of patients who have a wide range of personality traits and circumstances. These individuals will be faced with depression, terminal illnesses, chronic pain, addiction, and other problems. Some of them will be kind and a joy to see; others will be angry, frustrating, and challenging.

As a physician, you will need to get along with almost everybody well enough to do your job and, at the same time, develop a decent reputation. Your mission, of course, is to assure that your patients receive the best medical care that you can deliver, in a nonjudgmental way, no matter what their personal characteristics are. How well you accomplish this mission will in large part determine the kind of physician you are.

By carefully considering your patients' personality traits and circumstances, you'll be able to provide compassionate as well as scientific care to your patients. Keeping in mind that people are much more complex than any one of these characteristics, you might consider the following "types" of patients:

• Pleasant patients are usually very easy to care for. Most patients fall into this category. However, there are still some preventable problems that may occur. You have to guard against getting too attached, which decreases your objectivity. You may want to be more reassuring and optimistic than you should be when realism dictates otherwise. In addition, you may be tempted to honor requests that may not be in the best interests of good medical care.

• Courageous patients have emotional strength, fortitude, acceptance, and understanding in the face of great adversity. We deeply admire these people and hope we can muster the same strength in ourselves when we need it.

• Angry patients and/or families often arouse in us an instinctive response to retaliate with our own anger. Responding with anger almost always makes the problem worse both for you and the patient. Try to understand why the person is angry and be on their side in helping them resolve the source of the frustration, if it is reasonable to do so. Allow them to vent and then try to correct the problem quickly. If you can't correct the problem, explain calmly why things are the way they are, for example, by showing the person how the current policy or plan benefits them and reduces risk.

Remember that anger may be the patient's defense mechanism for some other underlying emotion such as fear, anxiety, or depression. Anger may also be an attempt to manipulate others into doing something they would not ordinarily do. If you are at an impasse in trying to resolve the problem, or you feel yourself becoming angry, then excuse yourself and get someone else to try to rectify the situation -- perhaps a family member or chaplain, or someone who can provide an objective view. Most of the time, problems can be resolved to the patient's satisfaction if you remain calm and concerned for their welfare and if you go out of your way to make things better.

• Manipulative patients have learned how to get what they want whether it's good for them or not. We need to be able to recognize when we are being manipulated and be careful to avoid "giving in" when we know it's not in the patient's best interests.

• Demanding patients require a lot of attention, insisting that you go out of your way to perform various tasks that may not be necessary or that they could potentially do themselves. They usually are not doing this intentionally. Sometimes you have to gently set limits on what you can and cannot do for them.

• Drug-seeking patients may also be angry, manipulative, or demanding. These individuals are sometimes difficult to spot. Certain red flags to consider include the ongoing need for higher doses of opioids when symptoms are out of proportion to physical findings, frequently "losing" opioid prescriptions, or always running out of pain medications too early. Drug-seekers are very nice in the beginning but can become angry or manipulative if you try to decrease their dosages. It's important to be firm but never judgmental in these (or any of the above) situations. Encourage them to seek counseling for addiction, though this is sometimes difficult to sell.

• Direct patients like to be in control. They tell you what they want and don't hesitate to disagree with you if they don't like what you are saying or doing, or not doing. They are not always angry -- it just seems that way.

• All-knowing patients tend to believe that they are very knowledgeable about medical subjects and know as much or more than you do about certain topics. They may actually have some limited knowledge about a subject, but they often don't have enough experience with it to put it into the proper perspective. They like to bring in newspaper or Internet articles about medical issues so that you can become as knowledgeable as they are about the subject. It's best to be patient and understanding. Don't try to compete with them.

• Noncompliant patients can be frustrating because they never seem to want to carry on with the treatment you prescribe despite continuing to complain about the symptoms that brought them to you in the first place -- like smokers whose lungs continue to worsen despite being told not to smoke, or severely hypertensive patients who won't take their medicine and won't show up for follow-up visits. Sometimes, however, you find out it's because they don't understand the importance of certain treatments, or in some cases, can't afford the medicine and are too embarrassed to let you know that.

• Anxious patients can be time-consuming and often require a lot of reassurance. The extreme here is the hypochondriacal patient who runs to the emergency department with every back pain, worrying that their kidneys are failing, or that they have cancer. However, there is a significant risk for missing diagnoses in these patients because sometimes you find yourself reassuring them for a symptom that really is a sign of something serious. You have to remember that these people can get sick too.

• Psychosomatic patients present with very confounding dilemmas. Their symptoms are real but defy diagnosis despite usually large, expensive work-ups. You're worried that you might be missing something, and, of course, the patient is convinced that something has to be wrong. When the evaluation turns out normal and you try to convince the patient that the problem may be psychosomatic or "stress-related," they often become upset and disbelieving. They sometimes think you don't understand them or don't take them seriously. You have to convince them otherwise.

• Depressed patients are commonly seen in private practice. Some people know they are depressed and will tell you, whereas others will come in with a variety of symptoms including fatigue, lack of energy, sleeplessness at night and tiredness during the day, or lack of interest in anything. They may also think of depression as a sign of weakness in character. It's important to find out whether they have been having thoughts of suicide, and if they do, call the psychiatric center.

• Confused or demented individuals often require a lot of patience, especially when they ask the same questions or tell the same stories over and over again. Sometimes they are challenging if they become agitated, which happens often because they are frightened and feel that they have lost control. They frequently don't understand the need for certain tests or procedures. You may have to explain and re-explain things. Of course, in these situations the families should be involved in helping make decisions.

• Nonterminal patients with chronic pain are one of the most challenging types you will encounter, because there are very fine lines within the spectrum of need, abuse, and danger. Beware of certain inherent risks to both you and the patients. The patients are at risk for accidental overdose and death for a nonmalignant condition. The physician is at risk both professionally and legally; licenses have been lost and careers destroyed because of a desire to help people who are in severe pain. For these reasons, many physicians avoid these types of patients as much as possible, which is unfortunate because many of them are needlessly suffering, miserable, and nonfunctional due to inadequate treatment.

• Dying patients are sometimes difficult to care for because the sadness surrounding them tends to be infective and pervasive, and sometimes you take it home at night. Some physicians withdraw from these patients because it forces them to recognize their own mortality, or they don't think there is anything more they can do, they don't know what to say, or they fear that they will say the wrong thing. However, this is the time that the patient needs you the most. They need you to be honest and compassionate and to explain what's happening and why. They also need to know that you won't allow them to suffer needlessly. Although sad, it is often ultimately a gratifying experience if you can provide comfort to the patient and the family in this time of great need.

These characteristics occur in all walks of life, not just in medicine. However, illness or stress can bring out patients' personal strengths and weaknesses.

In addition, most people you encounter will fit into more than one of these types. For example, you may see a kind patient who also happens to be very demanding and somewhat manipulative. Or you may care for someone who is anxious and depressed and has a number of psychosomatic complaints, or an anxious patient who is also noncompliant. This is part of what makes patient care so interesting and challenging. It would be boring if they, and we, were all the same.

How will you respond to different types of patients? Remember that your reactions are a product of your own background, set of values, and characteristics, some of which may not be perfect. Consider your own personality, and be honest with yourself as you think about the following questions:

  • Am I easily angered, irritable, defensive?

  • Do I become emotional, easily saddened, or even fearful about certain situations?

  • Am I too abrupt or impatient?

  • How much compassion or concern do I have for others who are total strangers?

  • What is my flexibility level?

  • Am I congenial, or antisocial?

  • Can I appear calm even when I feel anxious?

  • Do I have a sense of humor, and do I know how to use it appropriately?

  • Do I have to be in control?

  • Can I take criticism well?

  • Do I have prejudices that might influence my ability to be objective?

If you can answer all these questions easily and honestly, you probably know yourself pretty well. This will help you interact with others. You may realize that you need to practice tempering some of your emotions or having more patience than you might otherwise have in certain situations. Remember, nobody is perfect.

Lastly, there are some guidelines that you may consider when encountering any and every patient. These will almost always be helpful in almost every situation. (Notice the word almost.)

  • Put your patient first -- not yourself, not the nurses, not the hospital administrators, not the insurance companies. Be your patient's advocate.

  • Be as compassionate and empathetic as you can.

  • Never respond to anger (or any other frustrating situation) with anger.

  • Try to understand why the patient is acting or responding the way s/he is. (Is it loss of control? Underlying fear?)

  • Don't be judgmental. You may have ended up the same way had you not been lucky enough to be born and grow up where you did.

  • Remember your mission -- to deliver the best medical care possible to all your patients, no matter what personality traits or characteristics they might have.

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